The lives of millions of people are at stake
Patricia Akinyi (42) is from Busia, Kenya, but she currently lives in central Nairobi with her sister because she has to visit a TB treatment clinic at Kenyatta National Hospital every day. She will have to do this for at least another year, possibly more.
Akinyi has multiple drug resistant TB and is also HIV positive. She is one of the 24 patients who have to come to the Kenyatta National Hospital isolation center every day. The treatments Akinyi is given for her TB and HIV are mostly funded by the Global Fund, which channels funds into developing countries to fight AIDS, TB and Malaria.
AIDS is the biggest killer, with nearly 2 million AIDS-related deaths occurring across the globe annually. About 33 million people in the world are believed to be infected with HIV, 95 percent of them in developing countries. TB affects an estimated 14 million around the world and it claimed nearly as many lives as HIV in 2009. Studies show that HIV patients are 30 percent more likely to develop TB. Malaria claims nearly 800,000 lives every year.
Born out of a G-8 summit in Japan, the Global Fund was founded in 2002 and is the main sponsor of antiretroviral drugs in most of Africa. Currently, 8.2 million people like Akinyi are on antiretroviral therapy, a combination of usually three or four antiretroviral drugs used to treat those who are infected with HIV.
Josephine Mwagiru, head of the Comprehensive Care Clinic (CCC) for HIV patients at Kenya’s Bagathi district hospital, says she shudders to imagine what would happen should there be any cuts in funding, a gnawing worry which has good basis, as people have died in other parts of the country because of drug shortages in the past.
Although the Global Fund has a sound mechanism for monitoring spending in receiving countries, high levels of corruption in some of the countries where the fund is active spell trouble. An independent review of the fund released in September highlighted a loss of confidence in the fund, despite its every effort to make sure that the money given to the governments goes to the right places. The economic crisis and austerity measures in donor countries have also had their toll, with donors becoming increasingly unwilling to give.
“As in most other hospitals, the money for the antiretroviral drugs we give our patients is from foreigners, such as the Global Fund and US Aid,” Mwagiru says, explaining her patients’ dependence on foreign aid.
For the donors, cutting funding for the Global Fund might be just adapting to changing conditions, but it is literally a matter of life and death for the people the fund reaches out to.
The clinic that Akinyi visits has treated 63 patients to date, most of whom have completed the treatment and been cured. About 24 are still being treated. The treatment is free and patients are given about $6 per day to cover their transportation costs. A few people have dropped out, but the results have been successful. Kenya now has TB clinics across the country, but more needs to be done because there are an estimated 2,000 cases of multi-drug resistant TB per year in Kenya.
There are similar clinics all across Kenya, from far off rural settlements to district centers. Kenya has managed to decentralize the services offered for the three diseases to a great extent. The government also runs programs to teach people about the three diseases in schools and prisons, while civil society groups and other organizations have campaigns targeting higher-risk groups, such as sex workers.
Programs in schools, prisons
The Nairobi West Men’s Prison in Langata, Nairobi, has about 500 inmates. Eleven of them are infected with HIV and three of them are co-infected, meaning they also have TB. There is a dispensary for the infected inmates to continue their treatments in the compound. In Kenya’s prisons, 3,455 inmates are infected with HIV nationwide.
Inside the prison, inmates are given group classes on protection against and living with HIV. Some of them, such as Jackson Wainaina Kiman (47), who is not infected, have become HIV counselors and educators themselves. Kiman, a former accountant, was sentenced to three years for handling a monetary transaction involving a stolen car. He will be out in February, but does not plan to go back to accounting. “I want to continue being able to do this,” he says, noting that he enjoys helping others.
Kenny Donega, an inmate at Nairobi West, says: “We are taught here that AIDS doesn’t kill, as long as opportunistic infections don’t take hold, that patients should take their drugs without fail. We are also educated on how to avoid infecting others. We are all thankful to the Global Fund.”
Programs in schools
In an afternoon class, 80 or more students of the Kutus Primary School in Kenya’s Mwea constituency respond accurately and in unison to questions Principal Sinclair Mussar asks on HIV, TB and malaria.
Outside the classroom, on a wall inside the schoolyard, a large poster preaches abstinence. Like most other schools, Kutus has programs to educate the children against the three diseases, but most of these schools, including Kutus, need better funding and sponsorship. “The roof leaks when it rains,” says Mussar. The school, which has 747 students between the ages of 6 and 12, has 97 HIV orphans, children who have lost one or both parents to AIDS. Most of Kutus’ students will not continue on to secondary school, which is why it is crucial that primary education equips Kenya’s young people with the knowledge to fight the three diseases.
Sex workers and HIV
The SWOP clinic, located on the forth floor of a business center on the busy Keerokok Road in central Nairobi, fills a unique and vital gap in Kenya’s National Aids Program. The clinic, a joint project between the Universities of Nairobi and Manitoba, Canada, has so far reached out to 16,000 sex workers, mostly through their field officers, who go out to clubs or massage parlors, talk to street walkers and find any sex worker they can to inform them about the services offered at their clinic.
