The “Missing in Action: HIV response in fragile and neglected countries,” session at the International Conference on AIDS and STIs in Africa (ICASA) focused on people who are not yet on treatment. Panelists noted that while there has been progress in the fight against HIV/AIDS, the progress has been very uneven, including geographically. According to the speakers, there are 30 countries where a large majority of people are living with unmet antiretroviral (ARV) needs. In Africa, the worst performing countries are: Nigeria (by far the highest unmet need), South Africa, Mozambique, DRC, Tanzania, Uganda, Kenya, Ethiopia, Cameroon, and Malawi. In West and Central Africa, which this session focused on, there are 2 million people with unmet needs. One of the most interesting points was that these are not necessarily the highest prevalence countries – but due to population size, relatively low prevalence can still translate into high burden due to lack of access (with Nigeria, again, topping the list in this category).
One panelist noted that many talk about the “tipping point” when the number of those on treatment exceeds new infections. But in West and Central Africa, we are very far from reaching this point – there have been 600,000 new infections, but only 250,000 new initiations. Some of the reasons cited are conflict (with continuity of treatment being a challenge); weak health systems; and relatively low prevalence rates, resulting in a lack of national and international attention to the issue, including on the part of the media, political leaders, and donors.
Regarding the situation in the Democratic Republic of Congo (DRC), one panelist noted that the fact that HIV treatment is embedded in weak or inaccessible health systems means that there are weak results for treating those living with HIV. The fact that patients have to pay for services, including drugs, means that many simply can’t access them. In fact, according to Médecins Sans Frontières (MSF), 46 percent of all HIV costs are paid by households in out-of-pocket expenses – in a country where 70 percent of the population lives on less than $1 a day.
Testing and counseling is often missing at the health facility level in the DRC, and in one study in three Kindasha hospitals, the organization found that 91 percent of patients had never been tested before – with 90 percent saying they had never even been offered a test. The speaker noted that international donors are withdrawing from the DRC, which will lead to even greater challenges for people living with HIV in the country, the majority of whom are already excluded from timely ARV treatment.
Another panelist from MSF talked about the challenges in providing treatment in the Central African Republic (CAR) – a very timely topic. She said that CAR suffers from a generalized epidemic, but with pockets of high prevalence in urban areas (especially the capital, Bangui). There is 20 percent antiretroviral therapy (ART) coverage (mainly in the capital). Prevention of mother to child transmission (PMTCT) coverage is unknown due to a lack of information, but thought to be very low. It is estimated that less than 50 percent of clinics have integrated PMTCT services.
There is low political commitment to HIV treatment, low levels of international funding, and few and unqualified human resources. There is also a lot of stigma and discrimination, and little community involvement in the issue.
Thirty percent of deaths in children under 15 are linked to HIV/AIDS (2011-12), according to a mortality survey conducted in Carnot City (a more stable area near Cameroon).
MSF has done some very important work in CAR, focusing on simplified approaches with context-adapted protocols, capacity building and task-shifting.
One of their conclusions was that the provision and continuity of HIV care is feasible, even in low availability and conflict settings, but we need to adapt to the context. We also desperately need stronger commitment from the international community – instability and weak health systems cannot be an excuse for inaction.
Eliane Drakopoulos is EGPAF’s Public Policy and Advocacy Officer based in Geneva, Switzerland.
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Insights from ICASA is a blog series featuring the stories and thoughts of EGPAF experts and staff participating in and attending the 17th International Conference on STIs in Africa