Asha Fadhili, 45, was already struggling with how to shake off stigma associated with HIV/Aids before the acute shortage of Septrin hit hard across the country from early April this year.

The shortage of Septrin—a  vital antibiotic for People Living with HIV/Aids (PLWHA) with low CD4 count— in major facilities across the country has forced many patients to access it out of pocket, consequently causing anxiety and fear among PLWHA, especially among young people. 

Fadhili currently lives in Bungoma county with her three daughters and son. She has no permanent job and relies on support from relatives to make ends meet.

Before Covid-19 struck, she used to access medication at Lugari District Hospital, several kilometres from Bungoma town for fear of stigma and victimisation.

Many others in the county go as far as Kisumu, Eldoret, Busia and Malaba to get their medications. She has been on Septrin since early 2011. 

Cotrimoxazole, which sells in the market as Septrin, is used as a prophylaxis or preventive drug to PLWHA  from opportunistic infections such as Pneumocystis jirovecii pneumonia (PCP) and a wide range of common bacterial, parasitic, viral and yeast infections.

It is taken once daily. Although the risk of PCP is markedly reduced when the virus is suppressed, most authorities recommend continued prophylaxis because of additional benefit for other respiratory, urinary and intestinal infections.

The average monthly cost of Septrin from most retail outlets is Sh2,000, way beyond the reach of most individuals.

Fadhili, for example, spends about Sh100 to buy a few doses of the drug from the chemists. Money, she says, is hard to come by in this pandemic.

“I used to go all the way to Lugari for a multi-month drug dispensation. I was getting three months’ supply of Anti-Retroviral (ARVs) and Septrin,” says Fadhili.

The mother of three decided to relocate to Lugari permanently for a while. But when she came back to live with her children, after a lot of persuasion from a close relative and the advent of Covid-19, she forgot to pack some drugs, certificates and identification documents she uses to access treatment. 

“I hurriedly packed and forgot some of these vital documents. And now with no money, I haven’t been able to go back and collect them,” she narrates.

The fear of limited availability of the antibiotic has led to opportunistic infections, ranging from simple to complicated life-threatening, and their management can be quite expensive and difficult.

When we met her, she had started showing effects of skipping the medication.

Aftert one week without her medication, she had started developing wounds on her body as a result of opportunistic infections.

“We really need help. We lack the money to buy Septrin over the counter. And for some of us without jobs, we are barely surviving,” Fadhili explains.

Several metres away in a small mud-walled room, Rukia Musa, 52, recalls how she was treated for typhoid fever three times before finally realising she was HIV-infected.

“I used to get sickly on and off. I used to be told by some doctors, that I was suffering from typhoid,” she begins.

But her curiosity and progressively worsening health triggered her to go out and get tested despite the feeling of stigma and intense fear she had inside her.

“I had attended a couple’s seminar by Red Cross and when I relate what they had taught us, I decided to go for a checkup.

At first, the medics wanted to chase me away because I had gone there alone, but I insisted I wanted to know my status,” recalls the mother of nine and grandmother of seven.

Since 2004, Musa, now widowed and the family’s breadwinner, has been on ARVs and Septrin.

Unlike Fadhili and thousands of HIV-infected rural women who rely on support from family and well-wishers, Musa runs a food kiosk on the busy Bungoma-Webuye highway. However, since the onset of the pandemic, her business has received severe beating.

“Due to the pandemic, very few people come to the kiosk to buy food. My income has really reduced.

Sometimes I only get Sh400 as profit, but I need to feed my nine children and other grandchildren and still buy Septrin. It has been hard on me,” she says.

Prolonged stock-out of septrin does not only affect people living with HIV/Aids, but also many people around the country since it is a first-line regimen for many other respiratory, urinary tract and gastrointestinal conditions in HIV- people.

And organisations working with PLWHA have also joined the ‘anti-Septrin shortage crusade’.

Two months ago, officials at The National Empowerment Network of People Living with HIV/AIDS (Nephak) and the Kenya Aids NGO Consortium said stock-outs meant 1.3 million Kenyans who take the drug daily are going through the consequences of missing it.

