More than 15,000 people living with HIV in the Central African Republic (CAR) had their life-prolonging antiretroviral (ARV) treatment interrupted as a result of the instability before, during and after the 24 March coup by the Séléka rebel group. NGOs are now struggling to ensure these people resume their regimens to reduce the risk of illness, drug resistance and death.
“The medical care in CAR, including ART [antiretroviral therapy] and cotrimoxazole [an antibiotic used to prevent infection in HIV-positive patients] prophylaxis, have been interrupted and the patients have been without drugs for last three months," Ellen Van Der Velden, head of mission for Médecins Sans Frontières (MSF) in CAR, told IRIN by telephone. "There are drug stock-outs. The HIV patients are struggling. The whole health system was disrupted. The Séléka takeover was preceded by the period of looting and disorder. The ARV drugs and other medicines in many health facilities have disappeared."
She added, "The HIV treatment was disrupted as the health workers and people fled for safety. After the takeover, many of these stations [health facilities] have not received the drugs. The people who had received their ARVs before the coup... they have run out."
Interrupting HIV treatment can have dangerous consequences, including speeding up progression to AIDS and drug resistance, which requires patients to be placed on more expensive second- and third-line therapies.
A March 2013 paper, written by researchers at Brown University in the US, stated that "treatment interruptions due to political conflicts, not infrequent in resource-limited settings, result in disruptions in health care, infrastructure, or treatment facilities and patient displacement".
According to a 2010 national survey, the HIV prevalence among those 15 to 49 years old in CAR was at 5.9 percent; the capital, Bangui, has a significantly higher prevalence - 10.6 percent. An estimated 130,000 people are HIV-positive, while up to 13,000 die from HIV-related complications annually, according to 2011 estimates published by UNAIDS.
The coup took an already struggling HIV programme - in 2012 the country had HIV treatment failure rates of 30 percent among adults and 50 percent among children - to new lows.
"We know that even before the crisis, CAR had one of the highest mother-to-child [HIV] transmission rates in the region, and only 33 percent of people living with HIV had access to ARVs, but even this limited supply has come to a halt since fighting began in December 2012," Linda Tom, chief of external communication for the UN Children's Fund (UNICEF) in CAR, told IRIN.
"Many hospitals and health centres, both in Bangui and across the country, were looted of what little supplies they had. Medicines, beds, mattresses and equipment were taken. Most doctors have left, and very few supplies and medicines are getting through. There are now very few fridges and petrol supplies across the country to allow basic health services, such as vaccination services, to continue," Tom said.
"UNICEF is working with the Global Fund, the CNLS [the national HIV/AIDS control programme] and partners to get ARVs to health centres in Bangui and surrounding areas as access becomes available. UNICEF has provided 11 PEP (post-exposure prophylaxis) kits to hospitals and partners in Bangui, Haut Mbomou and other areas that have witnessed the highest levels of sexual violence," said Tom.
"The most urgent priorities are to disseminate HIV-prevention messages among at risk-groups and to re-establish HIV testing services, especially for victims of GBV [gender-based violence],” she added.
On 3 June, MSF began a two-month emergency initiative to provide ARVs to HIV patients who have been without drugs since the crisis. "We hope to have another shipment in the next three months, and we hope by that time, the government supply system would have resumed,” said MSF's Van Der Velden.
"While there has been some improvement since the coup, humanitarian access to those in need remains the biggest challenge to healthcare delivery in CAR due to ongoing insecurity and the heavy presence of armed groups,” Tom said. "When people get sick, they are afraid to go to hospitals or health centres, and when they do go they may find there are no health facilities open or no health staff or medicines available."
Development partners are calling for security guarantees that will enable health workers to return their duty stations.
"The most important thing at the moment is to bring the drugs to the places where they are critically needed. We are calling on NGOs and donors to come to help the population get treatment," Van Der Velden said.