SIERRA LEONE: Shortage of Drugs, Breakdown of Viral Load Machine Undermine Rights to Life of Persons Living with HIV
Over the years, Sierra Leone has continued to experience erratic supplies of Anti-Retroviral drugs (ARVs), HIV test kits, drugs to treat opportunistic infections, Dried Blood Spot (DBS) cards, and other crucial diagnostic tools for HIV care.
The shortage of these facilities for persons living with HIV threatens their fundamental human rights which is guaranteed by Chapter III of the 1991 Constitution Act №6, of 1991.
Executive Director of Network of HIV Positives in Sierra Leone (NETHIPS), a Network that was established to bridge the gap in the treatment of HIV positives, Dr. Idrissa Songo said that a few years earlier, Sierra Leone adopted the “test all, treat all and retain all” strategy which means all persons testing positive for HIV will be put on treatment within seven days.
He added that the Country also adopted the Three Multi-Months dispensing (3MMD) initiative which provides ARV that will last for three months to all Recipients of Care (RoC) on treatment that meet the criteria, noting that as a result of repeated stock-out, the Country had woefully reneged on the initiative which is working very well in other countries.
He explained that some countries had already gone from three months, six months, and nine months-dispensing depending on how well the person is doing on treatment.
He said that Sierra Leone started the three months in 2020, but she did not do well because of stock out of drugs.
“And in some facilities, they are giving drugs to people for two weeks, which means, instead of coming to the facility once every three months, you will come there 12 times in three months,” he said. “And in some cases, people are not getting their drugs.”
He explained that people who are stable on treatment are qualified for the 3MMD, stating that to be stable on treatment means that a person must have been going for their treatment and must have shown improvements on it.
Dr. Songo said that the 3MMD is very helpful for persons living with HIV and also for service providers because it will reduce the number of people accessing the health facilities on a regular basis.
He attributed the stock out to mismanagement, delay in clearing the drugs at Queen Elizabeth II Quay, and taking informed management decisions, among others.
He added that whilst some facilities are having stock out repeatedly, other drugs are expiring within the same period in other facilities.
“I consider this as mismanagement because if you say you don’t have drugs at a given facility and for the same period you have drugs expiring at other facilities, it means you are not able to manage your stock well,” he emphasized. He pointed out that some facilities go without drugs and for those facilities that had been overstocked, they are the ones that have expiring drugs.
The Director General of the National AIDS Secretariat (NAS), Abdul Rahman Chernoh Sessay acknowledged that the HIV program had a challenge, explaining that the challenge is not like a shortage of drugs, but the problem is about pulling/clearing the drugs from the Port.
“The drugs are already in the country, but there have been delays on the part of the people who are responsible for clearing the drugs from the Quay to the Warehouse. And the Integrated Health Project Management Unit within the Ministry of Health is responsible for the clearing of the drugs from the Quay,” the Director General explained. “So, we get drugs at the Quay whilst the facilities are being starved. I will say that there are stock-out issues.”
He explained that the drugs are brought under the Global Fund program.
He pointed out that the drugs are duty-free, but when they go into demurrage, they accrue charges and the demurrage payment does not go to the Government of Sierra Leone but to the shipping agency.
HUMAN RIGHTS
Dr. Songo said that on a larger scale, people are enjoying their fundamental human rights because there is an enabling environment to implement HIV services and programmes, but the Country is still battling with stigmatization.
“As I speak, we have eight cases in court where people have been stigmatized because of living with HIV. And the National HIV Commission Act of 2011 clearly says that nobody not even a medical doctor has the right to disclose the status of a person living with HIV to anyone,” he said. “If you do that, it is a violation of the human rights of that person and the penalty here is Le 20 million or five imprisonment of both.”
He said that close to 60% of Global Funds donation is committed to HIV treatment. So, they shouldn’t be struggling for drugs when there are resources.
“My biggest concern is not for the Western Area to have drugs. It is not about Bo to have drugs, but every facility in this country to have adequate HIV drugs irrespective of where it is,” he said.
The Director General of the National AIDS Secretariat (NAS), Abdul Rahman Chernoh Sessay said that currently, the prevalent rate of HIV according to the 2013 Demographic Health Survey conducted by Statistics Sierra Leone is 1.7%.
