KINSHASA — The Democratic Republic of Congo is listed in the 20 nations with the highest percentage of HIV/AIDS cases. More than one million people are known to be infected, but the exact numbers are not clear because of years of war.
Whatever the figures, there is no doubt that access to treatment is low. Lack of infrastructure and health services are major obstacles to delivering treatment and life-saving drugs the country receives have not always been well distributed.
Statistics in the DR Congo are notoriously unreliable. In the past, the government claimed that four percent of the population was HIV positive. Most scientists now think the real figure is closer to two percent. But, even at two percent, the country has one of the lowest treatment rates in the world - with less than one of five of those with the disease receiving anti-retroviral drugs, or ARVs.
Patients charged for treatment
One reason for this is that ARVs are seldom free here, although by law they are supposed to be. Health centers not only routinely charge for the medication, they also charge for the CD4 test that HIV patients must take to determine if they are eligible for the treatment.
Thierry Detier, a consultant for the non-governmental organization Doctors Without Borders, says the charges can be a real barrier.
"There is a real need for free access to ARVs," he said. "A lot of people are being asked for $5 a month, or $15 for a CD4 test which is quite unachievable for most Congolese."
Doctors without Borders is one of the only organizations in Kinshasa which offers totally free treatment. One of its patients, a widow, says that she had abandoned her course of treatment at another center.
She says she was going to the Mukole Center and they started asking her for $5 a month. She could not pay it and stopped taking the drugs. It was only after she had fallen seriously ill that she was referred to Doctors Without Borders.
Testing, prevention strategy
Another reason for the low rate of treatment is that the Congo does not have a cogent strategy on disease testing and prevention.
For example, in some other African countries, pregnant women are routinely offered tests. And, in Zimbabwe, politicians recently submitted to being tested publicly to encourage the population to do the same. That is not the case in the DRC, where people are usually only tested after they show symptoms of the virus - and often, not even then.
Some health zones have even been discouraged from HIV testing because of a system of quotas which limits the number of new patients they could treat.
The French NGO Doctors of the World is running two health zones in Eastern Congo. Staffer Francois Berdougo says the quota has resulted in many of their patients being denied drug therapy.
He says that until this year they were allowed to take only 10 new patients for ARV treatment each quarter and that at the end of last year they had about 800 people on a waiting list. This year the United Nations Development Program (UNDP), which had been managing the supply of ARVs, increased the patient quota, but did not increase the drugs supply.
Detier from Doctors Without Borders says those drugs are often not distributed properly.
"In the past many health zones made a lot of testing and there were many people who were supposed to be on ARVs and they didn’t access them," he said. "At the same time in other health zones they were not testing at all, so the health centers received ARVs but they didn’t use them."
The UNDP had been managing the Congo’s procurement of ARVs from the Global Fund for the Fight against HIV/AIDS, Malaria and Tuberculosis. But the Global Fund has stripped the UNDP of its roll because of poor performance.
Dr. Bouzid Samir, who had been running the UNDP program,says distribution was not perfect, but says he thinks the Global Fund move was not fair. He suggests politics will plague whatever agency oversees drug distribution.
"The issue was mainly linked to distribution of top up salaries [to state health personnel] because to give top up salaries we needed a harmonized system, and to get this agreement has taken almost two years," said Samir.
The government has not pushed the ARV program as hard as it might have done because it has many other challenges for which it is also seeking donor support. It also knows that in future it will be expected to pay part of the ARV bill itself.
The Global Fund is insisting that, from now on, all countries pay five percent of the bill. The other main ARV donor, the U.S. President’s Emergency Plan for AIDS Relief is looking for a similar commitment.
Five percent of the Global Fund’s current program in Congo would come to about $5 million.
Kinshasa has not yet given a written commitment to pay the contribution, without which activists warn, future funding for HIV/AIDS programs in Congo is not guaranteed.