Monthly Archives: April 2012

Uganda: HIV- Aids Increase in Karamoja


MOROTO, 30 April 2012 (PlusNews) – The nomadic Karimojong ethnic group, once regarded as a low-risk HIV population because regional instability in northeastern Uganda and strong adherence to their culture kept them relatively isolated, have not been a priority on the country’s HIV agenda, but recent statistics show prevalence among this community is now 5.8 percent, up from 3.5 percent five years ago.

Over the past decade large numbers of Karimojong have settled in urban centres, where business is flourishing and many NGOs have set up shop; there has also been heavy military deployment in the area as part of a disarmament exercise. These and other changes in a strongly traditionalist society have combined to push prevalence closer to the national average of 6.7 percent.

“The drivers of the pandemic that exist elsewhere are now occurring here. There is also a lot of alcoholism and [domestic] abuse here, which is one of the drivers of HIV/AIDS infection,” Dr Michael Omeke, health officer for the Karamoja region’s Moroto District, told IRIN/PlusNews.

Limited Health Services
Just five hospitals serve seven districts and a population of 1.2 million scattered over some 28,000 square kilometres. “In general, HIV treatment and care services are still low in the region,” said David Wakoko, Karamoja area manager for the Mulago-Mbarara Teaching Hospitals’ Joint AIDS Programme (MJAP).

Most health centres in the region do not have clinical officers trained to provide life-prolonging antiretroviral (ARV) drugs or offer HIV care and treatment. Kaabong District for example, has five health facilities, but only the district hospital has a medical officer authorised to treat HIV-positive patients, and the hospital does not have a CD4 machine to test blood samples and measure immune strength.

Few health workers are keen to live in the remote and underdeveloped region. “Human resources are a big challenge. You need someone who is qualified to help these people, but we are not attracting… personnel,” said Dr John Anguzu, District Health Officer in Nakapiripirit. “Even the local people we try to train here to help, they leave.”

The region has also not been spared the drug shortages that have occurred in other parts of the country. “We do experience ARVs stock-outs… We are trying to work with the Ministry of Health and National Medical Stores to see that these stock-outs are reduced,” said Omeke.

A lack of food in the arid region and the long distances to health centres are major problems for people living with HIV. “These are weak people and can’t move long distances to go for treatment and drugs. The health centres are too far,” said Gabriel Lokubal, who lives in Moroto. “ARVs are very strong drugs, which require a lot of eating. However, most of us don’t have food, so some people have stopped going for drugs.”

Knowledge about HIV is also very low. A recently released preliminary report on the AIDS Indicator Survey shows that just 30 percent of women and 45 percent of men in the northeast are well-informed about HIV/AIDS.

A complex region

Spreading the word about HIV is not easy in Karamoja, where open discussions about sex are extremely unusual and the population is largely uneducated. According to MJAP statistics only 35 percent of Karimojong men have accessed HIV/AIDS services, compared to 65 percent of women.

“Because of the nature of the society and tradition, the men remain in the kraals [communal cattle pens] and are on the move in search of pasture and water for their cattle. They have little interest in seeking HIV services,” said MJAP’s Wakoko. “Most of those who access HIV/AIDS services are women, especially the pregnant ones, who visit health facilities for ante-natal services.”

“The HIV patients also tie HIV services to food. If you don’t have food, people don’t come,” Anguzu said in Nakapiripirit.

Stigma is highly problematic for health services trying to reach people living with HIV. “When you test a person and… [the result] is HIV-positive, he or she will never come back again for further… [treatment],” said a nurse at the ARV clinic at Moroto Regional Referral Hospital. “We are trying to sensitize the community to accept their status and learn to live positively.”

In an effort to bring the services closer to the people, Uganda’s Ministry of Health and MJAP are running a home-based HIV counselling and testing programme, but low staffing and occasional insecurity in the region are affecting the door-to-door campaign.

“The security situation remains fluid, as it changes any time despite general improvement in the sub-region, thereby affecting the implementation of programme in most of the catchment areas,” said MJAP’s Wakoko.

Health workers in the region say the nature of the causes and effects of HIV mean it cannot be tackled in isolation, and a holistic approach should be used.

“The interventions need to be shared among sectors – health is concept which is determined by social, economic and cultural aspects,” said Samuel Enginyu, a health educator with the Ministry of Health. “We are working on an integrated and collaborative approach with the Minister of Gender and Culture and other stakeholders.”

