Date: 10/24/2022
There is no rapid diagnostic test, no CD4 count and no HIV medicines to provide in Ayder Comprhensive Specialized Hospital
Ayder Comprehensive Specialized Hospital (ACSH) is the largest hospital in Tigray. It used to be the only hospital in the region that provides a comprehensive tertiary care. But now due to the ongoing war and siege that lasted for almost two years, the hospital is almost in the verge of collapse. ART clinic is one of the outpatient clinics that runs under the department of Internal Medicine and pediatrics. The main services given in this unit were providing care and ART drugs, determining CD4 count and Viral load to HIV patients, and voluntary counseling and testing(VCT) for both adults and pediatrics. But since war broke out in Tigray, HIV care delivery has been severely compromised. Since the war, followed by seige, erupted in November 2020 there are a total of 1246 adult and 69 pediatric HIV patients on follow up in the ART clinic but from this, 488 are drop outs and among them 17 are children, and 92 are lost to follow-up. From this significant number could be dead,as there is no way to know what happened to this huge number of drop outs and lost to follow ups because of a total communication blackout in the region.
The main reasons stated for the above statements are; unavailability of ART drugs, lack of transportation, communication blackouts and expired medications. Because of the lack of ART drugs , Clinicians are strained and forced to switch regimens of their patients to the available ART drugs regardless of their previous exposure because of lack of options to continue their patient’s life than seeing them die. Here in Tigray for health professionals, it is a leisure to follow guideline based practice. For example;
1) near to 900 HIV patients were on TDF+3TC+DTG based regimen ,according to the WHO and National HIV guideline. But since August/2022 due to the absence of this regimen all of them have stopped using this regimen.
2) Near to 154 patients were taking second line (TDF+3TC+ATV/r), but for the last two months, TDF+3Tc has not been available and we could not give them a single drug because it is dangerous to put HIV patients on mono-therapy. Remember, there are pregnant mothers who interrupted ART medication and the chance of having HIV infected baby will definitely be high. What is more on HIV treatment is, to give Tuberculosis prophylaxis for eligible ones, but for the last two years, this practice is cut because there is no Isoniazid (INH).
In our hospital, CD4 machine has not been functional for almost two years. Viral load determination has not been done for a year. This is not only in Ayder but also in the whole region so none of the patients have had viral load monitoring for a year long. VCT service has been cut since 7 months, so currently there is no HIV screening and testing for those who presented with clinically suspected HIV infection. Now in Tigray there is no way to confirm or diagnose HIV infection, and the care of HIV exposed infants is unthinkable. This is the most tragic health crisis Tigray is facing in the twenty first century. Before the war, nutritional supplementations were being given to all pediatric HIV and malnourished adult patients but none is available for two years.
Here below are the actual patient profiles that testify the above statement: tip of the iceberg
- Case-1: a 26 years old male patient admitted to medical ward after he presented with the diagnosis of extensive right lung abscess. At presentation he was wasted and has risky behavior for contracting HIV/AIDS like chewing chat, drinking alcohol and cigarette smoking. So the treating physician sent for HIV test and the first KHB test was positive, but the subsequent two tests were not available and to make things more complicated CD4 determination and antiretroviral drugs were not available in hospital and in the entire region as well. Finally after he completed treatment for lung abscess, he was discharged home with appointment. Let’s say, a miracle happens for a means to do confirmatory HIV tests and ART medications, there is no way to trace back this patient as there is no any mode of communication. The other catastrophe that may happen is; since this patient went back home he may transmit the virus to others. This is just one example, there are many more similar case scenarios happening every day in Tigray.
In conclusion, this case shows us, for a newly HIV infected people there is no rapid diagnostic test, no CD4 count and no ART to provide.
- A 13 years old female client from Mekelle who was on follow up at the ART clinic in Ayder for the last six years. Two years back her regimen was shifted to TLD (TDF+3TC+DTG) based on medical indications, which was standard. She was adherent, was being supplemented with plumpynut. For the last one year there was no plumpy nut supplementation, viral load and CD4+ determination and her follow up was only clinical follow up which is likely to compromise the care, drug adherence and drug side effect. During her visit in this month, she was adherent and there was some clinical deterioration (developed stage T2 defining disease of HIV and moderate malnutrition). Unfortunately, we can’t prescribe her the treatment (ART) that is TDF+3TC+DTG, since the hospital has stockout of the ART drugs, we looked for other options, like TLE(TDF+3TC+EFV) and 2nd line options but only Kaletra (ATV/LPV) was present. We searched at all health facilities in Mekelle, but was not available. Now she has not been on any ART drugs for the last one month. This case scenario is the tip of the iceberg among our clients at the ART clinic at Ayder hospital in particular and Tigray health facilities in general. Therefore, this scenario will further lead to disease progression, drug resistance possibly subsequent loss of lives if action is not taken urgently.
Therefore; health professionals here are struggling to continue medical service while hospitals run out of medication. This days,we clinicians are hopeless and helpless because our daily routine activity is seeing our patient's suffering as we are barehanded to do something.
ART drugs used to be available for free to the whole country, Ethiopia, But Tigray is completely denied. In other conflict affected countries, there is no report of deliberate hindrance of access to ART medications. This is an insult in the era of modern medicine where humanity is practiced at its best level. Our appeal to the international community especially to the medical world is to put pressure on the Ethiopian government and its allies to allow unfettered access for medications and medical supplies.
Doctors of Ayder Comprehensive Specialized Hospital