Several patients are now forced to share drugs. In addition, other HIV/Aids drugs such as Nevirapine for children, Pyrixodine used to treat tuberculosis, are also in short supply.

Jectone Chilo, vice chairman at Nephak, says medical facilities are running on empty, with a good number of its members not getting the drug.

“It is getting desperate. We are worried gains we have realised in HIV/Aids prevention and management risks being eroded, if this shortage persists,” said Chilo.

HIV damages the body’s immune system, making the individual more susceptible to secondary or opportunistic infections.

Prevention of such infections is important for better quality of life and optimum health outcomes for people living with HIV.

According to Dr Dismas Oketch, an HIV expert and Fellow of the HIV Cure Academy, Septrin plays “Critical role in prevention and treatment of opportunistic infections among immunosuppressed individuals, of which PCP is the most important”. 

The risk of PCP without prophylaxis is 60-70 per cent. Septrin reduces this risk by nine-fold, thus significantly reducing PCP-associated morbidity and mortality. Untreated, PCP is invariably fatal.

Even with hospitalisation and optimum treatment, mortality from PCP adds up to 20 per cent. This behooves all of us to do everything possible to prevent it, he says.

In July 2020, Ambassador for Youth and Adolescent Rep Health Programme (Ayarep), an adolescent and youth reproductive, health project working with and for adolescent and the young PLWHA, organised a campaign to mobilise young people to hold leaders accountable for this shortage.

The campaign targeted the Ministry of Health and National Aids and STIs Control Programme (Nascop) under the banner “Our Lives At Risk”. The ministry assured Septrin would be available in all facilities by July 2020.

Even as the shortage persisted on the backdrop of the pandemic, several patients interviewed in Kisumu county said they were being turned away from public hospitals because Septrin is not available.

“For the past three months, we have been given ARVs, but told there is no Septrin.

We have to source for it from private hospital at a cost,” says a woman from Obunga slums in Kisumu who only preferred one name, Alice.

Kenya’s Ministry of Health in a statement to the People Daily noted the challenge with availability of Septrin tablets 960 mgs was occasioned by a delay in supply by the first contracted supplier.

The ministry has since cancelled the tender and retendered six weeks ago, the statement read in part.

While regretting the disruption the stock-out had occasioned, the ministry noted that the supply of 1.7 million of the drugs is expected in the country in the next one month.

“This supply will be able to last the country for 18 months. In addition, the government will each year buy Septrin worth Sh1.2 billion to ensure the country does not run out of this essential drug again,” said the statement.

As at September 9, 2020, the Ministry of Health via Nascop and Kenya Medical Supplies Authority reviewed the HIV commodity stock status reporting enough stocks of ARVs.

“As it is, the country has enough ARVs medicine to support 1.8 million people living with HIV currently on treatment without disruptions and jeopardising their health.

The ARVs are available for free in all public facilities,” noted the statement.

Medicines used for the first line regimens for adults including pregnant women are available and had no stock-out in the last four months.

“In view of the low stock levels of Nevirapine syrup and Zidovudine (AZT) syrup, that is below the nine-month recommended threshold, Nascop has monitored and re-distributed the available stock to avert disruptions of supply at facilities,” it further said.

The country has also received deliveries of key products for Elimination of Mother to Child Transmission programme, thus stabilizing the supply chain.

Dr Oketch  however, advises that during such shortages, there is need to prioritise distribution of any commodities in short supply to those for whom missing regular doses can lead to the most dire health consequences.

He recommends adoption of a ‘differentiated care approach’ where individuals who are severely immunosuppressed are prioritised over those who are relatively virally suppressed.

Encouraging PLWHA to engage in income-generating activities to improve their livelihoods is a key factor in sustaining their long-term health and social outcomes, especially during such emergencies. However, they still decry lack of funding or access to capital to engage in small and medium enterprises.

“We need funding and support to start and run small businesses to empower PLWHA, especially unemployed women,” says Fadhili.