He said there are about 76,000 Sierra Leoneans living with HIV, close to 60,000 are taking treatment, and added that the treatment is really effective.
“We have people that have been taking treatment for over 25 years now, and these people have gotten viral suppression. That is, they are unable to transmit because the virus is no longer detective when they do their viral load test,” he said. “That does not mean that they are cured, but means the treatment is working for them.”
THE HIV RESPONSE IS FAILING OUR CHILDREN
The Director General disclosed that the artificial shortage of drugs will affect children living with HIV, disclosing that in the HIV response, children have been left behind.
“So, we are really trying to ensure that we bring them along because when you look at the number of children infected and compare it with the number that are on treatment, I think we are not doing well,” he said. “What has been happening over the years is that we have been trying to lay emphasis on the treatment of adults leaving the children behind. But this time around, we will ensure that we bring the children along with the adult as well, that is why we have been able to bring out the Elimination of Mother to Child Transmission (EMTCT) strategy.
DG Sessay “We are also focusing on pediatric care, especially for the Early Infant Diagnosis (EID),” he added, noting that they are areas that the Country had not been doing well, so they at the HIV Secretariat are really trying to push it and UNICEF has really supported their drive.
The Executive Director of NETHIPS stated that if children living with HIV are not found, put on antiretroviral treatment, and given the care they need, they cannot live long, or have healthy lives, noting that they therefore need as a matter of moral responsibility, to strengthen the strategy to eliminate Mother-to-Child-Transmission of HIV.
He explained that Early Infant Diagnosis (EID) using Point-of-Care (PoC) machines makes it easy to test infants for HIV and the machines can improve health outcomes for children if parents and caregivers take their children to get tested.
“However there have been serious challenges with our EID and EMTCT interventions,” he emphasized. “It is unethical to give birth to an HIV-positive child at this time when treatment is not available.”
He noted that it is very sad and frustrating to note that in the majority of the facilities, there is no Nevirapene syrup to give to the child within seventy-two hours after birth. There are no DBS kits for EID services and no paediatric formulations in most health facilities. THIS MUST STOP!
He said that the global goal is to end HIV by 2023. “Meaning, we want to ensure that we achieve the 95, 95, 95 targets. The first 95 means that 95% of all Sierra Leoneans living with HIV know their status, and for all those that are HIV positive, 95% of them will be put on treatment. And those who are on treatment, 95% of them will have viral suppression which means they are unable to transmit.
So, if we are able to achieve that, it means that we have ended AIDS because that is the criteria.
Mr. Sessay acknowledged that the Viral Load Machine had broken down and they [Ministry] had placed an order, but he doubted if it had arrived, noting that they were also trying to go into agreement with the private sector to bring the machine including all the reagent and kits and this person will just do the test and they [the HIV Programme and not the recipient of care] will pay for it from the monies available to buy reagents and test kits.
“We don’t want to rely on one mechanism now. We want to rely on several mechanisms to see how we can actually push.”
He confirmed that Sierra Leone faces the challenge of drugs expiring as a result of not clearing it at the quay. “When we are normally placing an order, they will do some quantifications, meaning, from this particular period to that, this is the quantum of drugs that we need and if it reaches the period and we have a stock out issue that takes long, the recipient of care will miss their dosage and they will double dose because it is a daily medication,” he stated.
“If it takes you three months and you clear the drugs from the quay, it means that three months load is already there and you cannot force the recipient of care. When once you missed out, you have missed out for that day and because of that, you do expect expiring,” he said, pointing out that the shelf life of the drugs is not that long, that is, two years and maximum three years.
He disclosed that the delay affects the shelf life of the drugs.
Weakness of the National AIDS Commission Act 2011
Mr. Sessay said that the act needs to be repealed because there are a lot of weaknesses in it, noting that their collaboration with the Judiciary will enhance the enforcement of the Act and a possible repeal.
He said that the issue relating to stigma and discrimination is weak within the act, noting that there are lot of stigma surrounding the fight against HIV.
