Access to HIV and TB Services in Mauritius

Report presented by YUVA at the ToT of ARASA, Johannesburg

  1. What is Mauritius’ HIV prevalence?

Mauritius HIV prevalence is 0.9%. This report was according to the World Bank collection of development indicators revealed by Trading Economics (2016). Over 70 million people have been infected with the Human Immunodeficiency Virus (HIV) and approximately 35 million people have died of HIV, from the onset of the epidemic. Also, a global record revealed that about 36.7 million people living with HIV as at the end of 2015 according to the World Health Organization. Although, Mauritius has been able to control the spread of HIV infection; the trend of HIV infection has it that in 2004 -2008, the estimated prevalence of HIV infection in the country was 1.2%, between 2009-2010 a prevalence rate of 1.15% was recorded. Between 2011 to 2013, a prevalence of 1.0% was reported and in 2014-2015, an estimated prevalence of 0.9% was observed for the population aged 15 -49 years according to the report of Trading Economics (2018).

Further stratification of the prevalence of HIV base on gender, Mauritius in 2015 had a sex-specific HIV prevalence of 0.2% and 0.1% for female and male respectively. Also, HIV epidemic in Mauritius is concentrated with high prevalence among key populations particularly among people who inject drugs, female sex workers (FSW), men who have sex with men (MSM) and prison inmates (PI) with prevalence rates of (44.3%), 15%, 17% and 19% respectively. Historically, the first case of HIV and AIDS was reported in 1987 in Mauritius. In 2015, the estimated prevalence of HIV infection among all ages in the country was 0.65% and 0.88% in the age group of 15 to 49 years. However, a Central Intelligence Agency reported a prevalence of 0.8%. Also, it is estimated that some 8,000 persons are living with the HIV in Mauritius. The average monthly number of new HIV cases was 46 during the period 2006-2010 and 26 in the period 2011-2015. Furthermore, 262 new cases of HIV/AIDS were registered with an average of 33 per month as at 2015 whereas, 921 cases in 2005 and 568 cases in 2010. The 0.9% prevalence of HIV infection according to the low number of cases; point to a decreasing trend in the incidence of HIV and AIDs in Mauritius (CIA World Factbook; Republic of Mauritius Ministry of Health and Quality Life Draft, 2016; Trading Economics, 2018, WHO, 2015). It is important to note that, HIV prevalence estimated at 0.80% in 2015 had remained under control during 2016 and 2017. Mauritius has endorsed a National Action Plan (NAP) for HIV/AIDS covering the period 2017–2021 with the intention of meeting the UNAIDS 90-90-90 treatment targets (WHO Mauritius Biennium 2016/2017 Report). However, the target of reducing the prevalence of HIV among pregnant women aged 15-24 years from 0.72% in 2015 to 0.34% and the general reduction in 2020 is yet to be achieved. Thus, there is a need to scale up HIV programmes to reduce the incidence of HIV infection and to achieve this prevalence from the current prevalence of 0.8% following the set target.

  1. What is Mauritius’ TB prevalence?

Mauritius TB prevalence is 35 per 100,000 people, with an incidence of 22 according to the World Bank collection of development indicators. (Trending Economics, 2018; WHO, 2015). In 2016, the incidence of tuberculosis for Mauritius was 22 cases per 100,000 people. The incidence of tuberculosis of Mauritius fell gradually from 24 cases per 100,000 people in 2002 to 22 cases per 100,000 people in 2016. Mauritius generally has low TB burden as a country, in 2015 Incidence rate of 9.8 per 100,000 population and 127 notified cases. Co-infection of TB with HIV is about 14 cases, 25 cases seen in foreigners. Extrapulmonary TB is about 10 and multidrug-resistant TB (MDR) is 1. Number of death due to TB is 8. A number of predisposing factors have been implicated to cause TB in Mauritius like Alcohol about 50%, Diabetes 20%, TB Contacts 5%, HIV 5%, Migrant Workers 5 % and others 15% according to 2015 global tuberculosis report (Mudoo, 2015; Purryag, 2015).

However, the goal is that by 2050 the global incidence of active TB is reduced to <1 case per 1 million population per year hence Mauritius still need to fight to combat this disease. Mauritius has maintained low TB disease frequency. Record shows that as of 2016, the burden of TB in Mauritius continued low with an incidence of 22 per 100,000 population and mortality (HIV and TB only) of 1.4 per 100,000 population.