[Courtesy of IRIN News]


DRC: Mother-to-Child HIV transmission – “Catastrophe”


KINSHASA, 24 April 2012 (PlusNews) – Poorly integrated maternal health services, a lack of human resources and a serious shortage of money for treatment mean the Democratic Republic of Congo (DRC) is unlikely to meet the global plan of eliminating mother-to-child transmission by 2015.

“It is a catastrophe. An HIV test during antenatal visits is not automatic – the information may be given but the tests may not be available, or the treatment may not be available,” said Thérèse Kabale Omari, the director for Kinshasa Province of Femme Plus, an organization that works with women living with HIV in seven provinces of the DRC.

Only one laboratory in the country is equipped to carry out polymerase chain reaction tests for early infant diagnosis. “When an HIV-positive mother has a baby in [the southern province of] Kasai-Occidental, the centre must send the sample to Kinshasa, the capital of DRC. Getting results back can take weeks, and these women often don’t live near the health centre,” Omari said.

According to 2011 government statistics, just 5.6 percent of HIV-positive pregnant Congolese women receive ARVs to prevent transmission of HIV to their babies, but the official estimate puts the mother-to-child transmission rate at 36.8 percent.

A nationwide shortage of life-prolonging antiretroviral (ARV) drugs after the closure of some HIV projects and reduced funding for others means Omari is often forced to negotiate with doctors for HIV-positive women to be accepted in local treatment programmes. “I have to plead with them to prioritize pregnant women when someone dies or drops out off treatment,” she said.

“If you help someone to find out their HIV status, then you should have a way to treat them if they test HIV-positive, but today we can’t give women that assurance,” Omari noted. Dr John Ditekemena, country director of the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF), says while the DRC has strong policies and strategies for fighting HIV, and for the prevention of mother-to-child transmission (PMTCT), a severe lack of resources means they cannot be fully implemented.

“A main problem is coverage – many pregnant women who are tested will not return to the same facility for delivery. The DRC is a huge country with very limited resources – human resources, logistics, problems with the supply chain coordination – and the disastrous situation of the health infrastructure mean we won’t be able to reach the goal of eliminating mother-to-child transmission by 2015,” he said.

Femme Plus’s Omari noted that ‘free’ treatment was rarely completely free. “For example, the HIV test may be free, but you have to pay for the patient card, for the syringe they use if you need some treatment, for transport – the costs add up and few women can afford them,” she said.

Mariam, in her 20s, was diagnosed with HIV while she was pregnant a year ago, but has not started on ARVs because she cannot afford the US$15 it costs to get a CD4 test, which measures immune strength. She has since had her baby but the child has not been tested for HIV.

Mariam’s husband travelled to the southeastern city of Lubumbashi shortly before she was diagnosed and has not returned. She suspects he has left her and their children for good. To make ends meet, she sells plastic bags of drinking water on the streets of Kinshasa, the capital, but the money she makes is barely enough to feed her family, let alone pay for health care.

“I have not been tested and I think I am getting sick because I have noticed an itchy rash all over my arms recently,” she told IRIN/PlusNews. “I have two other children who are healthy but the baby gets sick often – I am worried.”

EGPAF and its partners, under a project known as Projet Intégré de VIH/SIDA au Congo – Integrated HIV/AIDS Project (ProVIC) – supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR), are assisting 24 maternal health facilities in five provinces of the DRC. Separately but also funded by PEPFAR, EGPAF is supporting 53 sites in Kinshasa and 17 in Lubumbashi as part of the “Malamu” project – meaning ‘good’ in the local Lingala language – to accelerate the pace of PMTCT in the DRC.

“The idea is to have a network of sites where women can receive the full package of PMTCT services, which will help improve coverage,” said Ditekemena, adding that the project was working to build up other areas of PMTCT such as male involvement and counselling on infant feeding.

“If you invite 100 women to the antenatal clinic with their husbands, only 10 or 12 will show up – we are extending the hours of service to allow men to come in after work or at the weekend,” he added. “Mother and infant follow-up is difficult if she is not counselled properly, especially if she does not have a support system around her – spouse, family, community.”

The ProVIC project aims to see 50,000 pregnant women tested for HIV and get their results in 2012, while the Malamu project aims to test 30,000 women.

“Slowly, step by step, we can increase coverage and improve the quality of care,” said EGPAF’s Ditekemena. “Perhaps by 2019 we will have eliminated mother-to-child HIV transmission in the DRC.”

