(By Masuzyo Chakwe and Oliver Chisenga)
THE audit report for the Global Fund grants to Zambia for 2017 has revealed that only 36 per cent of infants born to HIV positive women had received a virological test for HIV within two months of birth against a target of 53.8 per cent as at June 2016.
And rights activist McDonald Chipenzi says health minister Dr Chitalu Chilufya must resign and has called on citizens to demand accountability at the Ministry of Health. The report states that there were challenges in diagnosing HIV-exposed infants. The audit covered two principal recipients of the Global Fund grants in Zambia, namely the Ministry of Health and the Churches Health Association of Zambia (CHAZ).
The audit covered the period January 2015 to May 2017 and focused on the active grants that are currently under implementation. The auditors visited 34 health facilities, including hospitals, district health offices, Ministry of Health and CHAZ facilities, both urban and rural, across five different provinces.
The facilities visited had an estimated catchment population of over five million people (30 per cent of the country’s population) and reported 1.5 million patient consultations in 2016. They also provided antiretroviral treatment for one in five of people living with HIV on treatment in the country.
It stated that quality of services affected by limitations in prevention, testing and patient monitoring.
The report stated that Global Fund investments in Zambia had contributed to the scale-up of key interventions across the three disease programmes as mentioned. However, more focus is required to improve diagnosis, monitoring and retention of patients on treatment.
The audit noted challenges in treating and retaining on treatment multidrug-resistant TB patients which impacts clinical outcomes.
“Only 8.5 per cent of estimated multidrug-resistant TB cases in the country are reported as receiving treatment. Out of these, 62 per cent and 45 per cent in 2015 and 2016 respectively of the cohort of patients initiated on multidrug-resistant. TB treatment either died or were lost to follow up,” it stated. “Delays in mobilising funding for multidrug – resistant TB patient treatment affected the number of facilities that could initiate treatment. There were challenges in diagnosing HIV-exposed infants: Over 126,000 HIV exposed infants have been tested over the past two years, but challenges remain with timely delivery of results.”
The report stated that HIV-TB grants focused on early infant diagnosis as a key intervention to ensure children access ART and the reduction of child mortality.
“As at June 2016, only 36 per cent of infants born to HIV positive women had received a virological test for HIV within two months of birth against a target of 53.8 per cent. Seventy percent (70 per cent) of HIV – exposed infants in the 30 health facilities visited had not received their HIV test results before they were eight weeks old as required by the national guidelines. This delayed access to life – saving antiretroviral treatment to infants diagnosed as HIV positive. This was primarily caused by delays in the collection, processsing, transportation and communication of results from the laboratories.Turnaround time in the facilities visited by the OIG averaged 27.8 weeks against a one – two – week standard set for the receipt of results. These facilities also faced challenges in collecting blood samples for testing with 27 per cent of them having blood samples rejected due to their poor quality,” it stated.
The report also stated that people living with HIV are not consistently monitored to ensure efficacy of treatment regimens, detection and management of side effects.
It stated that Zambia has made progress in the implementation of viral load monitoring since it was first introduced in 2013.
“Coverage at a national level has increased from 5 per cent in 2015 to 30 per cent in 2016, although this fell short of the 2016 target of 52 per cent. In the 30 facilities visited, out of the 12,569 people initiated on antiretroviral treatment in 2016, only 26 per cent and 43 per cent of people had a viral load and CD4 count test done respectively. The failure to undertake viral load testing is attributed to problems in collecting, processing, transporting and communicating results as well as the sub – optimal use of available viral load equipment,” it stated. “The Service Availability and Readiness Assessment (SARA) Report 2015 identified that ‘ While 52 per cent of facilities stated to offer antiretroviral therapy to HIV patients, only 33 per cent (50 per cent of the 66 per cent who stated to offer ARV treatment or follow up) could perform CD4 count or viral load’. “
It stated that grant funds have been provided for the establishment of a routine system (worth US$2 million) to monitor resistance to antiretroviral medication and to manage people identified as drug resistant.
However, at the time of the audit (six months before grant closure), this system was yet to be established.
There were also challenges in infection control and prevention of TB transmission among people living with HIV: National guidelines recommend Isoniazid Preventive Therapy (IPT) for people living with HIV on antiretroviral treatment and who are TB – negative.
However, the implementation of this guidance has been impacted by the limited availability of medicines and the reluctance by clinicians to implement.
