Zimbabwe's government adopted new guidelines set by the World Health Organization (WHO) for treating people living with HIV almost a year ago, but funding constraints have made it difficult to implement them - until now.
On 1 April 2011, Zimbabwe started phasing out the combination antiretroviral treatment (ARV) Stavudine, Lamivudine and Nevirapine as its first-line option for the national programme, replacing it with the less toxic Tenofovir-based regimens for adults and Zidovudine-based regimens for children, as recommended by the 2010 WHO guidelines. Stavudine is widely used in developing countries because of its lower cost, but produces more serious side-effects.
Following the new WHO guidelines, the National Drug and Therapeutics Policy Advisory Committee and the Ministry of Health and Child Welfare’s AIDS and Tuberculosis (TB) Unit revised and produced the National Guidelines for ART Therapy in Zimbabwe in May 2010.
These suggest starting ARV therapy at a CD4 cell count of 350 for adults, while pregnant women and infants living with the virus should begin treatment regardless of their CD4 count and clinical stage.
In a circular to implementing partners, Permanent Secretary in the Ministry of Health and Child Welfare, Gerald Gwinji, said due to resource constraints the implementation of the new guidelines would be phased in over three years from April.
Gwinji said because the country still had a lot of Stavudine stock, all new patients would continue to be initiated on the drug while those already experiencing side-effects would be moved to the new drug regimen until stocks were finished.
However, Gwinji said all HIV-positive pregnant women eligible for ART would be immediately placed on the new ARV regimens. Children eligible for treatment would be given paediatric Stavudine until stocks at national and facility levels are finished because of the high stock levels.
"We therefore encourage all workers, at all levels, to follow this guidance until further notice is issued in order to prevent ARV drug supply interruptions. Drug stock-outs at facility level may lead to HIV drug resistance," wrote Gwinji in the circular.
The newer drugs are estimated to be one-and-a-half times more expensive than Stavudine. With HIV/AIDS funding levels already worryingly low, AIDS activists have expressed concern that if these new expensive regimens are adopted, many people may fail to access treatment in the long run.
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Around 226,000 people are obtaining ARVs from Zimbabwe's public health system, leaving a treatment gap of about 340,000, but the new guidelines mean that at least half a million people will now qualify for treatment, at a cost of US$7 per person per month.
"Zimbabwe already has a very high treatment gap and many people in need of treatment are failing to access it as we speak," said the deputy president of the Zimbabwe HIV/AIDS Activist Union, Stanley Takaona.
"We all know that these new ARVs are expensive and we wonder how government will be able to ensure everyone has access to these expensive drugs when it can’t afford to provide treatment for everyone with the older and cheaper ARVs," he added.
National Coordinator of the Ministry of Health and Child Welfare’s AIDS and TB Unit, Owen Mugurungi, said the new ARV regimen would be initially funded by the National AIDS Council's "AIDS Levy" or the National AIDS Trust Fund (NATF) while government engages the donor community to help it adopt the new WHO guidelines. The AIDS levy - a three percent tax on income - was introduced in 1999 to help finance HIV/AIDS programmes, particularly ARV purchases.
He admitted that the new drug regimen was expensive but said in the long term it would turn out much cheaper. "When you do a cost-benefit analysis adopting the new drug regimen is recommendable," Mugurungi said.
"We may be able to put many people on ARVs now using the cheaper regimens but five years from now we will be losing a lot of money... treating people for side-effects from Stavudine-based regimens. Many people require physiotherapy, for example [as a result of side-effects], and we know how expensive this is... our hope is that our development partners will assist us fund the implementation of these new guidelines, we cannot do it alone."