  1. What does Mauritius’ National HIV Strategic Plan/ Framework say about access to HIV and TB services?

The Government of Mauritius has a high level of commitment towards improving treatment, care and support for people living with HIV/AIDS. Both economic and psychosocial support like; Economic aid for PLWHA who are not able to work, Transport refund for those who attend the National Day Centres for treatment and follow-up, Milk substitution for babies born to HIV positive mothers Psychological support provided in collaboration with NGOs, Treatment literacy to improve adherence. Moreover, there are policies and guidelines supportive of the national response, which has been highly structured and implemented by Mauritius. These policies include but not limited to the National HIV and AIDS Policy (2012); the key guidelines developed by WHO, the UNAIDS Strategic Framework 2016-2021. Also, WHO backed up the development of a costed National Action Plan, which will span from 2016-2021. This is to certify translation of these policies and guidelines into action, as well as leveraging an enabling conducive policy and planning environment towards the response. Known the demonstrated capacity to maintain a fast ART scale-up, the 2016-2021 NAP aims to meet the 90-90-90 Treatment targets released by UNAIDS in 2014, with a diagnosis of 90% of all PLHIV, 90% of people diagnosed with HIV initiated on (WHO Mauritius Biennium 2016/2017 Report). Also, WCO Mauritius has ensured the procurement of HIV Rapid Diagnostics Test Kits as part of a medium-term plan strategy to promote Voluntary Counselling Testing among the hard to reach population as well as strengthening prompt laboratory diagnosis for HIV according to WHO Mauritius Biennium 2016/2017 Report. In the case of TB, molecular rapid TB diagnostics technologies (GeneXpert MTB/RIF) for TB diagnosis and resistance testing of drugs provided and supported by WCO.

HIV and TB Medicines

  1. How is the situation about access to HIV and TB services in Mauritius?

Very accessible compared to other Africa countries! The United Nation has been behind scaling up services towards the goal of universal access to comprehensive HIV prevention programmes, treatment, care and support since 2010. However, there are constraints to this universal access ranging from inadequate planning cum coordination, scarcity of funds, not enough human resources, feeble systems-almost failing systems, unavailability of drugs as well as prevention stuff, ignorance, stigmatization/discrimination by family/friends/co-workers/health workers/society with lack of respect for human rights, and lack of accountability for results. These challenges were obtained by the Joint United Nations Programme on HIV/AIDS (UNAIDS) in early 2006. These birthed the setting of national targets for prevention, treatment, care and support.

Universal access that is ongoing is really not a new initiative rather a process that builds on past initiatives and infuses existing initiatives with new drive met to reverse the course of the epidemics. Although, it is a complex process seemly ambiguous to achieve Mauritius country set specific targets and collaborative effort-private, NGO, religious bodies etc. In biding of carrying everyone along, Mauritius has put up policies bordering around equality- services and information fairly distributed to all irrespective of the status (health, socio-economic, sexual orientation etc). This has incorporated even the vulnerable groups including men who have sex with men, sex workers and injecting drug users. Accessibility of information, materials and services as at when due and where it is needed, however, there is a limit to this in Mauritius despite the laws because some of the target population still nurse fear but they need to be able to utilize the available facility/information without fear of prejudice or discrimination. TB and HIV drugs in Mauritius are affordable as the country’s way to reach the goal of universal access. There are free drugs available however, decentralization of therapeutic centres even Genexpert diagnostic centres, DOT centres, ART VCT centres, ARV testing centres, ART centres etc needs to be enhanced as to increase the coverage for TB and HIV in Mauritius (UNAID, 2006; Mauritius Ministry of health and quality life (2016).

  1. What is Mauritius providing for first and second line HIV drugs?

First line drugs = Zidovudine / Tenofovir + Lamivudine + Nevirapine.

Second line drugs = Zidovudine / Tenofovir + Lamivudine + Efavirenz.

The above-mentioned drugs form the group E on the list of the essential drug in Mauritius according to Ministry of Health and Quality of Life, Republic of Mauritius (2017). Also, HIV/AIDS is placed high on the socio-economic development agenda of Government of Mauritius. Health services, including prevention services to reduce the prevalence of HIV infection among the population and these antiretroviral drugs are provided free of any user cost to People Living with HIV/ AIDS (PLHIV) treatment according to Mauritius Ministry of health and quality life (2016).

  1. Does Mauritius have any policy/operational guidelines on viral load testing?

Yes, Mauritius has any policy/operational guidelines on viral load testing; the country uses the WHO 2015 Guidelines. In response to the vision of UNAIDS to achieve major reductions in new HIV infections, HIV-related mortality and the fast track 90-90-90 targets, one of the key recommendations is to initiate ART to all HIV infected individuals, irrespective of their immune status (CD4 count). This is recommended as Test and Treat in the new 2015 WHO Guidelines. Mauritius is using the WHO 2015 Guidelines. Currently, ART is provided to those with CD4 cell counts ≤ 500 cells/mm3 (WHO 2013 Guidelines) as reported by Mauritius Ministry of health and quality life (2016).

