PlusNews, 19 November 2002, MOZAMBIQUE: Focus on ARV programme

MAPUTO, (IRIN) - Medecins Sans Frontieres (MSF) plans to launch a five-year pilot programme in collaboration with the Mozambican government to provide free antiretrovirals (ARVs) to a selected group of HIV-positive people in the northern province of Tete and in the capital, Maputo.

The programme, to be introduced before the end of December, would begin with 350 people in
Maputo and 350 in Tete during the first year, and gradually increase to 1,500 people by the end of the second year.

No exact figures of how much the programme would cost are available as yet, because discussions on the best prices and methods are ongoing. But MSF's Marc Biot estimated that the treatment and the monitoring would cost about US $60 per month, per patient at the most.

The triple ARV therapy would consist of taking only two pills each day. Biot said the treatment would not have a "lot of side effects", but the patient's liver and blood toxicity would be monitored every three to four months.


The MSF programme follows an announcement last month that an Indian manufacturing company, approved by the UN's World Health Organisation, would begin supplying Mozambican pharmacies with cheap generic ARVs.

Mozambique, one of the world's poorest countries has one of the world's highest HIV infection rates, officially at 12.2 percent.

"The announcement [on the supply of generics] was a surprise," said Arlindo Fernandes, the president of Kindlimuka, a Maputo-based association for people living with and affected by HIV/AIDS. "It is a step in the right direction, but myself and most of our members around 350 - still won't be able to afford them," said Fernandes, who fell sick and tested HIV-positive five years ago.

The new triple therapy generics would cost about US $80 per month, about twice as much as what most Mozambicans in the formal sector earn each month. Most of those who have been infected are poor, work in the informal sector or in subsistence farming, with limited or little access to quality medical care for even opportunistic infections associated with HIV/AIDS.

But Biot said he was excited about the availability of the new generics, which although not a solution, could offer hope to some HIV-positive people.

"One year ago, the public sector was against providing drugs and now we start to see people from the health ministry saying that we can offer drugs at this kind of price. This means that they feel responsible now and do not feel it is unrealistic and unfeasible in
Mozambique. Even though they have to buy, it is still a guarantee of decreased prices. Through the public system they can be sold without commercial interests," he told IRIN.


The MSF programme would provide ARVs free to those who qualified for the scheme. Biot conceded that difficult decisions would have to be made, notably who would qualify to participate.

A selection committee made up of a representative from the provincial department of health, a counsellor, a nurse and a doctor would be set up to propose potential participants, he said. The first criteria would be medical, that candidates were in phase four of the illness, whereby the immunity or CD4 cell count was very low and they already manifested a combination of AIDS-related illnesses.

Participants would also have to show that they have in the past complied, when necessary, with other treatments. For example, those who have suffered tuberculosis would have taken the full course of tablets or had been cooperative about keeping previous appointments.

"It is an unfortunate reality that we can't put everyone [who needs it] on treatment," said Biot. He also added that stopping the programme after five years would be "tough".

But he hoped it would be a "learning phase and other partners will take on and expand throughout the country, and that we will convince donors and they won't have an excuse any more to say it is not feasible".

"Doing anything in HIV/AIDS care in
Mozambique means a direct improvement on medical care. HIV is an opportunity to finally address the real issue, which is the complete under financing of the medical sector." Biot criticised the pressure developing countries were under to pay back debts and to privatise the social sector. "You can't keep this logic when you have an HIV/AIDS epidemic, letting people die too early, your economy is collapsing and people are demanding more medical care."

Veerle Huyst, a medical doctor, who has been working for MSF in Tete with some 800 HIV/AIDS patients added: "I have lost some of my patients because there was no ARVs for them. They knew it existed but they had no money for it."

"There is a misunderstanding that those people who do receive ARVs give you [as a doctor] more work. I was seeing people who were in phase 4 [the last phase of the disease and those who would be entitled under the programme to receive ARVs] sometimes every two weeks. Then they get better from that sickness, then they fall sick again with another," she said.

"If you start ARVs, it is true at the beginning you have a lot of work. You have to monitor adherence, do the laboratory monitoring and offer a lot of counselling. But once they are settled it does depend, but usually you end up only seeing them three to four times per year, which is a huge difference from every two weeks," Huyst noted.


But others argue that providing ARVs is just not practical in such a poor country, where most people are not even receiving quality medical care for simple ailments. Illiteracy levels are over 40 percent and the level of HIV awareness in the countryside especially, is questionable. Only 40 percent of the population have access to the health service. In rural areas where most people live, health units are few and far between. More than 70 percent of the rural population take more than an hour to reach their nearest health unit.

Dr. Muhammed Olumoh, a private practitioner who has worked in
Mozambique for the past 11 years, was sceptical about the practicalities of providing ARVs countrywide. "It is a very complex issue", he said, " Mozambique has so many other problems of which this [the HIV/AIDS epidemic] is just one."

"How much medication can you bring? For how many people? We're not talking about one off vaccinations. You need to give this medicine on a regular basis for the whole time while a person is alive. What is the level of awareness of people in the rural areas? It is a lot of a responsibility. I think the first thing we should concentrate on outside the preventive measures, is prevention of mother to child transmission [PMTCT] for now. That is one thing that we can possibly control."

PMTCT pilot projects began in
Mozambique this year, but the real push in the past years has been towards preventive efforts. In an attempt to give more assistance to people living with HIV, a programme called Vida Positiva/Positive Living programme, a "social education" project targeting those infected and affected by the disease, was being introduced throughout the country.

The project includes information on how people who cannot afford ARVs can still live positively without them, in part through better nutrition.

Olumoh feels strongly that a mass introduction of free ARVs at this stage would be too risky for many reasons, not least the danger of people not complying with the treatment, which could then produce drug resistant strains of the virus. "We could end up with a bigger problem," he added.

Biot agreed that creating resistant viruses could be a problem. "We have to go slowly. The nurses and the doctors won't be the best people to help patients comply. The best people will be the patients themselves and the patients' support groups, like Kindlimuka. These people are essential as they know the local language and the local culture."

Similar ARV programme have been successfully launched in poor communities in
South Africa, Uganda and Malawi.

"People living with HIV/AIDS are not just passive beggars of medicines, they can be responsible as long as you give them the tools and the knowledge to take care of themselves and others," Biot noted.