“Only 15 per cent and between 23 – 25 per cent of people with HIV received IPT in 2015 and 2016 respectively. Only 28 per cent of the 30 facilities visited had provided IPT in May 2017. Contrary to the National TB Program infection control guidelines in place, the audit also identified gaps in infection control at facility level. For example, 37 per cent of the facilities visited did not have a designated isolated area where patients can produce sputum specimens for TB diagnosis,” it stated. “Furthermore, 87 per cent of the facilities visited did not have masks in stock. These gaps in the provision of IPT could create an environment conducive to the spread of TB in health facilities among patients, health workers and the general community. The underlying causes of the service delivery issues noted above include the following: (i) Gaps in diagnostic capacity:
The effectiveness of the country’s diagnostic services have been affected by either the limited availability of machines or non – functional machines. Viral load equipment is operating at a rate of between 66 per cent – 81 per cent due to frequent and prolonged breakdowns (sometimes up to 12 days).”
It stated that backlogs of samples for testing were estimated at 17,900 in 2015.
“Available data also showed that the utilisation of the 59 GeneXpert machines in 2015 stood at 22.5 per cent. This is due to GeneXpert machines not having been identified as the primary diagnostic method for TB cases. The Service Availability and Readiness Assessment (SARA) Report 2015 identified approximately five per cent of health facilities in Zambia reported using the GeneXpert MTB/RIF to diagnose TB, with four per cent of them diagnosing TB by culture. The protocol has subsequently been revised to address this which should increase the use rates of the machines. Another reason noted by the OIG was the shortage in GeneXpert cartridges and the lack of real time monitoring of the use of existing machines. Funding to establish GXalert, a mechanism to receive orders for diagnosis which automatically sends results, is available but is yet to be used,” the audit stated.
The report also noted the low health worker density: Human resource capacity stands at 30 percent of what is required for effective service delivery.
“Community health workers are expected to help fill gaps in the staff component. Up to 77 per cent of facilities are linked to community health workers who provide HIV testing services. However a reduction in current grant funding resulted in an estimated drop from 10,000 in 2014 to an estimated 2,000 at the end of 2016. This impacted the availability of adherence support workers who were responsible for encouraging patients on antiretroviral medicine and multidrug – resistant TB to remain on treatment,” it stated.
“A key challenge also includes the current diagnostic policy and algorithms not being sensitive enough to identify all cases and forms of TB. In addition to this, non – compliance with guidelines has been primarily due to gaps in proficiency testing, training and supervision of service providers. For example, grant funds for training and supervision of HIV testing services were reallocated to supervise door – to – door counselling in ten districts. As a result, only 34 out of the 229 (15 per cent) service providers certified to conduct HIV testing actually participated in proficiency testing, which has implications for the reliability of test results.”
It stated that other areas where staff had not received training (in the 30 facilities visited) included rapid diagnostic test use; malaria case management; identifying and reporting adverse drug reactions; screening children for TB using different methods; and TB – related infection control.
It stated that supervision arrangements were also suboptimal in strengthening staff skills since they were not consistently undertaken and feedback rarely provided to facilities.
And in a statement on his Facebook page, Chipenzi stated that what the recent report had revealed in terms of abuse of the Global Fund was clear display of lack of morality in Zambia’s leaders and a lack of social shame.
The report indicates that in some health facilities, malaria drugs were out of stock for up to three months while ARVs had also been out of stock for almost a month.
The report further showed that TB drugs were out of stock for up to nine months in one facility and 74 days in five facilities. There was also a stocking of expired HIV drugs worth US$4m in 2016, TB drugs valued at US$0.11m in 2016 and another of the same value at risk in 2017.
“Let us demand accountability at the Ministry of Health. Dr Chitalu Chilufya must resign. What the report on Global Fund has revealed in terms of abuse of the global fund is clear display of lack of morality in our leaders and lack of social shame among them, because by now, heads would have rolled. Dr Chilufya Chitalu would have resigned,” stated Chipenzi.
“But as per norm in Zambia, in the face of this, Dr Chilufya was proudly talking about wellness of the nation during the launch of health week…what a mockery. Dr Chilufya Chitalu must come out clean on this matter and must not gloss over this very devastating report on his ministry. Ministry of National Guidance and Religious Affairs, if at all she believes in morality without a national moral code, must tell Dr Chilufya to resign immediately.”