Mulanje: A miracle in danger

Last year, Mulanje District Hospital won a national award in recognition of quality delivery of HIV and Aids services. However, erratic supply of life-prolonging drugs and test kits is threatening the success story. JAMES CHAVULA writes.

For people living with HIV and Aids, taking antiretroviral drugs (ARVs) is a matter of life and death—when you start, you are not supposed to stop it.

However, the on-and-off supply of the life-prolonging drugs could be a silent threat to the lives they are meant to prolong.

The stark side-effects of intermittent ARVs’ supply present uncertainties on fragile lives, such as Chikumbu-based small-scale businessperson Elina, who tested HIV-positive when she was pregnant in May last year. The mother of six might have been put on ARVs straightaway, as required by the Ministry of Health, but she has had to endure ARV dry spells sometimes running up to two weeks.

She explained: “When we go to replenish our dose, health workers always remind us to take the drugs continuously. Every time we are told there are no drugs in our hospitals, we wonder what government is thinking about our lives.”

Crediting antiretroviral therapy (ART) for restoring her health following multiple ailments, the woman feels the erratic drug supply discourages some people living with the virus from treatment.

However, her concern mirrors the mood among the overwhelmed health workforce in the district, where 17 out of every 100 people are infected. This represents the second-highest prevalence in the country after Thyolo where 18 percent are infected. The country’s HIV prevalence rate is currently 10 percent.

“Scarcity of ARVs was one of the major challenges for the past year and sometimes it could go as far as two weeks,” Mulanje district health officer Khuliena Kabwere told experts on a fact-finding tour organised by the National Aids Commission (NAC) ahead of the National Aids Conference slated for October.

The health official reported that apart from the nationwide drug crisis the country faced which compelled prominent medics to write an open letter to President Joyce Banda, the problem is worsened by an influx of Mozambicans. He believes the migrants exert pressure on the border district’s hospitals of which 18 are State-owned, four run by the Christian Health Association and one private.

He explained: “The national budget does not give us any extra allocation to cater for patients from Mozambique. In the absence of the national registration system, it is not easy to distinguish Mozambicans from Malawians, but they present a major burden on our resources.”

The country has been grappling with an increasing workload and pressure on essential medical supplies due to the influx of Mozambicans and other nationals accessing free treatment in hospitals near the borders.

Like Kabwere acknowledges, this is a concern for all border districts—a crisis not only on ARVs but all spheres of the country’s healthcare system. Briefing the NAC delegates, Mwanza district commissioner Gift Lapozo termed the migrants health needs an extra pressure on the district’s health budget. Similar sentiments have been reported from Ntcheu, Dedza, Karonga, Mchinji and Likoma.

But the gravity of the problem in Mulanje lies in the figures at the DHO’s fingertips: the sporadic drug unavailability accounted for 76 days in the financial year.

This means that some of the 93 500 infected people in the tea-growing district which has a population of 550 000, spent nearly three months without taking the drugs.

This constitutes a “significant threat to lives”, according to renowned surgeon Dr George Nga Ntafu who sits on the board of NAC, which coordinates national response to HIV and Aids.

This impression sums up what the medics lamented in the January petition to the President when the drug crisis hit a record low: Shortage of essential drugs leads to avoidable deaths.

And the district’s ART coordinator Stella Katuma was graphic when asked how they are making sure that no life is lost so easily at a time the world is struggling to reduce Aids-related deaths to zero.

Katuma said: “Before the crisis, the clients would get a dosage for three months. During the lean period, we reduced it to one month. With time, we started talking about weeks. Later, first line drugs almost became scarce as the suppliers failed to supply consistently.”

The situation might have led to graver problems as some clinics had no option but to switch the clients to new combinations. Those that were allergic to combinations in stock were left to nurse a life-threatening dilemma. To Frank Chimbwandira, director of HIV and Aids services in the Ministry of Health, this meant “combinations were not available for people living with HIV and Aids to make reliable choices.”

Affirmed Katuma: “It is a big challenge to switch patients from one combination to another, but we are compelled to do it because the clients need to be on ARVs continuously given the impact of breaks on their lives.”

The World Health Organisation cites worsening immunity to opportunistic ailments and heightening resistance to further treatment among the impacts of breaks in ARVs dosage. As expected, this increases the death toll at a time the country is striving to reduce HIV-related deaths.

Yet this is not the only problem threatening responses to the pandemic in Mulanje, whose main hospital boasts a certificate of recognition for quality delivery of HIV and Aids services.

Equally erratic is the supply of test kits.

“There are times we have clients and patients seeking HIV testing, but we send them back because we have no test kits,” Katuma said.

To PMTCT coordinator Dora Sakwata, the absence of the testing material is a setback to prevention of mother-to-child transmission (PMTCT).

With government requiring all pregnant women to undergo HIV testing, figures from the DHO’s office shows 94 in every 100 women who tested positive were put on ARVs. Those that gave birth to HIV-positive children were able to access nevarapine syrup.

“The danger is that if you send back an untested pregnant woman due to lack of basics such as test kits, you might as well have chased them away from a vital service which has proved a miracle in safeguarding babies from HIV infection,” said Sakwata.

The miracle under threat is clear in the figures. Between August last year and July this year, only four in every 100 babies were born with the virus which causes Aids. The remainder (96 percent) offers a human face of how uninterrupted testing and ARVs are cementing strides towards building an HIV-free generation.

As a matter of fact, this, coupled with the imperative desire to ensure no Malawian dies due to Aids-related infection, is the reason delegates to the National Aids Conference must dare to explore ways of closing the gaps in the country’s struggle for universal access to testing, treatment, support and care services.