Wednesday, September 23, 2009

International Policy Network Partly Right and Partly Wrong About HIV/Aids

Philip Stevens of the International Policy Network questions the wisdom of spending so much money on a single illness, HIV/Aids, and asks if this can do more harm than good. I have long been asking the same question. My feelings are that it has done very little good and has probably done a lot of harm, especially to HIV prevention efforts.

The health of a nation is unlikely to be made or broken by one, single health condition. Even when there is a serious epidemic, there are probably always more people suffering from and dying from ordinary, every day things than from that epidemic disease. Health depends on people's lifestyles, living conditions, levels of nutrition and food security, education and economic circumstances, for example.

Stevens rightly criticizes UNAIDS's prioritization of treatment over prevention. Since treatments for HIV have been developed, far more money has always been spent on that than on prevention. So while many have been treated, millions more have become infected. Greater emphasis on prevention could have made a lot of difference, although precious few effective prevention interventions have been developed and implemented in any high HIV prevalence countries.

Stevens also mentions the poor and declining state of health infrastructure in high HIV prevalence countries. Indeed, some of the major funding bodies involved in pouring money into HIV treatment and care (and a little prevention) were, at the same time, urging developing countries to reduce spending on health, education and other social services.

If it is the case that some parties have claimed that everyone in the world is at equal risk of becoming infected with HIV, then this is truly shameful. I think the message was that every sexually active person is at risk, which is true. But it is not true that everyone faces equal risk. Perhaps this message has been confused by publicists, politicians, church leaders and various money grabbers who knew nothing about health, least of all HIV, but still wanted to get on the bandwaggon for their own ends.

And Stevens is wrong to claim that UNAIDS exaggerated the numbers of people infected and were 'embarrassingly forced to revise down the estimates for dozens of countries'. Methods of estimating numbers were improved, that's why the figures went down. Many figures are still very doubtful in that they could be higher or lower than presently estimated. Kenya was one of the countries for whom figures were revised down. A short time later they had to be revised up again.

Stephens' analysis, I think, is misleading. He makes it sound as if HIV/Aids is still a problem, but less of a problem that it was. I disagree. I believe that we neither have enough data to support his view nor directly to refute it. But there is plenty of evidence that people in high HIV prevalence countries still face serious and perhaps increasing risk of becoming infected.

I hope Stevens is right that donors have finally realized the folly of directing so much money towards one disease. However, I don't think he is right. I think he has allowed himself to be fooled by all the rhetoric about strengthening primary health care and health systems. If that is ever going to happen, I'll believe it when I see it.



KenyaChristian said...

Hey they seem to have found an AIDS vaccine

Claire said...

I think the glacial movement of development partners may be in the direction of less concentration on one disease, but there's a long way to go before we hear of a declaration of multi-targeted aid, or something that people can quote and memorise and fret over, like e.g. the "Three ones". People are talking about it more and more, so the UN and others will eventually catch on, they usually do, i reckon, but quite often too late.

Simon said...

Hi Kenya Christian
Good to hear they have had some success at last, let's hope they progress well and there may one day be a viable vaccine. Then we can address overall health, health systems, health personnel shortages, health education, etc, and the other conditions that affect Kenya and other developing countries.

Indeed Claire, the movement may be too slow. The 'three by five' initiative was achieved several years too late and is not much to boast about. Unfortunately those moving glacially slow seem to think that HIV will also spread slowly but that may not be so.

Claire said...

That's right. I was thinking of the big declarations that people rally around, especially when a change of approach is required because big agencies have not got their strategy right - e.g. UNAIDS' three ones:
One agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners.
One National AIDS Coordinating Authority, with a broad-based multisectoral mandate.
One agreed country-level Monitoring and Evaluation System.

Simon said...

Hi Claire
Yes, it's great to have just one of each, but only if they actually do something. The middle of the three ones is particularly bad here.

claire said...

that's right, and anyway, these principles are all about focussing resources on one disease. One framework? Well OK, good to make sure NGOs aren't doing anything silly like bursting into schools giving bags of condoms to 5 year olds. One authority? That's an in-country UNAIDS, isn't it? To argue for more resources at the expense of others? One M&E - this would highlight progress in combating this one disease and cause diversion of resources away from broader programs. I think the three ones are looking very out of line with the best thinking at the moment.

Simon said...

Hi Claire
I'm just glad to see others questioning the wisdom of targeting one disease. The approach seems to fly in the face of all that is known about public health or even that was known about public health in the 1980s. I'm disappointed to see people like Stephen Lewis and Michel Kazatchkine and others, still beating the drum for something that has been a miserable but very expensive failure. It's called UNAIDS, BTW! But the whole approach needs to change.

Philip Stevens said...

Hi Simon

It's great to see this kind of discussion on the blogosphere at this very important strategic juncture.

I'd just take issue with the AIDS figures revision presided over by UNAIDS. It's true that data collection methods have improved, but have they improved so much as to slash prevalence estimates by over 50% in some countries? Why did UNAIDS take so long to revise down these figures when many people within the epidemiology community were saying it all along?

I think the real issue is one of prioritisation. HIV is certainly a major problem in SSA, but so are myriad other diseases, many of which are easily preventable and / or treatable.

In that regard, it's good that the global health community is finally beginning to see that improving overall primary health is a better way of fighting disease - including HIV.

All the best


Simon said...

Hi Philip
Thanks for your comment. Well, epidemiologists have said all sorts of things and will probably continue to do so because the kind of data UNAIDS have is so flimsy that you can interpret it in many ways: the figures are too high; the figures are too low; some groups have been ignored; some groups have been given too much attention; HIV is spreading faster/slower/among different groups/among the same groups, etc. Even within Kenya, I believe there are significantly different subepidemics but organisations like UNAIDS paint everything with the same brush.

It's ironic that the Alma-Ata Declaration on primary health care was being signed at the same time as HIV was spreading quickly through many countries, as yet, unidentified. But when HIV was identified it was approached in the opposite way from which commitment to the Declaration would have suggested. There have been other declarations since then which have been treated with the same indifference.

UNAIDS needs to be reabsorbed back into the WHO, as long as the WHO can come up with a broad enough strategy to address the whole spectrum of health and development needs of people living in high HIV prevalence countries. Approaching HIV on its own has been a very expensive mistake and one the signatories of Alma-Ata and similar declarations should never have made.

It is good to doubt figures like those produced by UNAIDS. It's better to look at development indicators, broadly, such as those from Human Rights Watch and other organisations. In the case of Kenya, these show that many people are worse off than they were a decade ago and their lives are disimproving in many ways. As to whether prevalence of HIV or any other disease is going up or down, the smart money is on 'up'.

The smart money needs to be spent on primary health care, but also food, food security, nutrition, education, literacy, gender imbalances, governance, infrastructure and all other areas of development.

Developing countries, just like developed countries, have many needs. Spending huge amounts of money on politically or commercially or ideologically driven issues has never helped anyone and never will.