  1. What TB medicines are being administered in Mauritius?

The TB medicines in being administered in Mauritius to Tuberculosis patients are based on Standard WHO treatment regimens: It comprises of 2 Isoniazid, Rifampicin, Pyrazinamide & Ethambutol for phase one called intensive phase while 4 Isoniazid and Rifampicin are used for continuation phase. These drugs are enlisted in the essential drug list as group C on the list published by the Ministry of Health and Quality of Life, Republic of Mauritius (2017).

  1. Are there any reported stock outs on HIV and TB medicines in Mauritius?

No available record is seen. Measures of access to medicine for vulnerable groups in Mauritius using indicators like; Adults with chronic conditions not taking all medicines because they cannot afford them (%) and Adults with chronic conditions not taking all medicines because the medicines were not available (%) were all 0% according to the report of Mauritius Pharmaceutical Country Profile Published by Ministry of Health and Quality of Life of Mauritius in collaboration with the World Health Organization (June 2011).

Human Rights violations / Advocacy issues in Mauritius

  1. Which populations are identified as a key population in the HIV National Strategic plan?

The key population are populations that are known to be involved in high-risk behaviour and practices and the rate of infection of HIV have been evident to be high among them (Mauritius Ministry of Health and Quality Life, 2016). Key population in the HIV National Strategic plan includes: People Who Inject Drug (PWID), Men Having Sex with Men (MSM), sex workers like Female Sex Workers (FSW), transgender, prison inmates, People living with HIV and Youth. According to data from national surveillance surveys conducted by the National AIDS Secretariat and the Ministry of Health and Quality of Life (Integrated Biological and Behavioural Surveillance Surveys), the prevalence of HIV in key affected populations namely, People Who Inject Drug (PWID), Men Having Sex with Men (MSM) and Female Sex Workers (FSW) was 47.3% (2013), 17.2% (2015) and 15.0% (2015), respectively (Mauritius Ministry of Health and Quality Life, 2016).

  1. Are there any laws, which criminalise key populations (as defined by your National strategic plans) in Mauritius?

Yes, there are laws, which criminalise key populations. Gender and Human Rights Issues: Human rights issues have continued to play a role in preventing key populations from accessing prevention materials. PWID, FSW, MSM and transgender all described problems with police accusing (and/or detaining) them due to their possession of syringes or condoms, or subjecting them (and their residences) to searches due to previous arrest/ detention for drug use or sex work. There were also reports of violence towards women, including from police, especially towards female PWID and FSW. The Sodomy Law, while generally not used to prosecute MSM or transgender, enables police and others to threaten or intimidate these communities.

Generally, criminalisation is discriminatory laws and policies against the key population. It refers to laws that criminalise infected people based on their status (TB/HIV) which could either be specific laws or general criminal laws that prosecute: in essence; HIV criminalisation; unintentional HIV transmission, potential or perceived exposure to HIV where HIV was not transmitted and non-disclosure of known HIV-positive status. About 72 countries have adopted laws that specifically allow for HIV criminalisation according to the HIV Justice Network. The rationale behind these laws is to deter perceived morally unacceptable behaviour through fear of punishment. However, a wealth of evidence shows how HIV criminalisation is a poor public health strategy and actually undermines the response to HIV. Also, criminalisation of sex work, drug use and sexual orientation that push key affected populace away from vital HIV and health services and restrict their ability to demand their rights.

  1. What are the 3 major Human Rights challenges affecting people in accessing HIV TB, treatment, care and support?

Gender inequality, Stigmatisation and discrimination against PLHIV still persist to some extent in society despite the wide and aggressive sensitisation campaigns conducted by Government and NGOs. Moreover, a human rights-based response to HIV is split broadly into three main areas; human rights laws and treaties (although, not all nations have signed- so, it is a setback e.g. the International Covenant on Civil and Political Rights provides for rights such as equality, privacy and dignity. These rights apply to all individuals, including people affected by HIV and AIDS. Also, a treaty, the Convention on the Elimination of All Forms of Discrimination Against Women, contains guidance on women’s rights and gender equality), political declarations (e.g. the 2016 Political Declaration on Ending AIDS contains essential commitments by all governments to protect and promote the human rights of people living with, at risk of, and affected by HIV; UNAIDS International Guidelines on HIV/AIDS and Human Rights, a tool that provides 12 guidelines for what countries must do to fulfil their human rights commitments. Though some nations do not implement this anyway) and human rights principles in HIV/TB programming. Human rights are essential to reducing vulnerability to HIV. A human rights approach provides a common framework for translating international and national human rights documentation into practical programming at a national level, improving the universal access to health and HIV-specific programmes according to National AIDS Foundation, Mongolia

