PRETORIA -- Inadequate health services are forcing hospitals and clinics in sub-Saharan Africa to limit the number of patients who receive life-extending AIDS drugs, raising a major new obstacle to expanding treatment programs in the region.
After battling for years to gain access to the antiretroviral drugs at reduced prices, many African countries are now struggling to train more doctors, nurses, and lab technicians, as well as set up programs to deliver the drugs. That effort will take years, say African doctors, Bush administration officials, and AIDS activists, who note that many countries are now running into capacity problems after enrolling just a few thousand patients in AIDS drug regimens.
While realizing the challenges that lie ahead, many still believe that reaching this point represents a significant accomplishment.
"We have moved from destructive chaos four years ago, when the epidemic was wreaking havoc and little was being done, to a kind of happy chaos," said Paul Zeitz, head of the Global AIDS Alliance, an advocacy group based in Washington, D.C. "We want these kind of problems. Now we need to rapidly upgrade health systems to improve capacity."
At the end of last year, an estimated 700,000 people in the developing world were receiving treatment, a 75 percent increase in one year. In sub-Saharan Africa, which bears the highest burden of cases, about 310,000 people were receiving treatment by December 2004, up from 150,000 a year before. Still, some estimate that as many as 6 million people in the developing world are now in need of the medicines.
But already, the growing treatment programs are taking a heavy toll on health workers. Limits on new patients are being seen in more than 20 countries in Africa, AIDS specialists estimate.
In Botswana, which runs perhaps the most advanced AIDS treatment program in Africa, lab technicians are daily processing 800 to 900 patients' CD4 counts, which measure the immune system's ability to fight off HIV; a similar-sized lab in the United States would handle at most 100 tests a day, AIDS specialists say. The Botswana program is enrolling several hundred new people a week, but the backlog grows: Most patients are waiting several hours before they see a doctor.
"From the get-go, we've had capacity problems. We're constantly running to stay ahead," said Dr. Ernest Darkoh, outgoing operations manager of a public-private partnership that helps run Botswana's antiretroviral program. "And it's been consistently bad in terms of the stress levels for workers."
In the central Nigerian city of Jos, the AIDS treatment program has evolved so rapidly that it has limited new patients to 18 a day because the clinic cannot handle any more.
"Some days, we have 120 to 150 people in our clinic. There's hardly a place to put your legs," said Dr. John Idoko, one of Africa's leading AIDS doctors. He runs a program funded by the Bush administration in Jos that has 2,000 people on antiretrovirals. "In order for people to get into the program, they come to the clinic before 5 a.m."
Many places, even entire countries, are still not ready to start programs. In the small West African nation of Guinea-Bissau, a shipment last month of Brazilian-made antiretroviral drugs arrived at the airport -- and there it sits, because the country does not have trained health workers to oversee distribution.
"That is incredibly striking," Dr. Mark Dybul, deputy chief of the President's Emergency Plan for AIDS Relief, or PEPFAR, said of the Guinea-Bissau situation. "It shows how important capacity is."
Around Africa, "drug-distribution systems are a massive, massive problem," Dybul said by telephone from Washington. "It's not just the supply chain, it's capacity overall. We're going from doubling, or tripling, the number of people on therapy, and the production capacity isn't there."
But Dybul also was forced to confront some bad news this month when he learned that manufacturers of two branded drugs currently purchased by the US program would soon have trouble meeting orders because of the increased demand. Officials from
Several heads of US-funded AIDS programs said the projected drug shortages raise long-term concerns about whether pharmaceutical companies or generic manufacturers have the capacity to keep up with rising future demands.
Still, the biggest long-term problem for AIDS treatment programs is the lack of trained health workers, specialists said.
"There's nowhere where we're not facing some form of human resource problem, even in South Africa," said Jim Yong Kim, director of HIV/AIDS programs at the World Health Organization in Geneva. South Africa, which fell far short of its treatment targets last year, is acknowledged as having Africa's strongest health system.
Kim, who helped craft WHO's initiative of treating 3 million people in the developing world by the end of 2005, said donors will have to find ways to increase the salaries of health workers in poor countries to prevent more from leaving their jobs. One important step was the British development agency's decision to give nearly $200 million to the government of Malawi with the express purpose of increasing health workers' pay.
Almost no one believes the 3-million goal will be reached because of the capacity problems ahead; Kim, in a meeting of AIDS researchers in Boston on Tuesday, acknowledged the difficulties.
For AIDS specialists, the treatment of adults won't be the only stress on health systems' capacities.
Also ahead will be pressure for pediatric care of children with HIV, more HIV testing centers, and the expansion of programs preventing the transmission of HIV from mother to child.
"All of this means not only do you have to train the health workers, but you have to pay them," said Zeitz of the Global AIDS Alliance. "There are a ton of vibrant people who would love to get trained as community health workers. It would help the unemployment problem in many countries."
John Donnelly can be reached at firstname.lastname@example.org.