The right to access HIV/Aids treatment and care, a game changer

To bring down the trajectory of the pandemic, the report recommends that it is imperative that lifesaving programs can be reached without fear by all who need them. 

The Greater Masaka sub-region is doing quite well in service delivery related to HIV/Aids prevention treatment and care. The introduction of a community pharmacy model has boosted access to care, with over 3,000 people enrolled on the programme to complement refilling points at public and private health units.   
  
Dr. Kakumba Kizito, the centre program manager at The Aids Support Organisation (TASO) Masaka, says the organisation has two pharmacies under the programme, with K Frank Pharmacy in Masaka City serving over 180 clients. 

“This model has addressed the challenge of continuity in care, particularly for those people who used to struggle with the inflexible hours of Antiretroviral Therapy (ART) clinics. People pick up medication at their convenience, even during hours when facilities like TASO and regular clinics are closed,” he explains.

Dr Paul Kavuma, the programmes manager for the Infectious Disease Institute (IDI) under the Masaka-Wakiso HIV Project, adds that the community pharmacy model, an innovation of IDI, is now implemented in over 16 pharmacies and 18 health facilities in the sub-region. 

“The programme brings services closer to people, reducing the need for costly success travel to public health facilities or ART clinics. The selected pharmacies are more accessible, and people can get their treatment even in the middle of the night,” Dr Kavuma says.

As much as the community pharmacy model has been a game changer in south-central Uganda, its has not been replicated in other regions, where people still wait long hours to access services such as supportive counseling, refills, treatment for opportunistic infections, chronic care for HIV patients, and TB-HIV infection assessment.  

Delays at ART clinics
When this publication visited the ART Clinic at Gulu Regional Referral at 12.20pm on Monday, an overwhelming number of clients had turned up. Notable among them were women and mothers with children between 3 and 6 months.

For nearly two and half-hours no client satisfactorily walked out of the facility. Dozens were sitting on the wooden bench, while others sat on the floor under a tent. They were visibly irritated, exhausted, and most looked hungry.

Some clients, who had packed a meal, fed on bread and boiled maize soothed down their throats by gulps of bottled juice and water. Dr James Kyayimba, the in-charge and clinical care coordinator of the ART Clinic admits that there are delays. 

“Our laboratory has a significant gap today. I attribute the delays to the numerous processes each client above 45 years has to go through such as screening for blood pressure, diabetes, and other conditions before they finally receive their refills,” he says.

Dr Kyayimba adds that although staffing gaps in the triage section cannot be addressed immediately, over the course of the past two months, the clinic is experiencing improvements in the delays. 

At Kitgum General Hospital in Kitgum Municipality, Beatrice Oyella, the chairperson of Back to 60s, an association of persons living with HIV/Aids noted that sometimes they spend close to seven hours waiting to get refills at the ART Clinic.

“When you come here at 7am, you may leave at 1pm. This is because we undergo many tests and counseling at the facility. We get refills for between three to six months. Our association has 120 members and is in charge of following up on clients’ adherence to treatment,” she says. 

In Kwania district, people living with HIV/Aids are facing difficulties in accessing treatment and care due to long distances and drug stock outs.

“Some of our members deep in the villages are far away from the health facilities. Their situation has been worsened by the constant rains we are experiencing. Some of them have abandoned treatment,” says Oscar Ewa, the chairperson of young people living with HIV/Aids in the district.

Lack of drugs
The HIV prevalence rate for Kalangala district is six percent, however, the challenge is accessibility to drugs, according to Teddy Namuli, the district’s HIV/Aids focal person.

“The district has 84 islands, but is served by only 16 health centers located on nine islands. This makes it hard for islanders to access treatment and care. We tried to mitigate this by taking antiretroviral drugs (ARVs) to different landing sites in our outreach visits,” she says. 

However, the cost of fuel and boat hiring was too huge a burden for them to bear. Now, instead of traveling to landing sites every month to deliver ARVs, go every quarter.

Paul Kiibi, the councilor for Buggala Parish in Mazinga sub-county, says the drugs used to be delivered to Nkose Island once every month. But, there was a time when the clients spent two months without getting refills. 

“Now, those who need ARV refills contribute money to buy fuel to travel to the nearest health facility. For instance, in Mazinga, clients travel to Mazinga Health Centre III on Kachungwa Island, a distance that consumes over seven litres of fuel,” he says.

However, Rajab Ssemakula, the district LCIVchairperson, says the use of drones to deliver drugs has helped more than 100 women in Bufumira sub-county stay on treatment. The district is considering extending the drone services to more islands.