[Courtesy of IRIN News]

ETHIOPIA: Still too many deaths in childbirth


ADDIS ABABA, 25 April 2012 (IRIN) – A lack of awareness of the importance of skilled hospital deliveries in Ethiopia, cultural beliefs, and transport challenges in rural areas are causing a high number of deaths during childbirth, say officials.

Only 10 percent of deliveries take place within health facilities, according to the Ethiopia’s latest (April) Demographic Health Survey results. Nevertheless, the figure is a significant improvement on 6 percent in the previous 2005 survey.

Commenting on the results, Health Minister Kesetebirhan Admasu said: “About 60 percent of mothers who did not attend health facilities while giving birth do not see the benefit of delivering in health facilities, while the remaining 30 percent abstain from going there by giving culture and beliefs as their reason.

“That [the] majority of women did not appreciate the value of institutional delivery, calls for a concerted effort to educate women and families about the importance of skilled birth attendance and postnatal care.”

Many women prefer delivering at home in the company of known and trusted relatives and friends, where customs and traditions can be observed, according to a 2011 study published in the Ethiopian Journal of Health.

“Even though communities are aware of the dangers around childbirth, contingencies for potential complications are rarely discussed or made, such that most families hope or pray that things will turn out well. When things go wrong precious time is lost in finding resources and manpower to assist in the transfer to a health facility,” the study said.

About 80 percent of all maternal deaths in Ethiopia, are due to haemorrhage, infection, unsafe abortion, hypertensive disorders, and obstructed labour, along with HIV/AIDS and malaria, said a senior Health Ministry maternal health expert, Frewoine Gebrehiwot.

The maternal mortality ratio in Ethiopia is 676 for every 100,000 births. This compares to an average of 290 per 100,000 births in developing countries, and 14 per 100,000 in developed countries, according to the UN World Health Organization.

Besides death, at least 500,000 Ethiopian women and girls who miss out on skilled health care during delivery, end up suffering other complications including obstetric fistula.

Behaviour change needed

The Health Ministry is working on behaviour change through health extension programmes and is providing each of Ethiopia’s550 districts with an ambulance to facilitate transport for pregnant mothers who want to deliver in health facilities free of charge.

But some of the hospitals are lacking in equipment, skills or policy guidance to enable them to provide basic emergency obstetric and newborn care, according to a study by the Health Ministry and its partners, who, using 2008 data, found that only 51 percent of hospitals qualified as offering comprehensive care.

“Most of the health facilities which are far from Addis Ababa are either not fully staffed with skilled service providers or fully equipped with the necessary supplies and equipment that can provide quality services related to complications during pregnancy and childbirth,” said the UN Population Fund (UNFPA).

“Limited human resources, especially midwives, hamper efforts to provide adequate services, especially in rural areas. Gaps in training and remuneration have led to attrition and turnover among public sector health care professionals.”

According to UNFPA, public facilities routinely suffer stockouts and obstetric care equipment shortages due to budget deficits and poor management.

Free services provided at health centres are to blame for the shortages, according to the Health Ministry which hopes a new health insurance scheme, to be piloted in 13 rural districts, will help to provide more funding.

At present, the ministry is seeking to increase the number of women delivering in hospitals by tapping into those seeking antenatal care and providing sustained family planning services at the district level.

“We are particularly trying to decrease mothers’ deaths by retaining the significant numbers of pregnant women who come to receive antenatal care from hospitals but [go] missing [during] delivery,” said Frewoine.

At least 34 percent of pregnant women aged 15-49 receive antenatal care from a skilled health provider such as a doctor, nurse or midwife, but only 10 percent give birth there.

“The same can be said about the high unmet need for family planning in couples and also among young people,” she said, adding that plans are under way to assign two midwives to every health centre in every district in the next three years.

So far, close to 1,630 nurses have been trained as midwives in a one-year accelerated training programme. Their number is expected to reach 4,674 by 2015.

[courtesy of IRIN News]

HEALTH: Beating measles – one more push?


Vaccines against measles have been around for decades and are highly effective, yet the campaign against the disease in recent years has had a bumpy ride.

The first target of the 21st century – to halve the number of deaths from measles between 1999 and 2005 – was successfully met. So the World Health Organization (WHO) set an even more ambitious goal – to reduce deaths by 90 percent from 2000 levels by 2010.

Now some elaborate number crunching by experts from WHO, the US-based Centers for Disease Control and Prevention (CDC) and Pennsylvania State University has produced disappointing news. Their study, published today in the London-based medical journal,The Lancet, concludes that although gains were rapid between 2000 and 2007, progress slowed towards the end of the decade, and the final reduction in mortality by 2010 was only 74 percent – good, but not nearly as good as had been hoped.