  1. Are there any laws in Mauritius that protect Key populations from violence and HIV / TB infection?

Yes, Equal opportunities ACT: The new legislation adopted in December 2008 and reviewed in 2012 prohibits any form of discrimination, directly or indirectly. It is meant to ensure that every Mauritian gets equal opportunities to achieve his goals in every field. Therefore, protected from being wronged because of his age, ethnic origin, colour, race, physical state, caste, marital status, political opinions, belongings or sexual orientation. Also, the HIV and AIDS Act 2006 provides an effective legal framework to eliminate all forms of discrimination against those inflicted with HIV and AIDS. Health care services, including Voluntary Counselling and Testing (VCT), dispensing of anti-retroviral drugs to PLHIV, induction on methadone, implementation of the Needle Exchange Programme (NEP) and other services related to HIV and AIDS in Mauritius, are provided free to people. Also, Laws regarding the monitoring of Adverse Drug Reactions (ADR) exist in Mauritius. In addition, international human rights laws and treaties; every person has a right to health and to access HIV and other healthcare services. Furthermore HIV and AIDS Act 2006 is another law, this law gives measures regarding   the control and prevention of the propagation of HIV and AIDS and at the same time respect the human rights of persons affected or not with the virus according to the report of Republic of Mauritius Federal Ministry of Health and Quality Life (2016). In addition, civil status Act and Employment Act 31 2008. Civil Status Act: This law permits foreigner living with HIV/AIDS to marry a citizen from Mauritius without discrimination while the Employment Act 31 2008 basically disallows workplace discrimination and stigmatization of HIV positive and individual with different sexual orientation.

  1. What are the gaps (if any) in the NSP in regards to certain Key populations (i.e. people who use drugs, sex workers, LGBT, MSM)?

Access gap: Challenges of the needle exchange program; accessing care exposes PWID to police harassment, MWID (Minors who inject Drugs) and prison inmates do not have access to any services. Also, poor quality of material. The access to health care in Mauritius is not without challenges. Though report shows that estimated 8,000 persons may perhaps be living with HIV, so far only approximately 5,700 cases have been registered (Mauritius Ministry of Health and Quality Life, 2016) thus, the issue of unidentified, unreported and unregistered cases are of concern. Also, care retention, non-adherence and non-compliance to treatment have been identified. About 80% of identified cases are accessing treatment in Day Care Centres for the Immuno-suppressed. 3,100 of these patients are on antiretroviral (ARV) drugs, only 81% are complying with treatment protocols. In addition, unprotected sex is still being practised by some people in the high-risk group despite awareness sessions for the adoption of safe sexual behaviours and provision of condoms at no user cost, among others.

  1. What human rights violations are most frequently faced by key populations in Mauritius?

The human rights violations most frequently faced by key populations in Mauritius as gathered includes violence towards women, including from police, especially towards female PWID and FSW. The Sodomy Law, while generally not used to prosecute MSM or transgender, enables police and others to threaten or intimidate these communities. Also, Mauritius government and non government organizations have widely created awareness and been involved in aggressive sensitization as it concerns human right especially as it pertains the key population but in spite of these efforts stigmatisation and discrimination against key population still persist to some extent in Mauritius even against PLHIV (Mauritius Ministry of Health and Quality Life, 2016; Mauritius Research Council, 2013).

Are there any intellectual property barriers that prevent access to new diagnostics for TB and HIV in Mauritius?  

Yes, Intellectual property rights in health in the context of medicines and pharmaceutical products of TB and HIV refers to utilising TRIPS flexibilities in order to work around the exclusion from making, using, or selling diagnostic and therapeutic inventions like TB/HIV concerns. World Trade Organisation (WTO) members adopted the Agreement on Trade-Related Aspects of Intellectual Property Rights known as the TRIPS Agreement in 1994. The TRIPS Agreement obliged all WTO members, including developing countries, to grant patents on, among other fields of technology, pharmaceutical products. This Agreement disadvantaged developing countries, which could not access or manufacture medicines for HIV and AIDS. Currently, there is now a pool of expertise on Intellectual Property (IP), TRIPS and Trade, which can be mobilised to provide technical expertise for member states. There is limited manufacturing capacity available in the region Mauritius. Mauritius is at an advanced stage of tackling available treatment options provided. There are already two pharmacy laboratories operating that undertake testing. Medicine procurement for the public sector is undertaken by the government tender process. Intellectual property legislation add the provision for the need to strengthen the Regulatory authority. It can be said that although there is a willingness to utilize TRIPS flexibilities in Mauritius the need has not yet risen. Thus, areas for advocacy would point to developing regulations for implementation, which currently seem to be only at a policy level (Mauritius Research Council, 2013; The Global Fund, 2017).

References

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