Shortages of antiretroviral (ARV) and other drugs in public health facilities in Swaziland have been among a long list of grievances cited by protesters during several weeks of unprecedented political unrest ahead of parliamentary polls on Friday.
Health department officials have admitted that supplies of some ARV drugs ran low in July and August, but insist that the problem has been resolved.
"I can appreciate that people on treatment get very panicky when there are rumours about short supply, but there are people with a political agenda as well, who are using the drug issue to discredit government," said Dr Derek Von Wissel, director of the National Emergency Response Committee on HIV/AIDS (NERCHA).
NERCHA oversees the procurement of ARVs, making use of funds from both the government and the Global Fund to Fight AIDS, Tuberculosis and Malaria. "There's now a steady supply; stocks are good," he added.
However, Maphangisa Dlamini, a home-based care nurse with Swaziland Positive Living for Life (SWAPOL), an AIDS support organisation whose members have joined some of the demonstrations, told IRIN/PlusNews that a number of health facilities were still experiencing shortages of ARVs and medicines for treating opportunistic infections.
Dlamini said the ARV drug regimens of patients had been changed because certain items were out of stock. "People are complaining; you'll find someone has been on a regimen for four years and then they're changed to a new drug, which might cause side-effects, and they don't know whether to adhere or not."
He claimed that the ARV shortage started three months ago but that hospitals had lacked drugs to treat common infections in people living with HIV, such as oral ulcers, since November 2007. "You have to go to a pharmacist to buy the drugs a doctor has prescribed and poverty is high in Swaziland; people can't afford to buy drugs."
Dr Velephi Okello, ARV therapy coordinator for Swaziland's National AIDS Programme (SNAP), told IRIN/PlusNews that some patients had been switched to other first-line ARV drugs, partly because of the supply problem, but also in response to the latest treatment guidelines from the World Health Organisation.
"The drugs are there," she said. "We have had a challenge of very low stock, but we didn't send anyone home, we just had to ration the drugs to two-week supplies instead of a month."
She admitted that having to make an extra trip to the clinic was a serious obstacle to patients who struggled to afford the bus fare for even one trip a month.
Poverty impeding adherence
With the highest HIV prevalence in the world - 26 percent of adults - Swaziland has a worryingly high default rate for ARV treatment. According to Von Wissel, about 31 percent of patients drop out of treatment in their first year on the medication.
Dlamini is concerned that the drug supply issue may contribute to the high default rate and increase the number of people who develop drug resistance as a result of interrupting their treatment.
"My fear is that now we'll have an HIV that is very resistant to the drugs," he said. "It'll be difficult to treat these drug-resistant strains because second-line drugs are more expensive and not available everywhere."
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Okello cited other reasons why people stopped taking their medication. "There's a vicious cycle of poverty and HIV in Swaziland: first you're retrenched [laid off] from work because you're too weak, and then you lack money to buy food, so most of the patients become like beggars; if they find they don't have food, they don't take the medicine," she said. Taking ARVs without food can increase the side effects of the medication.
Two-thirds of Swaziland's people live in chronic poverty, according to the UN Development Programme, and a majority of the population - 600,000 out of less than one million people - depend on food aid from international donor organisations.
Most of the clinics distributing ARVs give patients food supplements provided by the World Food Programme, but Okello noted that hungry family members quickly consumed the monthly rations meant to help HIV-positive patients.
Poverty and the rising cost of transport have made decentralising ARV treatment an urgent priority. Starting in December 2003, treatment was initially rolled out to the country's six hospitals and six health centres. About 30 percent of local clinics now offer ARV treatment, while the goal is to make the drugs available at all of them.
The major difficulty is that most clinics are staffed solely by nurses, who cannot prescribe the medication. "We need to discuss the issue of task-shifting [in which nurses are trained to prescribe and dispense ARVs]," Okello said.
About 27,000 of the estimated 60,000 Swazis in need of ARV treatment are now taking the drugs, but Von Wissel said too many people were still dying unnecessarily. "People are not coming forward for testing and treatment - that's the biggest single challenge," he told IRIN/PlusNews.
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Dlamini blamed problems with the treatment programme on a lack of commitment by the government. "Maybe they don't have money for now because they spent it on other priorities, like royal family expenditures," he said, commenting that the money spent on this month's elaborate celebrations to mark the king's 40th birthday and 40 years of the country's independence could have been used to secure drug supplies.