He said that when people know that someone has HIV, even though he or she goes for his or her treatment, they will still stigmatize him or her thereby making it challenging for people to continue their treatment.
He said that engagement with the judiciary will be timely as it will help minimize stigma. He called for the establishment of an equity court in Sierra Leone and judges assigned to handle cases of discrimination.
“Next year [2024], we will try to engage with Parliament because, for me, my focus is going to be on breaking the human rights barriers as they are inimical to the HIV response in the country,” he said.
“Once we have engaged with Parliament, is like the Arms of government have become united to address HIV/AIDS so that things will move quickly.”
He added that HIV is not only a health issue, but a multi-sectoral one that resonates beyond the Health Ministry.
He explained that there is a biomedical aspect of it that sits within the Ministry of Health but added that the Ministry of Health doesn’t have the capacity to lead on the preventive aspect. He added that even the Ministry of Labour had a role to play by coming up with workplace policies to address stigma and discrimination in the workplace.
Addressing a two-day consultative dialogue with the theme: “Promoting Social Justice and Equal Rights in the Context of HIV and AIDS in Sierra Leone,” Sierra Leone’s Chief Justice, His Lordship Justice Desmond Babatunde Edwards condemned all forms of discrimination against persons living with HIV and assured that their rights will be protected in line with the Sierra Leone Constitution.
He said that the National AIDS Commission Act of 2011 guarantees the rights of all people in the country to HIV prevention and treatment services for persons living with or affected by HIV, adding that their rights to voluntary HIV testing, confidentiality and privacy, and protection from all forms of discrimination at home, school, the workplace and community at large.
He pointed out that the AIDS epidemic has raised new and complex legal and human rights challenges, leading to judicial rulings on matters related to HIV that have become part of the jurisdiction of many countries.
“There is however a big problem as stigma and discrimination continue to reverse progress made by Sierra Leone in particular to achieving epidemic control,” the Chief Justice added.
Breaking the human rights barriers
The Director General said that breaking the human rights barriers requires stakeholders’ engagement.
“Relating to drugs is the supply chain, we need to look at the supply chain because there may be issues along the chain and if you don’t address those issues it means the problem will continue,” he said. “Among the supply chain, we need to bring all the players together to discuss on how the chain will be strengthening for stock-out issues so that there will be no breakage along the chain.”
“We have the pharmacist, procurement people that place the order, we have NMSA which is responsible for the distribution, and other players that ensure that HIV drugs reach the last village. You need to visit all these people together to discuss frank discussion so that everyone will bring out the challenge that he or she is facing within his own domain to see how these challenges will be integrated and addressed as one rather than doing it when individual issues occur like the drugs getting stock at the port and you go and clear it.”
He said that they will keep talking to the recipient of care, but admitted that it is sometimes painful on their part.
He disclosed that their engagement with the Judiciary of Sierra Leone is a step in addressing some of the human rights barriers.
Dr. Songo emphasized that stock out, discrimination, access to healthcare, and lack of viral load machines are among the human rights barriers.
“If your access to health is denied, which will eventually lead to deaths, then it means, somebody somewhere is denying you your rights to live,” he said. So, among the human rights barriers, we can talk about uninterrupted access to healthcare because if access to healthcare is limited then it is a violation of human rights.”
“We are tired of this preventable crisis. It’s time for the government through the Ministry of Health to guarantee that stockouts will be a thing of the past. In this regard, we make the following demands:
We call on His Excellency the President to institutionalize a government waiver on all medicines and medical equipment donated freely to the Country, with a strict ultimatum for these medical containers to be cleared within two weeks of arrival at the ports. Greater automation at the ports and holding relevant officers accountable is an urgent imperative.
We call on the Ministry of Health through the National AIDS Control Programme (NACP), National Medical Supply Agency (NMSA), District Health Management Team, and other relevant government institutions in charge of the affected health facilities to urgently ensure that RoCs have uninterrupted access to their drugs.
He pleads with the government to find a workable solution for the clearing of medical equipment from the quay within two weeks.
The ministry should always make HIV drugs and equipment available and when this is done, we will join the rest of the world and celebrate the end of HIV by 2023.”
By Stephen V. Lansana