As SWOP clinic doctor Joshua Parmeres explains, the patients here are educated on a range of issues from condom use to prophylactic drugs. Each patient is tested for venereal diseases and HIV. The clinic also offers HIV care and treatment. There are currently 300 patients on antiretroviral therapy and about 30 percent of the sex workers in Nairobi are thought to be infected. Around 6,800 people come to the clinic. “We try to encourage them to come to the clinic and refer others,” says Parmeres.
Saida (31), who asked not to be referred to by her real name, has been a patient at SWOP for two years. She heard about the clinic through a friend, who told her about it when her CD count had gone down to 109. She learned about her HIV status in 1996.
Earlier, she frequented other private clinics and Kenyatta National Hospital, where she attended a clinical experiment with other women like herself who had HIV but took much longer than the average person to get sick. However, when she did get sick, she was not given the treatment she needed. “I have never gone anywhere else since I came here,” says Saida. She and other sex workers say that most customers are not happy about using condoms and sometimes workers have to consent to sex without protection, even if they might be infected.
A Rwandan success story
Rwanda, a tiny Eastern African country of 10 million that was built from scratch after the 1994 genocide, has performed exceptionally well in its fight against the three killers and, understandably, has become the biggest recipient of Global Fund financing. As of 2010, it had secured more than $923,877,060 in grants for various programs, an amount much higher than its neighbors and one that can be explained easily by Rwanda’s impeccable record.
Since the start of its prevention programs, the prevalence of malaria in Rwanda in the general population has fallen from 2.6 percent to 1.4 percent. The rate of HIV prevalence in the general population is currently 3 percent, down from 7.3 just six years ago. The HIV mother to child transmission rate in Rwanda was 9.7 percent in 2006. As of 2011, it has fallen to slightly above 2 percent. The Global Fund is one of the main contributors to the country’s health programs.
Explaining Rwanda’s success, its health ministry officials say the country already has a good health system and 86 percent of the population has health insurance. Rwanda’s Health Minister Agnes Binagwaho says proudly, “The Global Fund is a tool, and it can make miracles when its donations are given to honest, hardworking people.” According Binagwaho, what sets Rwanda apart from its neighbors is its vision, transparency and lack of corruption.
But isn’t she worried about less funding? “If you’re driven by your worry, you’ll never get anywhere,” Binagwaho says. She also points to a darker side of aid programs, saying that there is a “poverty business,” where people on the boards or staff of global aid organizations earn hefty salaries. “The world can afford to spend money on so many stupid things,” she says, asserting with confidence that there will always be funding for aid programs. She said leaving half the world in poverty and “still playing football in peace” would be the “stupidest thing” Europe and other Western countries could do, given the security benefits of helping developing countries for those nations.
Rwanda has an aggressive circumcision program, launched after studies confirmed that male circumcision can be 50 to 60 percent effective in preventing the transmission of HIV. On a lazy weekday, dozens of young men wait in a long line outside the circumcision clinic of the Gahini Health Center, which operates on 25 men a day, in Rwanda’s Kayonsa region. The patients are also educated on condom use as part of the circumcision program launched in October 2010 in the country’s HIV/AIDS prevention campaign.
Rwandan men are flocking to clinics, for the operation’s value is not limited to its potential benefits in hindering HIV transmission. Many women want their partners to be circumcised.
Amos Ruhigira (27) and Faustin Kwizera (20) are lying on a comfortable mat placed on the floor outside the circumcision room of the center in Gahini. They have just had the operation, and are taking a break lying down in their green hospital gowns. “I came here because I heard it protects against infection,” says Ruhigira. “I will also use a condom,” says Kwizera, who came after a friend recommended him to the clinic.
Jonathan Habyerimana (20) is waiting outside the center. He heard about the benefits of circumcision and its availability free of charge on a radio ad. His parents have also encouraged him.
Working with the people
Marie Therese (45), a nun working at Kivumu Health Center in the western province of Kivumu, explains in detail Rwanda’s performance-based system for health workers. Voluntary health workers, four for each village, are given a bonus of about 1,000 Rwandan francs (less than $2) for every infected person they manage to bring to the clinic.
In addition to the nationwide performance-based system, the Kivumu Center and other centers across the nation work together with witch doctors, such as the 38-year-old Uwanyirigira Zamuda, the healer of the Muhaga village near the clinic.
Zamuda says she specializes in treating skin infections, mental illness and breaking evil curses on people, but she knows when to refer her patients to clinics. She is trained to spot signs of TB, malaria and HIV every year by Ministry of Health officials. She also gets a bonus for the people she refers to the clinic, which is insignificant for Zamuda, who makes $200 per patient cured, but she does not see referring a person she knows she cannot help as losing business. “No, it is not about losing income. It is about helping people,” she says, putting her arm around her 4-year-old daughter, who will be the next healer of Muhaga.
For all the good work they do, the Global Fund, as the panel of independent reviewers noted, might find itself struggling in the following years. Funding from donor governments fell by 10 percent in 2010, according to figures from the Joint United Nations Programme on HIV/AIDS (UNAIDS). Funding from Germany fell by 23 percent, while Spanish funding fell by nearly 40 percent. In addition to improving scrutiny over the usage of funds by the donees, one viable way out could be enlisting new donors, which the Global Fund is already considering. As brutal as it sounds, the lives of millions of people are at stake and turning to prospering nations that have not traditionally been donors could help perpetuate the Global Fund’s life-saving results.