Medical Treatment before the lock-out

The medical part is easy compared to the struggle with corrupt Elites.
Our experience matches well with other programs and clinics worldwide (e.g. Haiti, Thailand). HIV/AIDS treatment turned out to be the easy part of the work and growth of patient numbers was only impaired by the immense workload of about 600 patients under care of a small team serving seven days a week. Frequently patients were waiting for care on weekends because of social problems, need of psychological support due to unexpected disease or long walking distance and bad weather.
Paul Farmer and Partners in Health , Doctors without Borders , the DREAM program of St. Egidio with their many publications, or even standard medical textbooks now can be used to study HIV/AIDS care – it is like any other aspect of developed medical care and treatment.
Bulongwa CTC followed generally accepted guidelines based on these experiences whenever possible up to the point when it was violently prevented from going on with improvements to the quantity and quality of care as result of the unwillingness and sabotage of the Elites.
The main drugs that were used were fixed dose combinations of d4T/3TC/NVP and AZT as EFZ and Cotrimoxazole, Fluconazole and Amoxicillin as TB drugs.
Our general impressions and conclusions from this start-up experience are nothing new to the world:
The adherence was very good mainly due to the “trust” in the drugs, extensive teachings and the help of the Treatment Advocates (“msaidizi wa karibu” ). It happened very occasionally that a patient did not turn up for an appointment and rarely was a dose was missed . If so, it was because of severe illness due to opportunistic infections, to the heavy rains that often visit the region or to long walking distances to the clinic. In many such cases, members of the self-help group PIUMA or patient relatives secured the delivery of drugs by walking . Very often the children of a patient’s or the patient’s neighbour’s child turned up in front of the clinic in order to collect drugs. MSF vehicles and the private car of the project coordinator were often used to follow up patients and bring them to the clinic in case they were bedridden.
The originally planned intake of patients was a bit behind schedule as availability of ARVs was delayed for a year. However, intake speeded up tremendously once that bottleneck was overcome and reached 450 registered Patients within 12 Months with 200 under antiretroviral therapy, or 4 times the originally set target for the first year!




The Treatment and Care Situation after the Lock-out


After the lock-out the acceleration of intake of new patients went down and the planned pace for increased enrolment couldn’t be sustained.
Rather the clinic turned into an “ARV distribution site” without proper laboratory monitoring and counselling or side effect monitoring. This probably is also the reason for the again raising death toll. Since the lock out 48 patients - out of about 650 under Care and Treatment and 300 under Antiretroviral Treatment – died by the end of 2006. We consider this number unnecessarily high after more than 24 months of available antiretroviral treatment.
Before the lock out, patient Cd4 counts were recorded on at least a 4 month schedule, even more frequently in cases of obvious clinical failure. Liver function testing was done in case of Nevirapine treatment side effects or any problem considered related to Hepatitis or other liver damage . These services were no longer provided after the lock-out.
The knowledge and experience about second line regimens in case of resistance or long term side effects and expected treatment problems is very poor and none of the present staff has been trained by NACP nor participated in the regular in-house training nor taken part in the daily routine of the CTC before they took over.