Bulletin of the World Health Organization

Uganda leads way in innovative HIV/AIDS treatment

Public health officials and doctors in sub-Saharan Africa say innovative approaches to treating AIDS in poor settings have so far been successful on a small scale. Can these efforts be expanded to provide antiretroviral therapy (ART) on a massive scale? Uganda is one of the sub-Saharan countries that has led the way in the treatment scale-up. But while the country is expected to reach the 50% treatment target, scaling up to provide ART treatment for every Ugandan who needs it will be a major challenge.

IN FOCUS
1 April 2005

HIV training session in Uganda’s Hoima district in 2004.
WHO/M. Jensen
HIV training session in Uganda’s Hoima district in 2004.

Building on years of AIDS awareness and prevention programmes, Uganda has almost completed training of health staff in all of its 56 districts to deliver a simplified version of chronic HIV/AIDS care — that includes ART — to people living with HIV/AIDS.

So far, just over one-third of patients in Uganda who need antiretroviral (ARV) drugs were receiving them at the end of December 2004 and the proportion is expected to reach 50% by July. This might appear low, but it is one of the highest proportions in Africa.

According to the ‘3 by 5’ progress report released by WHO in January, 72% of people in Africa who need ARVs were still not getting them at the end of last year. Botswana was the only African country that had reached the 50% target level by that time, the report said.

Many public health experts believe that the main obstacle to the ‘3 by 5’ campaign, which aims to scale-up delivery of ART to at least three million people in poor countries by the end of 2005, is the severe and growing shortage of health workers.

In an editorial on page 243 of this issue, Lincoln Chen, Director of the Global Equity Initiative, Harvard University, calls on governments for urgent action to address this shortage. Government officials from many countries gathered in Abuja, Nigeria last December conceded that the shortage of health workers in Africa threatened to derail development goals on the continent (Bulletin Vol. 83. No. 1, pp. 5–6).

In Uganda, officials say there are enough staff to treat the 42 000 patients currently on ARV drugs, but that more human resources and more drugs are needed to scale this up to the remaining 58 000 in need of treatment too.

Of those 42 000, three-quarters are paying for ARV medicines out of their own pockets, while a quarter get the drugs free from the Ugandan Government and donor projects.

Rosette Mutambi, coordinator of the Uganda Coalition for Access to Essential Medicines, argued that more should be done to make free and partly-subsidized ARV drugs more widely available. Mutambi said she feared emphasizing the shortage of health workers could slow down funding for ARV drugs in Africa. “The issue of human resources is not a problem at the moment, but it may be in future,” Mutambi told the Bulletin.

Dr Elizabeth Madraa, Manager of Uganda’s AIDS Control Programme, said that the workforce shortage was already a constraint and that this was largely due to the ‘brain drain’ of doctors and nurses. She said Uganda’s medical schools and nursing colleges do not produce enough doctors and nurses, and that there is a lack of public funds to recruit adequate numbers of health workers.

“We keep training and they go to NGOs (nongovernmental organizations) or abroad where they can get better money, then we have to train [more people] again,” said Madraa, who organizes and oversees ART training for health workers across Uganda.

In order to overcome the financial and staffing constraints, Uganda has adopted what Madraa called an “innovative” approach to treating HIV/AIDS patients.

Uganda is the first sub-Saharan country to roll-out ART on a national level taking this innovative approach. Ethiopia, the Eastern Cape region of South Africa, Swaziland and Zambia have also started training health workers to provide HIV/AIDS chronic health care using this simplified approach (see graph). If successful, Uganda’s ART roll-out could serve as a model for other low-income countries.

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"We keep training and they go to NGOs or abroad where they can get better money, then we have to train [more people] again." Dr Elizabeth Madraa, Manager of Uganda’s AIDS Control Programme.