Zimbabwe: HIV patients should not bear financial burden of donor retreat

In Zimbabwe, there are at least 66,000 people living with HIV who face the prospect of losing their current access to lifesaving antiretroviral (ARV) treatment because of a dangerous shortfall of international funding for local treatment programmes. To make up the shortfall, various segments of the Zimbabwean health sector proposed that certain HIV patients pay for their ARVs themselves. But what might initially appear as a cost saving measure will actually carry far greater costs—both in money and in lives—because it will undermine treatment adherence, quality and outcomes, as well as efforts to prevent more people from contracting the virus.

MSF, which supports treatment for more than 228,750 HIV patients in more than 20 countries, is deeply concerned by these and similar proposals that involve shifting the financial burden of buying ARVs from state budgets and donor funds to HIV patients themselves. This idea is being aired as international donors continue to retreat from previous funding commitments on ARVs, thus cutting off access to lifesaving treatment for patients in resource poor settings. Countries are struggling more than ever to find additional alternative sources of funding in order to avoid a return to rationing treatment and undoing much of the progress that has been made in HIV care over the past two decades. Interrupting treatment will also contribute to the growth of resistant strains of the virus.  

In Zimbabwe, ARVs are not currently covered by the Health Transition Fund (HTF), which creates serious problems. Until end 2011, a pool of funds financed by the UK, Sweden, Norway, Ireland and Canada paid for ARVs. This year, the HTF, absorbed this pool, but purchasing ARVs was no longer part of its mandate. This means that some 66,000 patients already on treatment do not know where their ARVs will come from, to say nothing about people waiting to begin treatment. If  donors, such as the United States, European member states or the European Commission through the HTF, do not mobilize to cover the gap, the next opportunity for additional funding would be a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria. The earliest that would happen, however, if it happened at all, would likely be in 2014.

The funding shortfalls have sparked much debate and calls from UNAIDS and others for countries gripped by the HIV crisis to step up domestic efforts. It is certainly true that national governments and ministries of health must make both political and monetary commitments to treating HIV. But passing the burden on to the patients themselves is not the answer. That would mean expecting people who are already vulnerable to pay for treatment that should be free; it also jeopardises the gains and results treatment programmes have made.

The World Health Organization—backed by medical evidence—holds that guaranteeing ARVs free of charge is crucial to maintaining good treatment outcomes and to slowing the spread of HIV. Most people accessing ARVs in high-burden countries through government health care, as in Zimbabwe, are already impoverished because they have lost income due to the disease and are shouldering ancillary health care costs. The majority of patients in Zimbabwe and similar low-income countries often live below the poverty line and already struggle to pay costs related to care, be it for drugs to treat opportunistic infections, registration and hospitalisation fees, x-rays, laboratory tests, or transport to clinics or hospitals. A study carried out by MSF in Kenya in 2007 compared retention in care among HIV patients with access to free ARVs to patients who had to pay a fee of approximately US$7 per month, while all other elements of care were the same. The result was that offering ARVs free of charge reduced the risk of loss to follow up by more than 56.6%.

To make vulnerable patients in poor resource settings pay for ARVs goes far beyond reasonable expectations. What’s more, fees collected from patients in a country where 80-90 percent of the population is not formally employed will not amount to much. And we know from experience that patients with unpredictable incomes may start rationing their ARV intake, taking less than the recommended dosages of pills in order to make drug supplies last longer. This leads to added complications, drug resistance and interrupted virus suppression—all of which would further increase the cost of care, wiping out any savings generated by the imposition of fees. In turn, it would increasingly burden health services, discourage health workers, and, worst of all, deter people from coming forward for testing and treatment.

A great deal of progress has been made in the fight against HIV/AIDS in Africa, but the emergency is far from over and the successes to date are far from assured. Any domestic funds that can realistically be raised in low resource settings now will not be sufficient to cover treatment for all people in need -  the number of people infected is still too high . Zimbabwe alone has one million people living with HIV. Economists estimate that most low income countries will have to remain reliant on external support for the next 20 years if they are going to ensure an effective HIV response that meets the needs of their populations. Zimbabwe’s National HIV and AIDS levy, which channels  domestic resources to the HIV response, is an effective model that shows the country’s increasing commitment to generating domestic financing for HIV, but international funding still is and will remain critical. The funds raised at home should be used to put more patients on treatment, rather than to fill gaps left by retreating donors.

Therefore, MSF urges donors to make sufficient funding available for free and effective HIV treatment to all who need it. Domestic resources must be augmented with consistent and continued international involvement. Only then can we curb the HIV epidemic in Zimbabwe and similar high-burden, low-income contexts.