Tuesday, February 24, 2009

Can Kenya Treat Its Way Out of the HIV Epidemic?

There is a question that is frequently being asked these days: 'Is it possible for a country to treat its way out of the HIV epidemic?' That is to say, given the treatment options available now, is it possible to reduce the rate of new infections to a very low level? The hope is that, although HIV may not be eradicated, it could change from being a pandemic to being a chronic but manageable disease that affects relatively few people.

It has been claimed, for example, that universal HIV testing and subsequent treatment (UTT) for everyone found to be HIV positive could reduce HIV prevalence to less than 1% within 50 years (using data from South Africa as a test case).

So in Kenya, there were 1.4 million HIV positive people in 2007 in Kenya. 190,000 (14%) of them were on ART by mid 2008. Proponents of UTT want all 1.4 million to be on antiretroviral treatment (ART) as soon as possible.

One of the problems is that, after independence Kenya experienced many improvements in social conditions. But these were partly reversed as a result of internal and external crises in following decades. A combination of poor governance and structural adjustment policies resulted in a reduction in health, education and other social services.

I don't believe the issues surrounding UTT have yet become polarised, as so many other issues relating to HIV have become. There are persuasive arguments that much can be done to reduce rates of transmission and that UTT could play a big part in this. There are equally persuasive arguments that very little of the prevention work that has been carried out so far appears to have been unambiguously successful.

That's not to say nothing has been done or that what is being done should stop. People need sex education, they need to protect themselves from dangers such as physical and emotional injury, diseases such as HIV and other sexually transmitted infections, unwanted pregnancy, social stigma and even imprisonment. But such education and awareness pertain to basic human rights. It is not necessary that there be a serious pandemic before these basic rights are recognised.

Similarly, people need access to nutritious food and clean water, they need assured food security to avoid shortages and famine, they need the means to provide for themselves, access to health services, infrastructure, power, transport, commerce and many other things. These too pertain to basic human rights. People are entitled to these rights whether there is a HIV pandemic or any other kind of pandemic.

Yet it is such basic rights that are being denied to people in Kenya and other developing countries. They also need medicines for malaria, malnutrition, cholera, meningitis and intestinal parasites. In fact, countries could do more than treat their way out of the HIV epidemic. They could treat their way out of almost all endemic diseases.

The reason that people do not have access to medicines is more often because they are too expensive than because they have yet to be developed. And most don’t have access to health care in Kenya because there are very few health facilities and personnel.

The reason people don't have enough food is because they have been marginalised to the extent that they cannot access basic goods, not because there is not enough food.

But what if available medicines were to be provided to all those who need them? For a start, what level of health service provision would be required to provide all HIV positive people with ART? At present, after nearly three decades of HIV, countries like Kenya are struggling to provide HIV testing for everyone. Until people know their status, they continue to do as they have always done. Once they know their status, some, perhaps most, will seek medical care of some form. As to whether they will receive the care they need, that's another matter.

Far from increasing health structures in Kenya, health spending has not even improved to keep pace with population increases and increases in the need for health care. In general, spending has been and continues to be curtailed by loan conditions imposed by international financial institutions. The Kenyan government appears to have little interest in health and even less interest in HIV. People from outside Kenya are more interested in resources, land and cheap labour than in improving conditions in the country.

For many people willing to be tested for HIV, the services are not reaching them. There are HIV positive people who could be on ART, which would improve their health and reduce their risk of their transmitting HIV. But they are not always able to get the medication they need, for example, because they live in an isolated area. Or they are lacking some of the things they need for the drugs to be effective, such as clean water and a reasonable level of nutrition.

So is the answer to the question 'yes, it is possible for a country to treat its way out of the HIV epidemic'? I think this would be the answer if all the relevant conditions for such an undertaking were met. Then questions arise as to whether Kenya is on the right track to be in a position to roll out ART to all who need it, whether people will be fully supported in this treatment, whether they and those indirectly affected will be allowed to enjoy their rights to education, health and other benefits.

For me, the question really boils down to this: many developing countries are not much better off and some are worse off than previously, despite high levels of development aid over a long period of time. If 'treating their way out of the HIV epidemic' in Kenya means allowing the country to develop in the areas that allowed HIV to spread rapidly since the 1980s, then the project should have a lot of success. And not just with HIV but with most development issues.

But if the intention behind the question is to continue with various development programmes and tack on another one that involves mass testing and drug distribution, this will not be very successful.

It’s true that many people now on ART are doing very well, there is little evidence that they are responsible for transmitting HIV, more people are receiving sex education and HIV positive people are less stigmatised than they were in the past; many things are changing.

But despite this, HIV transmission is still high, too high for HIV prevalence to reach the very low levels envisaged by proponents of mass HIV treatment campaigns.

For UTT to be feasible, HIV needs to be seen as one of many symptoms of serious, long term underdevelopment. It is not merely a health crisis, a disease that needs to be eliminated. There are numerous factors in the transmission of HIV. They will not just go away. These factors include inequality, poverty, unemployment, poor health, education and infrastructure.

Only after all relevant factors have been dealt with will adequate HIV treatment and care succeed in reducing transmission to a level where it will be a chronic, treatable disease.


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