EENHANA, 12 March (IRIN) - Namibia is hailed as one of the front-runners in AIDS treatment rollout, yet there is growing fear that this success might be short-lived if services do not reach rural communities.

The government has increased the number of sites offering antiretroviral (ARV) treatment from seven three years ago to 34 at present, but most of the clinics were set up in the densely populated northern regions, far from people living on farms and in rural villages.

Tuli Shanyengange, head nurse at the US Centre for Disease Control (CDC) clinic in Eenhana, capital of Ohangwena Region, in the far north of Namibia on the Angolan border, confirmed that although anti-AIDS services were more available than ever before, accessing them was often difficult for people living beyond the outskirts of urban centres.

"It is not unheard of for patients to walk up to 20 kilometres to Eenhana Hospital because they are short of cash to pay for a ride. Sometimes they come to the clinic and sometimes they don't," he told IRIN/Plusnews.

Namibia has one of the highest levels of income disparity in the world, with 50 percent of its 2.2 million people surviving on just 10 percent of the national income.

Outreach, or reaching for a dream?

As the ministry of health prepared to beat its national target of providing ARVs to 300,000 people by the end of 2008, concern has been growing over possible treatment interruptions for rural dwellers who start taking ARVs and are then unable to make follow-up visits.

Shanyengange stressed the importance of outreach programmes to people unable to afford the cost of travel to district hospitals at Eenhana, Okongo and Engela. "CDC and government are currently looking at ways of utilising smaller clinics situated at least halfway between the three hospitals in order to help reduce distances travelled, but the scarcity of trained healthcare staff in Namibia is also a worry."

Besides its financial woes, the nation is plagued by a shortage of at least 1,500 nurses. Many medical personnel have opted to work in other countries, where the pay is higher and conditions are better.

At present, health teams from the three main hospitals visit outlying clinics at least once a month to provide much-needed services.

Gabriel Kanykwa, the home-based care project co-ordinator for the Namibian Red Cross Society (NRCS) in Ohangwena, welcomed the prospect of bringing anti-AIDS care closer to people in rural areas, but stressed the need for careful planning. "This is so as not to disrupt the flow of services being rolled out at the district hospitals. We need to avoid a bottleneck situation on the days that some of the healthcare staff have to travel to the rural clinics."

According to the office of the Regional AIDS Coordinator for Ohangwena, 1,200 people are accessing ARVs at Eenhana, 1,400 at Engela and 400 at Okango.

Emmanuel Shinangolo, 41, a resident of Eenhana who started receiving ARVs from the hospital in 2005, said he would not have known what to do if he had lived as far away from the hospital as most people did.

Speaking with the aid of a translator, Emmanuel recalled how ill he had been. "My CD4 [cell count, which measures the strength of the immune system] was just 43, and I was already very weak. How would I have come to the hospital if I lived so far away? I would be dead by now," he said. ARV treatment is usually started when the patient's CD4 count is around 200.

Out of sight, out of mind

The lack of services in rural areas also makes it harder to acknowledge the presence of HIV/AIDS, and suicide is sometimes seen as the only antidote to steadily declining health.

Except for a "really bad cough", which grew more severe each day, Sofia Hanyemba, 82, said her son would still be alive if the healthcare facilities were not so far away. "It [the coughing] became so bad that he decided to take is own life. He hanged himself in that room," the old woman said, pointing to the remains of a thatched wooden hut that they had since destroyed.

Sofia now has the responsibility of caring for her two grandchildren on a pension of only 350 Namibian dollars (about US$48) per month. "We get some help from the Namibia Red Cross with food parcels and uniforms for the children, but they can only do so much for us," she said.

Kanykwa of the Namibian Red Cross lamented the uncertainty of funding for programmes, and acknowledged that their interventions were usually short-term. He stressed the need for increased HIV awareness and prevention campaigns in communities as a possible long-term solution.

"People in rural areas rely heavily on maize crops to feed themselves, but when AIDS takes hold, entire plantations wither and family stability is usually not far behind," he told IRIN/PlusNews.

An appeal was recently launched by the International Federation of Red Cross and Red Crescent Societies to fund the expansion of its anti-AIDS programmes in 10 Southern African countries, including Namibia, over the next five years.

The Federation has urged international donor communities to move beyond rhetoric to meet the needs of affected populations, and has appealed for US$300 million to implement new programmes in the region and strengthen existing ones.

Meanwhile, Sofia's greatest concern is her grandchildren's education and safety, should anything happen to her. "They [the children] are being taught about AIDS in school and they come home and tell me everything. I am glad that they are learning how to protect themselves."

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