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Govt’s new Test & Treat’ policy blamed for ARVs stockouts

36-year-old Prossy Nangobi was diagnosed with HIV in 2000. At the time, people living with HIV and Aids positive patients were started on anti-retroviral (ARV) therapy after their CD4 count was below 500.

CD4 are T-cells, a type of white blood cells that move through the body to find and destroy bacteria, viruses and other invading germs. In 2008, Nangobi was started on ARVs at Kawempe hospital. Once a month, on a Thursday, Nangobi has been waking up at 5:00am to make her way to Kawempe and queue up to receive ARVs, a task that she describes as tiring.

"I take my pills at night which makes it hard for me to wake up very early in the morning. But since I need my pills to live, I have been making an effort to wake up early on the days that I need to go hospital for refills."

Since July this year, however, Nangobi has been forced to endure the tiring journey of getting ARV refills at least four times a month.

"I was told in June that they would be giving me pills for a week as opposed to a month as they have been doing in the past," she says

One year after the introduction of the 'Test and Treat' program, government is currently unable to adequately provide ARV drugs for the one million Ugandans that need them.
  
Last year, Uganda launched the Test and Treat policy that starts all HIV positive Ugandans on treatment the moment they find out that they have the virus. This is the country's chosen policy to meet its 90:90:90 goals by the end of 2030.

The policy is part of the campaign by the World Health Organisation (WHO) targeting to make sure that 90 per cent of the people living with HIV in the world will know their HIV status, 90 per cent of people diagnosed with HIV infection will receive sustained anti-retroviral therapy and 90 per cent will have a suppressed viral load.

Dr Carol Nakkazzi, head of HIV Prevention at Uganda Aids Commission (UAC), says the country is currently facing a shortage of ARVs because more people were enrolled on the drugs following the introduction of the test and treat policy and yet the budget for the drugs has remained the same.

"We had projected ARVs for the other guidelines but now we have shortages. The other guidelines we used to say that the people we put on drugs should have a CD4 below 500 but the new guidelines ‘Test and Treat’ say give ARVs to whoever tests positive irrespective of their CD4 count. It is like preparing for 500 guests and then all of a sudden you get 2,000. So the food will not be enough. That is the problem we are having with ARVs", she said. 

Dr Nakkazzi says the country has been suffering from low drug supplies of mainly abacavir/lamuvidine, atanazavir, nevirapine and lopinavir that are used by both adults and children.
 
The minister for Presidency Esther Mbayo this week told the media that government is doing whatever is possible to address the situation. 
 
"There is inadequate supply for example somebody who has been getting the ARVs for one month he is encouraged to receive only one week. Now that inconvenience of going back four times in a month is what is causing all that problem. But we are working as government around the clock to ensure that there is immediate restocking", Mbayo said.

Mbayo attributes the stock-outs to the small financial envelope that is aimed towards procuring ARVs in the country. The government of Uganda only contributes seven per cent to AIDS financing, with 93 percent of the budget coming from donations. The President's Emergency Plan for Aids Relief (PEPFAR) contributes 65 per cent, Global Fund 28 per cent and other development partner programmes make three per cent.

A 2016 Auditor General's report on the 'Management of Procurement and Distribution of Essential Medicines and Health Supplies by National Medical Stores (NMS)' observed that the price at which NMS procure ARVs from local manufacturers is higher than that of donated drug prices.  The report says that this could lead to fewer quantities of drugs procured for distribution to health facilities.

Dr Nelson Musoba, acting director general Uganda Aids Commission says the decrease in the amount of ARVs should be expected with the implementation of a large policy transition.

"When you’re implementing a policy transition, it is not usually without things like what we’re seeing. We knew that we would have a higher requirement for ARVs than before", he said.

According to the Commission, 1.3 million Ugandans are currently estimated to be living with HIV. By June 2017, an estimated one million Ugandans are currently receiving antiretroviral therapy following the implementation of the test and treat policy.  This shows an increase of 330,000 people currently on HIV treatment from 728,000 in n 2015.

Dr Musoba says that so far the policy has been a success and more effective in leading Uganda towards its 90:90:90 goal of 2030. 

"This policy has been a success because we now have more than 60% of the population living with HIV on treatment. This is a very big improvement for us."

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