Stigma and discrimination
While some regions have full stock of the drugs needed by the clients, Jolly Mashomero Korugyendo, the chairperson of people living with HIV/Aids in Kabale district, says clients are staying away from the ART clinics for fear of being stigmatised. 

“There is a need for amplified guidance and counseling for HIV/Aids patients to overcome the stigma and discrimination that are currently affecting the uptake of ARVs,” she says.

Alfred Besigensi, the district’s health educator, confirms that the supply of ARVs has been stable in all the district’s government health facilities. 

“This is unlike in the past where we incurred shortages that required clients to pick drugs in the neighboring districts. Today, ARVs are even available at Bwaama Island health center III to specifically serve patients who live on the many islands of Lake Bunyonyi,” he says. 

He adds that the stable supply has reduced cases of drug resistance among the HIV/Aids patients.

Dr Filbert Nyeko, the director of Kabale Regional Referral Hospital, says the main challenge faced now is an inadequate supply of health workers to attend to all patients and clients coming into the facility.

“We appeal to the government to increase our staffing levels because the hospital is operating at 24 percent of its capacity,” he says.

The situation is no different in Kole district where some clients, like Philomena Okidi, who for the last 15 years has been accessing services at Aboke Health Centre IV, have tasked the government to deploy more health workers in the ART clinics.

“There are only two health workers here – the in-charge of the ART clinic and one other person. The number of clients is overwhelming to them. I am among six volunteers who work as linage persons, distributing ARVs to over 70 clients per week. At times, we used to take the drugs to their homes,” she says.

Success stories
Dr Emmanuel Bahane, the Kisoro Hospital medical superintendent, says the HIV/Aids cases have gone up due to patients coming in from the neighboring countries of Rwanda and the Democratic Republic of Congo (DRC).

“The drug supply is stable because partners such as USAID have demonstrated commitment to supply us. We have also gone an extra mile to engage village health team members and private pharmacies to provide the drugs to elite clients who are not comfortable with visiting the ART clinics for fear of being stigmatised,” he says.

Dr Behane adds that the district opted for community drug distribution where some clients are given drugs that last six months. 

At Mbarara Regional Referral Hospital, clients come in as early as 7am so that they are able to leave early. Youth receive services at the youth corner, with counselors to attend to them. 

Patrick Niwandinda, an HIV/Aids champion from Kanungu district, who received treatment and care at Rugyeyo health centre III, says he is yet to face challenges with getting his ARVs.

“Although there are delays due to the number of clients, the health workers give us all the attention we need. If you take your medicine consistently they can give you a refill that lasts six months and they make sure they check on you to see how you are faring,” he confides. 

At Jinja Regional Referral Hospital, an ART Clinic was recently launched to supplement the services offered by TASO. This has solved the issue of service delays. With the ART clinic supported by the government, ARVs are always in stock.

In Busia district, the waiting time at the ART clinic at Busia Health Center IV has reduced drastically. This publication observed that clients receive services in less than 30 minutes after they walk into the clinic. 

Clients have their weight taken to establish whether they are feeding well, are malnourished or deteriorating towards malnutrition.

"Once we establish that their health is in perfect order, we refer them to receive their refills and they go away. However, those in the Facility Based Group, a category that includes infants and older patients who have just been recruited on ARVs, may take longer,” Kamili Okoyo, a health worker says.

Dr Yusuf Lule, the in-charge at Busia Health Center IV, says the Facility Based Group has to interface with a clinician to establish whether they are reacting well to the treatment and whether they are taking the drugs consistently.

“The other category which experience delays in service delivery are the Facility Based Individual Management Group whose HIV count is not being suppressed even when on drugs. The ART clinic is well stocked with all the ARVs needed by categories of clients,” he says.

The UNAIDS report indicates that as of December 2023, four countries were on track to reduce numbers of new HIV infections by 90 percent by 2030, and an additional 18 countries were within reach of this target. Nine countries had reached the 95–95–95 targets, and a further ten countries were close to these targets. 

“Yet, although impressive advances in HIV treatment continue, the world is not close enough to reaching the HIV prevention and social enabler targets set out in the Global AIDS Strategy 2021–2026 and the 2021 Political Declaration on HIV and AIDS,” the report says.

In countries where national HIV responses are on track, these gains will be sustained only if disparities in service access and outcomes are closed and no one is left behind. 

Contributors: Robert Muhereza, Emmanuel Arineitwe, Emmy Daniel Ojara, Teddy Dokotho, Joanita Adong, Santo Ojok, Patrick Ebong, Felix Ainebyoona, Jovita Kyarisiima, David Sekayinga, Malk Fahad Jjingo, Noeline Nabukenya, Abubaker Kirunda, Godfrey Masiko, Tausi Nakato, Denis Edema, and David Awori.