The executive director of the UN Children’s Fund (UNICEF), Anthony Lake, says vaccination campaigns now reach around 95 percent of all the world’s children. “This shows,” he says, “that these campaigns can succeed, even in the world’s poorest countries and most remote communities. Really this is one of the most remarkable victories in the history of public health.

“The bad news is that every day measles still claims 382 lives, the vast majority of them children under five, and every one could have been saved by two doses of a 22 cent vaccine.”

Some parts of the world have been more successful than others. Measles has been effectively eliminated in the whole of the Americas since 2002 – reduced to the point where there is no more endemic transmission of the disease, and any cases or outbreaks are the result of imported infections from other regions. China and its neighbours are also getting close to getting rid of measles.

But the disease is so infectious and so efficient at seeking out those who have not been vaccinated that even these regions cannot afford to let their levels of vaccination coverage drop. Rebecca Martin, director of the Global Immunization Division at CDC, warns against complacency. “Measles is a serious and potentially fatal disease that will return when it has the opportunity to do so. In many countries the overwhelming success we have seen with the immunization programme has led to the decreased recognition and risk perception of the severe outcome of this disease, but it is always there and will come back if given the opportunity to do so.”

Almost all the cases now seen in the USA are imported, almost half of them from Europe. Europe has had outbreaks of measles in recent years, but contributes very little to the global death toll; good health care means that very few children there die of measles. It is the very fact that Europeans do not perceive it as a deadly disease that makes some parents careless about vaccinating their children against it.

India overtakes Africa

One of the biggest surprises from the new statistical estimates is that India has now overtaken Africa as the region with the most deaths from measles – 47 percent of estimated measles mortality in 2010, while the African region contributed 36 percent. One of the report’s authors, Peter Strebel from WHO’s expanded programme on immunization, told IRIN that, again, perceptions of how deadly measles is, influenced the priority given to prevention.

“In India they have used a single dose strategy right up until 2010 and really, I think, have not seen measles as a high enough public health priority to embark on the two-dose recommended strategy. The important thing to note is that in the Indian context the risk of dying from measles is less than in the African context… Up to 10 percent of children who get measles in an African setting will die. In India it is estimated at more like 1.5 percent. So there is a big differential in the risk of dying and this may partially explain why they were not as aggressive or as eager to take on the new strategy.”

Steve Cochi of CDC adds that measles also may have lost out to polio in the scale of priorities. “There was a lot of preoccupation with achieving polio eradication in India,” he told IRIN. “But now that polio has been eradicated from India, the last case being more than a year ago, in January 2011, India has been able to step up to the plate and expand greatly its measles activities.”

This new push in India should give a fresh impetus to the drive to cut measles deaths worldwide. There is also a new WHO Strategic Plan on Measles and Rubella which will link vaccines against both diseases in a single immunization. The GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization) has approved funding to immunize all children under 15 with the combined vaccine in the more than 50 countries which do not at present vaccinate against rubella. The higher age target is important, especially for girls, because rubella (sometimes known as German measles) contracted during pregnancy can cause babies to be born with congenital malformations.

WHO is not ready yet to set a target date to move from the elimination of measles in some regions to complete eradication worldwide, but the vaccines are effective, they are cheap, and experts say it is doable, so soon it may be possible to start planning for a world without measles.

[Courtesy of IRIN News]

Nepal: HIV-positive children, orphans neglected

RAKAM, 3 April 2012 (PlusNews) – In the village of Rakam in Dailekh District, about 700km northwest of the Nepalese capital, Kathmandu, 12-year-old Ravi* is living with HIV and has no idea if he will finish his education.

“I feel weak all the time. My uncle is tired of hearing my complaints,” he told IRIN. Barely six when he lost his parents to AIDS-related illnesses, he now lives with his father’s brother and family, who are struggling to support him.

It is proving a challenge. They can’t even afford the bumpy eight-hour bus journey to the nearest city of Surkhet for his CD4 count test, which measures immune strength.

According to the National Centre for AIDS and sexually transmitted disease (STD) Control (NCASC), there are close to 5,000 children under 14 years of age living with HIV in Nepal today, but local NGOs and health workers estimate the real number to be much higher.

“There could be many more orphans and children living with HIV, but the government of Nepal has failed to pay any attention to their plight. Supplying medicines is not enough,” said AIDS activist Deepa Bohara, the coordinator for NGO Parivartan ko Lagi Pahuch (Access for Change).

