The Implementation – Searchers in the field

Officially, the HAART project started 2004, as it was believed that the drugs would be available by that time. However, efforts to find funds, to coordinate with other programs and to clear up hurdles to the importation of the cd4 machine as well as the beginnings of intimations of the upcoming management and financial scandals within the hospital’s leadership - led to delays in the whole project’s timeframe –such that the Care and Treatment Clinic (CTC) could only open its doors in December 2005.
Almost immediately, two key aspects of the project diverged from the planners’ written approach:
Firstly, the training of stakeholders was largely boycotted by BLH and the diocese, as from the beginning no additional allowance was paid for training during working hours . The increasingly intense lack of cooperation from the hospital’s secretive management impaired many of the program’s pillars. With the BLH and SCD it was always unclear exactly who was responsible for decision-making. Community stakeholder training therefore could not be organized in the proposed way.
Nevertheless, the staff working with the CTC - who went on serving with their usual hospital duties as an additional burden - took part enthusiastically in the in-house training that was part of the implementation of the project. They were not expecting additional payments. The patients and their supporters (“msaidizi wa karibu”) tremendously increased treatment literacy during adherence sessions that preceded antiretroviral treatment. These sessions were increasingly done voluntarily by members of the self-help HIV patient group PIUMA. Voluntarism covered gaps that were created by the lack of cooperation by the SCD/ELCT.
Secondly, and more positively, the Involvement of PLWHA was much easier to implement and contributed much more to the patient’s uptake, adherence and well-being than had previously been thought possible; the sick and suffering Have Nots proved that they could really contribute to their own health care. Very often, they put to shame the stigmatizing and greedy health staff and church employees who, as part of the local Elites, were mainly interested in the HAART program as a way to access funds and allowances rather than as a way to solve a health catastrophe.
PLWHA volunteered to be interviewed for a locally produced HIV awareness video and carried out many public speeches and village outreach events whereby they sensitized about 2,000 people in an organized way, distributing condoms and advertising the CTC. As a result, PIUMA was funded as a self-help group by the patients and their supporters with very little financial input. The patients proved that treatment is a political act in the best sense of the word – done properly, a treatment program can empower the Have Nots. PLWHA learned that HIV/AIDS is not a death sentence or a punishment from God.


The team – no success without the Patient

All medical staffs were trained following the regulations of the National AIDS Control Program/MoH and until the lock-out took place, the clinic was running accordingly and effectively.
Staff members were initially paid following the national payroll in order to ensure an unproblematic take over by the government and the church at the end of the start-up period, but as additional duties were taken on by staff and evidence mounted that a lot of money was being stolen out of the hospital funds with a direct impact on the motivation of staff members, top ups began to be paid.
This decision was made in light of the fact that with careful use of the hospital’s income, a small increment in the salaries of all the employees would have be possible without any difficulty. (Unfortunately, the Do-gooders keep the system subsidized even though local Elites are stealing, and the people remain calm because minimal services are still provided).
The staff working and paid by the program but serving the needs of the entire hospital were:
• Two nurses
• One to two Medical Doctors (expatriates)
• Two clinical officers
• One Laboratory technician
• One Orthopedic Technician (combined outreach HIV/AIDS – orthopedic cases)
• One secretary (mainly paid by MSF)
• Two social workers
• One assistant coordinator
• One expatriate volunteer treasurer
• 2 – 7 part time VCT counselors
• One HIV positive volunteer from Austria as peer group educator
• Several volunteers from overseas
Médecins sans Frontières/Spain helped the project by doing the stock keeping of drugs donated to treat opportunistic infections and helped with clinicians during temporary shortages of staff. The cooperation was good and inspiring for the CTC Team.
The most important staff partners, however, turned out to be the sick Have Nots treated at the Clinic . We rapidly came to the conclusion that it will not be possible to overcome the human resource problem in the battle against HIV if the patients and PLWHA groups are not providing their manpower and precious skills and experiences.



Treatment as Preventive Meassure

Due to the de-stigmatising power of antiretroviral treatment (which turns AIDS from a death sentence into a chronic disease) and due to the subsequent advocacy of patients and relatives, VCT rates in the area served by our project increased tremendously by a factor of 10 compared to preceding years at the BLH.
From December 2004 to December 2006 more than 2000 clients were provided with VCT at the site of the Care and Treatment Clinic!
Additionally, through voluntarily PIUMA outreaches, 458 people in 15 villages were tested in late 2006, even after the programme was locked out
Up to 10 counsellors were partly paid by the program and it turned out that this duty was very much prized and thoroughly performed by the hospital’s staff. Extensive discussions about HIV/AIDS and went on within the staff. High status for the VCT and adherence counsellors could be achieved by being helpful to PLWHA.
From the very beginning the programs strived to provide strict confidentiality.

During farming seasons VCT rates went down!

After the violent lock out of the CTC staff and the members of the self-help group PIUMA, the trust of the community in the hospital VCT went down and interest in VCT only returned when village outreaches were organised by PIUMA.