NAMIBIA: A long walk to universal access
Hitting the treatment target
Windhoek, 30 October 2009 (IRIN) - In Onamutenya village, northern Namibia, the Shigwedha household leaves their homestead at the crack of dawn to make the monthly four-hour walk to fetch antiretroviral (ARV) medication from the local clinic.
Wilbard Shigwedha, 9, who is HIV-positive and an old hand at this early-morning routine, willingly gets up at 4 a.m. to make it in time to the clinic. By the time he and his mother Krestina, 35, who is also living with the virus, get to the packed health facility in Onayena after walking 20km, his brown pin-striped three-piece suit is coated in dust.
A return trip by minibus-taxi would have cost them 40 Namibian dollars (US$5) - too expensive for an employed widow and mother of four, two of whom are HIV-positive - and the sandy roads are tricky to negotiate by car, so taxis are also infrequent.
Distance and transportation are among the major challenges in rolling out HIV treatment in Namibia
, a vast country, with wide open spaces and a population density of less than 2 people per square kilometre.
About 15 percent of the 2.1 million people in the country are estimated to be living with the HI virus.
The long distances compelled the team of healthcare workers running the Shanamutango HIV clinic at the Onanjokwe Lutheran Mission hospital, in the Oshikoto region, to launch their outreach project to bring HIV services to remote clinics like the one in Onayena.
Northern Namibia is one of the poorest and most isolated parts of the country, where social services, employment opportunities and infrastructure are thin on the ground.
"Our patients travel as far as 100km. We don't provide transport ... a trip to come here can cost them 30 to 50 Namibian dollars one way, so our outreach programme is bringing the service closer to them," said Tutaleni Shilyomunhu, acting nursing manager at Shanamutango.
The Shanamutango HIV Clinic - funded by the US President Emergency Plan for AIDS Relief
(PEPFAR) - is one of the largest treatment sites in the country, providing ARVs to 8,000 of its 12,500 HIV-positive patients.
"[The country] is doing pretty well. The government has managed to roll out ARVs in a relatively short period of time ... it's a major achievement," Dr Robert Bennoun, the UNAIDS country coordinator, told IRIN/PlusNews.
The government set out to treat 70 percent of all HIV-positive adults in need of ARVs as part of its goals to provide universal access
to care, treatment and prevention; over 55,000 Namibians - more than 80 percent of those in need - are now receiving the life-prolonging medication.
Food, floods and alcohol
The programme still has many obstacles, with lack of food security
and transport among the biggest. At the Onanjokwe Lutheran mission hospital, principal medical officer Dr Sithembile Chinyoka commented: "We see it on a daily basis; the great distances our patients travel ... most of the children we admit are chronically malnourished."
Things are not much better in the rest of the country. "Everywhere we go the HIV-positive people we meet are crying of one thing - hunger," said Bernard Kamototo, who works for Lironga Eparu, the national network of people living with HIV/AIDS.
Most Namibians live on less than US$2 a day; having enough to eat is a constant burden, while water scarcity, erratic rainfall and poor soils have made subsistence agriculture even harder in recent years.
Chronic malnutrition is rising: figures from a recent demographic health survey indicate that 30 percent of Namibian children under five are so malnourished that their growth is stunted - in 2000 the stunting rate was 24 percent.
Dr Agostino Munyiri, chief of health and nutrition at the UN Children's Fund (UNICEF), noted that "nutrition is an area we are all grappling with ... the health system doesn't know how to approach this subject."
The worst floods
to hit Namibia in four decades have also hampered crop production, affecting more than 350,000 people in six regions with some of the highest HIV-prevalence rates in the country.
Bennoun told IRIN/PlusNews that the treatment of HIV-positive people in the flood-affected regions had been interrupted because they were cut off from health facilities and had no money to travel.
In the Caprivi Strip, a finger of territory bordered by Zambia in the north and Botswana in the south, widespread flooding when the Zambezi River burst its banks meant the only option was to go through Zambia to access ARVs, but most people had no travel documents or cash, he said.
Floods and lack of food were not the only reasons people defaulted on their therapy: colourfully-painted shebeens (unlicensed bars) are a common sight in Namibia's towns and townships, where they sell cheap local brews that have led to high levels of alcohol abuse
"Too many people are unemployed and struggling, and the only thing they can do to make themselves feel better is to drink ... but that is when the problems start," said Kamototo, who visits shebeens to raise awareness about how to prevent HIV and treatment adherence.
Prevention: the weakest link
The country's treatment success story has been largely due to external funding. Two-thirds of the treatment programme is financed by key donors such as PEPFAR and the Global Fund to fight AIDS, Tuberculosis and Malaria, while the rest of the bill is picked up by the ministry of health. "[The government] is moving towards sustainability, but they're not picking up as much as they can," Bennoun acknowledged.
Namibia is classified as lower-middle-income country, causing it to lose out on some much-needed donor funds; in the current global economic crisis, the country's health budget was going to be placed under even more pressure, he warned.
With the number of new infections still stubbornly high, the treatment programme might not be successful for very much longer. "This is one of the many reasons for the urgency of doing a hell of a lot better on prevention," Bennoun pointed out.
Implementing a treatment programme was always going to be easier than dealing with more complex human behaviour. For instance, the numbers of people being tested for the HI virus are still well below the universal access targets, and there has been no significant decline in HIV prevalence.
There is hope that the new national strategic plan covering 2010 to 2015, which is "very much evidence-based and results focused", will address inadequate prevention efforts.
"[The treatment programme] is a major achievement; the ministry of health is extremely active, vocal and visible," Bennoun told IRIN/PlusNews. "They haven't done well on prevention, but recognise that and are taking steps to lift their game."