Posts Tagged ‘Peter Mugyenyi’

Asia Russell, director of international policy for Health GAP, is currently in Uganda gathering first-hand accounts of the unfolding crisis in access to HIV treatment caused by stagnant funding for global AIDS programs, program realignment, the worldwide recession, and other problems. What follows is a sampling of what she has found so far, from a quick round of visits with implementers around Kampala. This information reinforces what Dr. Peter Mugyenyi, director of Uganda’s Joint Clinical Research Center, told US policymakers in a visit to Washington, D.C., last month.

 The Joint Clinical Research Centre (JCRC)

The experience has been that the ARV treatment program is being precipitiously transitioned to the Ministry of Health, which currently does not have the capacity to take it on.  Recently, JCRC referred 23 patients to government hospitals, but there was no treatment there. In some cases, some government treatment centers are providing week-to-week supplies of medicines to patients.  Reportedly, some clinics are reverting to use of d4T as well. Other clinic reports indicate that the sub optimal regimen of a single dose of nevirapine is still used for prevention of mother to child transmission—in order to keep costs down.

Before Dr. Mugyenyi’s recent testimony before Congress, OGAC indicated it would open up perhaps a few treatment slots for JCRC. But only on condition that the PEPFAR procurement partnership be used (the Partnership for Procurement and Supply Chain Management). Previously JCRC successfully procured and distributed drug supplies and had the flexibility to adjust treatment to the safest and most cost effective treatment according to advances in drug development.


Mildmay is definitely facing the current cutbacks as a crisis. The providers there are not recruiting new patients on treatment. They do not know the precise size of the waiting list, but they have moved from enrolling 260 patients on ARVs per month to about 25 to 30—enough to accommodate slots opening up due to patients currently on treatment who are transferred out, die, default, or are lost to follow up. Mildmay staff report that women and children will suffer the most as a result of these restrictions, because they are least able to afford to pay out of pocket for treatment.

There have been massive efforts to gain efficiencies through budget cuts, including grounding half of the vehicle fleet, cutting back on follow up to remotely located patients, not raising the salaries of staff for two years despite inflation–everything that is not an essential lifesaving intervention. 

At its main site, Mildmay used to do testing four out of five weekdays, regularly testing about 80 people per day, with about 25-30% of patients testing positive. Now they have reduced testing days to two per day, testing no more than 60 people. This has been the case for the last 5 months. Turning away people from testing will have a huge effect on prevention—and then there is nothing to give patients when they test positive. 

There is no way for the government health system to absorb these patients—perhaps slowly over time, but right now the capacity is not there—neither the health workers, nor the medicines, nor the motivation and training. 

Kiswa Health Center

Kiswa Health Center is very busy public facility serving the Kiswa neighborhood of Kampala. It is a Health Center III (HC III), meaning it provides basic preventive and curative care, although Kiswa is also providing ARV treatment through their HIV clinic four days per week. They have extremely limited staffing, with one doctor and one to two clinical officers, as is the case with other HC IIIs.

The major problems facing the facility include: lack of regular supplies of medicines and insufficient, poorly motivated, and/or absent health workers. The National Medical Stores (NMS—the medicines supplier for public sector facilities) cannot be depended upon to provide medicines in a timely fashion, despite correct and timely requests by facilities.

Several NGOs have been collaborating with Kiswa Health Center to provide HIV treatment and prevention and a range of other HIV services, including on-site HIV testing and counseling, ARV treatment, disease management, et cetera. According to health center staff, these PEPFAR NGOs have discontinued their services as of March 31. (There is a possibility there will be an extension until September, but this is unclear.)

This withdrawal has had a grave impact—the NGOs provided additional professional and non-professional health workers, essential medicines, reagents, and other crucial supplies and staff that were unavailable at Kiswa. These resources have now disappeared. At the same time, patients on waiting lists at other clinics, such as JCRC, are now coming to Kiswa to seek enrollment. These patients are being turned away. In addition, the public sector staff are now facing much higher workloads due to the discontinuation of services NGOs

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This Boston Globe story documents, for the first time, how U.S. government officials have told some PEPFAR-funded clinics to stop enrolling new HIV patients on lifesaving treatment.

“People are struggling to find resources to honor the commitments we have made,’’ Ambassador Eric Goosby, US global AIDS coordinator, told the Globe. “We’re not at a cap point yet. If it gets worse, we’ll have another discussion.’’

The story is a must-read for those concerned about the future of PEPFAR and the US commitment to fighting global AIDS. The paper reports that the decision “was prompted by tighter budgets as well as a debate over how limited global health care dollars can be spent most effectively, has sparked fears among AIDS advocates that the Obama administration is curtailing its commitment to a program that provides lifesaving drugs for 2.4 million people and that many view as President Bush’s most successful foreign policy legacy.” Click here for the full article.

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Dr. Mark Dybul, the former U.S. Global Coordinator for AIDS and the first director of PEPFAR, took note of our recent post outlining concerns about the Obama Administration’s new focus on health system strengthening. He weighed in with this very interesting post, saying that flat-funding AIDS treatment in Africa will harm overall medical services.

Dybul’s blog came in response to this item we posted last week outlining Dr.  Peter Mugyenyi’s fears about a pivot away from AIDS.

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The most griping message from Dr. Peter Mugyenyi this week was, of course, his stories about HIV patients in desperate need of treatment being turned away, including pregnant and breastfeeding women who risked passing the deadly virus on to their babies. As director of Uganda’s Joint Clinical Research Center, the largest PEPFAR implementer in East Africa, Dr. Mugyenyi painted a heart-wrenching image of patients who had been promised treatment going from one clinic to another, only to be told there would be no open slots until a currently enrolled patient died.

