Cheap ARV drugs are aplenty in Ethiopia, but only the wealthy can afford them. They are not available in public hospitals and clinics – the government blames poor infrastructure but others blame the government.
When 29-year-old Nefissa Ibrahim, an AIDS patient, grew desperate about her condition a year ago she turned to a local witch-doctor who claimed he had a cure.
She had little choice – although anti-retroviral (ARV) drugs that can make AIDS a manageable condition are available in Ethiopia on the open market, they can only be afforded by the wealthy few.
"The witch-doctor gave me a potion of green powder. I stirred it in water and drank it for a month, but the 'medicine' only made my illness worse," says Ibrahim.
The green powder that Ibrahim consumed was henna, a common hair dye.
Ibrahim, who lives in Addis Ababa with her two children aged 10 and seven years on an income of $42 a month, is one of 2.2 million Ethiopians living with HIV/AIDS – the third highest concentration in the world. A counsellor at an association of People Living With HIV/AIDS (PLWAs), she has recently succeeded in getting hold of ARV drugs through a religious charity.
Not everyone is as fortunate. More and more desperate AIDS patients are making risky attempts to prolong their lives – willing to try anything in the absence of drugs.
AIDS activists say this situation is avoidable: the Ethiopian government procured cheap Indian-made generic versions of ARVs as long ago as July 2003, but these have not been made available for free through government hospitals and clinics. Free distribution has been confined to non-governmental organisations, commercial providers and some pilot projects.
Although the government has spent more than $5 million on purchasing the generic drugs, only about 9,000 AIDS patients are currently on ARVs in Ethiopia – they are the wealthy who can afford to pay the market price of ARVs.
Branded ARVs on the open market cost between $840 and $1440 per month, as compared to the generic versions, which cost between $29 and $84.
"We are in desperate need of ARV treatment and we want the government to make it accessible to all. Getting treatment remains a matter of wishful thinking for most of us," says Yeshiwork Mekuria, 32, a counsellor at Meiraph Ethiopia, a PLWA association.
Hailesilassie Bihone, general manager of the Drug Administration and Control Authority (DACA), says the government recognises the need to scale up ARV provision to the poor and underprivileged in rural areas. Of Ethiopia's total population of 71 million, almost 85 percent live in rural settings with an HIV/AIDS prevalence of 3.7 percent, according to the health ministry.
The generic drugs, he says, will be made available in 52 hospitals across Ethiopia – to be administered by more than 600 trained professionals to 50,000 AIDS patients within a year from October 2004. The drugs will be sold at a subsidised price of not more than $15 per month for those who can pay but will be free of charge for children, people on low incomes, health workers who have contracted AIDS through accidental exposure and rape victims as well as for prevention of mother-to-child transmission.
According to the DACA's Bihone, ARV treatment requires training for health workers; specific clinical and laboratory equipment and better systems of procurement, storage, distribution and monitoring. Leadership and management problems are also cited as causes of the delay.
Activists, unimpressed by the plethora of figures thrown at them, accuse the government of doing too little too late in the first instance – and then needlessly delaying treatment.
Joanna Mesure, a medical coordinator at Medicins Sans Frontieres in Ethiopia says that the necessary infrastructures already exist in Ethiopia to provide ARV treatment, citing a project at Humara, a small village the province of Tigray, to bolster her case.
"It is possible to start the treatment programme today, while simultaneously conducting operational research to learn the best ways of delivering care in resource poor settings. Simpler drug regiments and diagnostic methods, coupled with medical training and infrastructure investment, will be necessary to expand treatment quickly to other areas with limited resources. But we cannot wait any longer.
"Infrastructure challenges are not a valid excuse to continue denying medical treatment to those in need," she says.
Activists say both treatment and prevention are needed to combat the epidemic: people have little incentive to get tested for HIV if they know there is little possibility of treatment.
"Providing ARV is a question of life and death in Ethiopia – I do not believe that the government is doing what is expected of it in terms of saving the lives of the poor," says Mengistu Zemene, general manager of Mekdim Ethiopia, a PLWA association. "There are countries like Nigeria, Burundi and Rwanda who have worked a lot to make the drugs accessible to PLWAs who can't afford to buy ARVs."
"The Ethiopian government wants to fight the HIV/AIDS pandemic but the fight is not bitter. It is not a fight for life and death. It is the mercenary soldier's fight: gradual, curious but most cautious."
Ethiopians with AIDS, he says, are fed up with the promises – and excuses – offered by the government and its wealthy donors. Activists put it down to a lack of political will in the government to provide treatment. They say the government woke up to the seriousness of the epidemic only after some prominent Ethiopians died due to AIDS.
Dr Endalamaw Aberra, HIV/AIDS programme officer with the World Health Organization in Addis Ababa, says Ethiopia has the capacity to provide ARV treatment to over 100,000 patients – double the number the government plans to reach by October 2005. Other estimates of current capacity put the figure at 150,000 patients.
In the meantime, the delay in providing treatment is leaving Ethiopian AIDS patients increasingly frustrated.
Sisay Abebe is print Journalist and Executive Director of the Ethiopian Volunteer Media Professionals Against AIDS, a media-based NGO.