Memorandum submitted by the Agency for
Cooperation and Research in Development (ACORD)
ACORD is an Africa-led international organisation
working for social justice and equality in sub-Saharan Africa.
ACORD was founded in 1975 and our focus was and remains
on giving a voice to the most marginalised and underprivileged
populations—the displaced, members of minority ethnic and
religious groups; pastoralist communities; widows; child-headed
households, and so on.
ACORD has been working on HIV/AIDS issues for over
a decade, primarily in the field of prevention, but increasingly
in the area of care and treatment.
ACORD's response to the Committee's inquiry concentrates
on the following three areas:
— The delivery of ARVs in resource-poor
settings.
— Gaps in treatment for vulnerable
groups.
— The balance between prevention and
treatment.
1. DELIVERY OF
ARVS IN
RESOURCE-POOR
SETTINGS
In many parts of Africa, close to 80% of the population
still live in the rural areas. Yet, services tend to remain concentrated
in the capital and other large urban centres. This centralisation
of services constitutes one of the biggest challenges in terms
of ARV delivery in the predominantly resource-poor settings of
sub-Saharan Africa.
Key problems include:
1.1 Limited access to information in rural
areas:
According to reports received from ACORD staff in
the countries where ACORD operates (approximately 20 countries
in sub-Saharan Africa), most people living outside the main urban
centres have not heard of ARVs. The main source of information
about ARVs are Voluntary Counseling and Testing Centers, Faith-Based
Organizations, NGOs and CBOs providing care and support for people
living with HIV/AIDS PLHAs, which are mostly found in urban or
peri-urban areas.
Owing to lack of accurate information, misconceptions
about ARVs are still widespread. For example, according to reports
from Tanzania, many people infected by HIV fear that taking ARVs
will make them worse and may result in sudden death. In addition,
few people have access to clear and accurate information about
the correct use of ARVs and/or criteria for eligibility (based
on CD4 count)
Case Study Tanzania
The Tanzania Care and Treatment Plan (2003-08) plans
to reach 432,000 PLHAs by 2008 and monitor and track disease progression
of the 1.2 million HIV positive people not eligible for HAART.
Under the terms of the Plan, Council Multi-Sectoral
Committees (CMACs) were established in 2003 in order to guide
responses at the District level and to play a role in resource
allocation based on local needs. To date, these Committees remain
divorced from national level decision-making processes. For example,
fewer than 20% of the CMACs in the Lake Zone of Tanzania know
anything about the treatment plan.
Up to July 2005, only 96 out of 126 districts
had been reached. The Ministry of Health Plans to enroll a further
106 health facilities, however these plans depend entirely on
external funding. Even if local level facilities are built, their
ability to serve the populations of marginal areas will be severely
undermined by the lack of prevention, counselling, VCT, trained
health facility staff and the overall infrastructure linked to
supplies.
1.2 Limited drug availability outside
urban areas
On the whole, despite government plans to scale up
and decentralise services, most ARV facilities are located in
district hospital and/or private health facilities. Rural areas,
where the large majority of the population is based, are yet to
be reached in many countries
1.3 Very weak infrastructure
There are very few health facility staff trained
in ARV management; there are not enough trained counselors; and
there are not enough prescribing doctors. For example, ACORD offices
in the Democratic Republic of Congo report that in the Eastern
Province, there are fewer than 10 prescribing doctors. There is
also a shortage of laboratory facilities for biological control
tests.
1.4 Lack of a supportive environment
Most PLWHAs are not able to disclose their status
due to stigma and discrimination, so they lack support from the
family.
1.5 Cost of ARVs
Despite the fall in prices of ARVs, the price is
still prohibitive for most people in sub-Saharan Africa. For example,
in DRC, generic drugs have been available since 2002 bringing
down the price of drugs from $58 per month in 2002 to $29 currently.
However, given that the average monthly salary is in the region
of $15 per month, few people can afford even this reduced price.
2. VULNERABLE
GROUPS
ACORD programmes are based in areas hardest hit by
conflict, drought, poverty and so on. While HIV vulnerability
in such areas is extremely high, they are usually among the worst
served in terms of ARV services and treatment.
One of the main problems relating to ARV delivery
affecting poor communities is the lack of access to an adequate
diet. This seriously undermines the benefits of ARVs. Other
vulnerable communities, such as nomadic pastoralists living
in remote areas, are also poorly served and access to information
and services for these groups is virtually non-existent.
Even where services do exist, vulnerable groups
are more likely to be affected by disruptions and problems related
to supply and service provision. For example, between April and
June 2005, the supply of drugs to facilities in Mwanza City, the
second largest town of Tanzania, were cut off. PLHAs from resource-poor
households both in the urban and rural areas were most affected.
80 women PLHAs supported by ACORD had their supply discontinued.
Mothers eligible for PCMCT were also badly affected.
3. BALANCE BETWEEN
PREVENTION AND
TREATMENT
The increased availability of treatment has had a
positive impact on some aspects of prevention, in particular the
use of testing facilities and readiness of people to find out
their sero-status. None the less, the general impression given
by ACORD offices is that the balance has been tipped in the direction
of treatment to the detriment of prevention efforts. The heavy
reliance of most African governments on external funding for ARV
initiatives means that they tend to conform to donor priorities,
which in the case of many donors (particularly the US) are in
the area of treatment. As a result, many governments are failing
in their duty to develop clear strategies for balancing prevention
and treatment in line with local and national needs and priorities.
Stigma and discrimination continue to undermine
both prevention and treatment efforts and increased resources
and efforts need to be directed at the development of stigma-reduction
strategies directed at every level of society, including individuals,
communities, service providers, local and religious leadership
structures, and others.
4. ACORD RESEARCH
UNDERWAY ON
ARV DELIVERY FOCUSING
ON MARGINALISED
AREAS AND
GROUPS
ACORD is currently carrying out research looking
at the delivery of ARVs to marginalised communities in Burkina
Faso. The research will provide insights into aspects relating
to delivery of services and information, but will also yield information
about the perspectives of PLHAs themselves and how access to ARVs
has affected their livelihoods, the family income, intra-household
relations, community-level stigma and so on. The findings of this
research will be disseminated at the forthcoming ICASA Conference
in Abuja, December 2005. They will also be posted on ACORD's website:
www.acord.org.uk
In 2006, ACORD is also planning to carry out similar
research in other countries where it works, including Rwanda,
Tanzania and possibly Mozambique.
November 2005
| 