There are as many as 15 HIV-positive orphans and children in Dailekh alone, the group reported. “We are extremely worried about the welfare of these children. We hope to get enough government support to help them,” said Khagendra Jung Shah, chief of the Dailekh District Hospital.

His office can only provide life-prolonging antiretroviral drugs – there is no separate budget to give these children any social support. Moreover, there are no programmes to sponsor their education, pay for medical expenses or offer psychosocial counselling.

Dailekh is one of the poorest districts in the country, with most people living on less than US$1 per day, according to government figures.

Stigma remains high in Nepal, and HIV-positive orphans sometimes face neglect from relatives after their parents die. In one extreme case six months ago, a five-year-old orphaned HIV-positive child (name withheld upon request) died of exposure after his relatives forced him to sleep in the barn out of fear that he would infect the other children.

“I don’t fear dying from AIDS, but constantly worry about the day when my mother dies and I will be alone in this world,” said Ashim *, 10, who lives with his HIV-positive mother.

“We are extremely worried, not only about the orphans, but also those whose HIV-positive parents are alive. What happens after their parents die?” said another health worker, Sushil Bikram Thapa from Nepal STD and AIDS Research Centre, a local NGO.

According to the National Centre for AIDS and STD Control in the Ministry of Health and Population, there are more than 50,000 adults and children living with HIV, and an estimated overall prevalence of 0.30 percent in the adult population (15-49 years old).

*Not his real name

[Courtesy of IRIN News]

Uganda: Deaf demand inclusion in HIV programmes

KAMPALA, 5 April 2012

Leaders of the deaf community in Uganda say the government’s HIV programmes have failed them because their special needs are not taken into consideration.
“I am disappointed with the way the government has acted… they are not sensitive to deaf persons. There are no specialized health facilities where the deaf can access HIV services,” Alex Ndezi, a deaf Ugandan legislator for persons with disabilities, told IRIN/PlusNews.

“The government has failed to train health workers in sign language. Whenever they [deaf people] go to health centres they need interpreters, who require payment… [few] can afford to pay… [them].”

According to UNAIDS, people with disabilities may be at risk of HIV infection for a number of reasons, including “insufficient access to appropriate HIV prevention and support services, and their higher risk of experiencing sexual assault or abuse… They may also be turned away from HIV education forums or not be invited by outreach workers because of assumptions that they are not sexually active, or do not engage in other risk behaviours such as injecting drugs.”

Alex Lawoko, chairperson of northern Uganda’s Gulu Association, told IRIN/PlusNews that deaf girls and women were particularly vulnerable to sexual exploitation and often became sex workers due to poverty.

“We need to include livelihood projects in fighting against HIV/AIDS in the deaf community… deaf females we interviewed in regard to their reasons for sexual trade said they are looking for income, as they lack money to support their life,” he said.

Deaf people miss out on radio programmes and adverts aimed at educating people about HIV, while television broadcasts on the topic are rarely accompanied by sign language interpretation.

Christine Ondoa, Uganda’s Health Minister, told IRIN/PlusNews that her ministry had finalized a document on HIV/AIDS strategic plans, programmes, services, and “all the HIV and related issues among people with disabilities; all [the points] they have raised are addressed in the document”.

The Ministry of Health, the US Centres for Disease Control (CDC) and the School of Public Health at Makerere University in the capital, Kampala, will soon begin the first ever HIV-related survey among deaf people in the greater Kampala area. There are no statistics on HIV levels among the deaf.

Using a video-based sign language questionnaire, the research will investigate respondents’ general health status, alcohol, tobacco, and drug use, as well as access to health care, HIV testing, treatment and care, and HIV-related risk behaviours. It will also offer participants the option to test for HIV and syphilis. Treatment for syphilis will be provided while HIV-infected respondents will be referred to care and treatment providers.

The survey, funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR), aims to interview a sample size of 1,000 deaf adults residing in Kampala, Mukono, Wakiso and Mpigi districts. It is expected to start by June 2012 and run for six months.

“Surveillance is a core public health function. It informs both policy-making and programme planning. Surveys are also used for public health advocacy and general community awareness,” said Wolfgang Hladik, an epidemiologist at CDC-Uganda.

The survey is the first step towards an opportunity to create well-informed, effective HIV prevention, treatment and care strategies for deaf people. “It’s a welcome move. We are going to support and ensure it succeeds,” said Ndezi. “There has been no information and data on HIV among the deaf persons.”

[Courtesy of IRIN Plus News]