But another vital perspective that got less attention in Dr. Mugyenyi’s meetings this week with members of Congress, the Executive Branch, and the press, was that the idea of health systems strengthening—at least as its being conceived in Washington today—may actually undermine, rather than bolster, the gains made in fighting AIDS.

Why? Dr. Mugyenyi says we must go back to the 1990s in Africa, before the historic roll out of antiretroviral treatment in the developing world, when HIV was a death sentence.

“In the 1990s, you just couldn’t strengthen health systems because they were clogged … Clogged with AIDS patients,” he said. He recalled serving as the head of a children’s ward in one of Uganda’s main hospitals and he said the entire ward was filled with sick, dying children. When they tested for HIV, 100 percent of the children were found to be positive. 

“If you went to the surgical ward, it was the same. If you went to the medical ward, it was the same,” he said. “What happened to the other diseases? Had they gone into recession? Of course not.” They had simply been displaced by the mayhem and crisis created by AIDS.  

Dr. Mugyenyi and others meet with Rep. McDermott

Today, when he goes to a medical ward in a hospital, patients with those other diseases are there, being successful treated and cured, because the AIDS patients are no longer filling all the beds.

Any effort to strengthen health systems, Dr. Mugyenyi said, “must be focused to the realities on the ground.” Those realities include AIDS being a continuing, consuming crisis that the world cannot afford to turn away from. An effort to strengthen health systems is welcome, he said, but not if it takes away from the focus on combating AIDS.

Dr. Mugyenyi was in Washington this past week for a series of meetings with policymakers, advocates, and the press, in a trip organized by the Center for Global Health Policy and several other groups. This is part of the Global Center’s efforts to make the voices of developing country physicians heard in American policy debates.

Click here to see a video interview with Dr. Mugyenyi or here to read a VOA story highlighting his concerns. This Huffington Post blog also takes a wider view of the messages Dr. Mugyenyi brought to Washington this week.

Dr. Mugyenyi meets with Rep. Henry Waxman on Capitol Hill

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Just as HIV experts are beginning to see new hope in beating the AIDS epidemic, a funding crisis threatens to throw us back a decade or more in the effort to combat this deadly virus. Dr. Peter Mugyenyi and other HIV experts delivered this forceful message to U.S. lawmakers today at a hearing before the House Foreign Affairs Subcommittee on Africa and Global Health.

Dr. Mugyenyi, director of Uganda’s Joint Clinical Research Center, was one of several witnesses who urged Congress to keep its promise on global AIDS by fully funding PEPFAR, instead of approving the near flat budget proposed by the White House for FY 2011.

Dr. Peter Mugyenyi testifies before a House Foreign Affairs subcommittee

Dr. Mugyenyi said that already, last year’s flat-funding has rippled across his home country of Uganda, forcing him and other health care providers to turn away sick patients who were promised treatment. Dr. Mugyenyi described having to turn away as many as 15 to 20 patients a day, including pregnant and breastfeeding women.

“Recently, an HIV-infected woman who was breastfeeding her HIV-negative child because she could not afford formula milk came to our clinic, having been turned away from three other clinics in Kampala because they had no slots. She knew that every day she breast fed her baby without being on treatment greatly increased the chances of her child getting infected, but she had no alternative,” he said.

The situation, he said, jeopardizes the incredible gains PEPFAR has achieved in its first five years. “PEPFAR has saved millions of lives in Africa,” he said. “These people—and their mothers, husbands, wives and children—got a chance to live” because of PEPFAR. The program has “helped ease the carnage that I and my fellow health care providers used to witness on a daily basis.”

Dr. Mugyenyi pointed to recent studies showing that treatment with antiretroviral drugs can also help prevent new infections. Research released at CROI last month documented a 90 percent reduction in HIV transmission among so-called “discordant couples,” in which one partner is HIV-infected and the other is not.

“This gives credence to recent modeling by the World Health Organization that shows some of the first good news on prevention in several years: that we could truly end the AIDS crisis within a generation,” he said. “However, a funding crisis threatens to reverse these highly positive changes and we could miss the opportunity to defeat the epidemic.”

Rep. Donald Payne, D-N.Y., chairman of the subcommittee, said he was “deeply concerned about the reports that the fight against HIV/AIDS is faltering and that continued rapid roll out of AIDS treatment is endangered in Africa. We must make sure we don’t start a decline.”

The panelists and lawmakers alike commended President Obama’s proposed Global Health Initiative, with its call to spend $63 billion over six years and its promise of an integrated approach to foreign health assistance. But experts testified that the GHI would only work if it was adequately funded

And so far, said Joanne Carter, executive director of the RESULTS Educational Fund, there’s a gap between rhetoric and reality on US global health funding. The White House’s budget request for FY 2011 “essentially flat funds our global AIDS programs,” she said, noting it’s more than $2 billion short of what was promised in the Lantos-Hyde Act that reauthorized PEPFAR.

The White House budget also calls for a $50 million cut to the US contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. And she noted that the GHI’s treatment targets for TB were significantly lower than mandated in Lantos-Hyde.

PEPFAR has been “nothing short of transformative,” Carter said. “We’ve made remarkable progress, and we can’t stop now.” (more…)

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This week, Dr. Peter Mugyenyi is visiting Washington from Uganda, where he directs the Joint Clinical Research Center, the largest PEPFAR implementer in East Africa. Dr. Mugyenyi was one of a half-dozen people in the room when PEPFAR was conceived back in 2003. As one of the program’s most eloquent supporters, Dr. Mugyenyi has recently begun voicing grave concern about the near flat-funding of PEPFAR’s budget. In this video interview, he talks about the on-the-ground consequences of a pullback from the fight against global AIDS. Dr. Mugyenyi will be testifying about this issue on Thursday at a hearing before a House Foreign Affairs subcommittee.

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