With billions of dollars pouring in to fight Africa’s HIV/AIDS epidemic, Tanzanian AIDS counsellor Gandencia Bazil has a simple request.
“We need a bicycle,” said Bazil, who heads the AIDS committee in this village near Lake Victoria, an area where an estimated 12 percent of people are infected with HIV.
“With a bicycle we could reach more people with health messages. But we cannot afford even that,” said Bazil, as other members of her committee nodded grimly following a meeting in a makeshift shelter near the village center.
“We are not getting the support we need.”
Welamasonga’s predicament is repeated across Africa, where despite a huge jump in overseas assistance and government AIDS budgets, the cash earmarked to fight the epidemic is often not making it to the desperate people who need it most.
In Mozambique, officials say only a fraction of some 70,000 children eligible for AIDS drug treatment will get it this year because of a shortage of trained doctors and nurses.
In badly-hit South Africa, health departments report being unable to spend their AIDS budgets, while in Nigeria inefficient bureaucracy has been blamed for missed treatment targets and questionable data.
Aid agency officials agree that the surge in AIDS spending has created bottlenecks, with fragile healthcare systems, disorganised government departments and fledgling community groups often ill-prepared to absorb the money flowing in.
The scale of the AIDS crisis in Africa - where some 26 million people are infected with HIV, more than 2 million died of AIDS in 2005 and well over 12 million children have lost one or both parents to the disease - still dwarfs the assistance being made available.
Nevertheless, both governments and United Nations’ agencies, which spent years fighting to raise AIDS funding, are now battling to develop new strategies to spend it.
“We all need to begin thinking out of the box,” Peter Piot, executive director of the United Nations’ AIDS agency UNAIDS, said during a recent inspection trip to Tanzania where he was often asked why cash was not reaching grassroots groups.
“Stopping the AIDS epidemic is going to require more than just a medical approach.”
Worldwide AIDS funding has jumped from $250 million in 1995 to more than $8 billion in 2005. UNAIDS says that will have to rise to $22 billion by 2008 if the HIV/AIDS disaster is to be contained.
The money has already had a major effect in Africa, and in the past two years is largely responsible for boosting the number of people receiving life-prolonging anti-retroviral (ARV) drug medication, often for free.
But officials say that despite the progress, only about 10 percent of Africans who need the ARVs are getting them, while other services, including help for AIDS orphans, are often equally limited.
Tanzania, for example, began offering free ARVs in 2004 and ramped up delivery to cover 22,000 people by December 2005 from just 2,000 at the beginning of the year.
But with an estimated 400,000 Tanzanians needing ARVs now, and about 2 million infected with the HIV virus, the task is to expand drug delivery while developing programmes to address other issues ranging from legal help for AIDS orphans to food assistance for struggling families.
Hawa Bayona, a 50-year-old lawyer in Dar es Salaam who fell sick with HIV in 2001, is an example of the expanding challenge as Africa’s AIDS epidemic enters its third decade.
While she has enrolled in the government ARV programme - keeping her alive - Bayona says her savings have been wiped out by hospital stays. Her landlord closed her law office for overdue rent and her clients drifted away, unsure if she would live long enough to see their cases through.
“Sometimes you just wonder what the next day will bring,” the frail woman said, sitting in a Dar es Salaam health clinic.
“I get the drugs, but they don’t cover any of my other problems with this sickness. I don’t know where to get money, or where to get food. I can only hope that God will provide.”
Like many HIV-positive Tanzanians, Bayona had angry words for TACAIDS, Tanzania’s official AIDS control organization and a key link between foreign donors and local AIDS groups.
“They spend a lot of money, but we don’t see any of it,” she said. “The programme is only interested in ARVs, workshops and seminars. Officials get cars, we don’t get anything.”
TACAIDS’ information chief Fatma Mwassa conceded Tanzania was finding it was hard to spend its AIDS money, but said the problem was due to donor requirements limiting the types of expenditures and groups that can receive AIDS grants.
“We don’t have enough capacity in Tanzania,” Mwassa said. “We are trying to switch to a more holistic approach, not only medical, but it will take time.”
Piot said the disconnect between how AIDS funding is structured and basic needs like free HIV tests or bicycles for health workers was a growing concern.
“It is hard to make the machine work,” he said. “Donors say you can’t buy things like bicycles. They see that as leakage,” he said. “We see this in many, many countries. These bottlenecks are everywhere.”
Bayona, whose two brothers are also HIV-positive and who supports more than a dozen dependents, said she worried that for many Africans the bottlenecks could prove deadly.
“In Tanzania, everything is at a standstill and we are dying,” she said. “We are standing on quicksand, but it doesn’t seem anybody knows how to help.”
Revision date: June 22, 2011
Last revised: by Andrew G. Epstein, M.D.