MBABANE, 23 January 2012 (PLUSNEWS) - Swaziland is still short of lab reagents needed for CD4 count testing, which is used to initiate and monitor patients on antiretroviral treatment, and HIV-positive people are growing increasingly frustrated as the country enters its fourth month without a way to establish the strength of their immune system.
"This is setting us back years in the way we treat people living with HIV and AIDS. Government says it has no money to buy the chemicals needed to determine CD4 counts," Thembi Nkambule, director of the Swaziland Network of People Living with HIV and AIDS (SWANEPHA), an umbrella organization for the country's HIV and AIDS support groups, told IRIN/Plus News.
Deciding on when to start a patient on ARV drugs is usually based on a combination of CD4 cell count test results and HIV disease progression, which the World Health Organization (WHO) has defined according to four clinical stages, with stage four being AIDS. In addition, guidelines for managing patients on ARV therapy also use CD4 count testing to measure the impact of the medication on the patient's health.
The government's ongoing financial crisis again hit the health sector in October 2011 when supplies of lab reagents - the chemicals needed to operate the CD4 count apparatus - began drying up. Since December, CD4 count testing has virtually ground to a halt in Swaziland, which has the world's highest HIV prevalence.
Shortages of HIV programme supplies in Swaziland were first reported in mid-2011. Although the stock-outs have been largely blamed on reduced revenues from the Southern African Customs Union (SACU), the country also opted not to apply for funding in Round 10 from the Global Fund to Fight AIDS, TB and Malaria. Instead, it chose to assume financial responsibility for HIV treatment itself, at a time when SACU revenues were already expected to decline.
Health Minister Themba Xaba said in a statement, "We need R7 million [US$875,000] to purchase the CD4 machine reagents, which is a lot of money. This, however, does not mean that patients are not getting any treatment. There are clinical stages and guidelines that are used."
In the absence of a CD4 count test, guidelines suggest that patients at stage three or four, determined by observable symptoms defined by the WHO, should be started on ARVs.
"Doctors can only go by how a patient tells them he or she is feeling, or if there are symptoms. The problem is that many people with HIV do not get sick or have physical symptoms while their CD4 counts are dropping to the level where they must take ARVs," said Nkambule.
"Not having accurate information on CD4 counts puts the doctor in the same position as performing surgery blindfolded."
According to Nkambule, equipment for monitoring liver and kidney function is also out of order. "When government ran out of money we were promised by government that the health sector would not be compromised," he added.
The health ministry is looking to the Ministry of Finance to come up with the necessary funding. Xaba has advised HIV-positive people to have their CD4 tests conducted at private labs. However, the test costs R150 ($19), which is unaffordable in a country where 70 percent of the population live below the poverty line.
"For many of us coming up with bus fare to the clinic is a big challenge. Taking CD4 tests is not a one-off thing. Many tests are required. I would say few people are going to private doctors for these tests," said Mandla Tsela, an AIDS testing and counselling officer in Manzini.
AIDS groups have criticized the constant uncertainty: in 2011, the country also experienced ARV stock-outs and had to be bailed out by the US President's Emergency Plan for AIDS Relief (PEPFAR), which gave the country $7 million in emergency funding in August. Swaziland now has a buffer stock of first-line ARVs that should last until April 2012.
"Why does there have to be a crisis or something has to break down before any action is taken? First the people living with HIV and AIDS were put at risk because of the supply of ARVs, and now we don't know really who should be on treatment because they don't have their CD4 counts," Nkambule said.
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