Monday, February 22, 2010

A Pill for Underdevelopment

An article published on the 24 of December last year claims that a three week drive to test as many people for HIV as possible succeeded in testing one and a half million people. Perhaps my scepticism is misplaced, but I find it hard to believe that over 6600 people were tested every day for three weeks. Still, if it's true that the country has the capacity to test this number of people this quickly, their aim to test 80% of the adult population by the end of 2010 should be fairly easy.

Unfortunately, providing antiretroviral treatment (ART) for everyone found to be in need of it may not be so easy. The Kenyan government has only ever provided a fraction of the money needed to supply ART to everyone who needs it. Most of the money came from donor funds, such as the (US) President's Emergency Fund for Aids Relief (PEPFAR), the Global Fund and the Clinton Foundation. But they are not due to increase their funding in line with the surge in numbers being found to be HIV positive. The Global Fund has even stopped some expected funding due to serious financial irregularities.

The funding gap is thought to be 2.5 billion shillings this year but will rise to many times that in the next few years. Kenya is currently almost out of stocks of some drugs and the Ministry of Health is applying for emergency funding that should tide them over for six months, if the money is forthcoming. The problem will be exacerbated by new World Health Organisation guidelines that recommend the use of more expensive drugs and putting HIV positive people on ART at an earlier stage of disease development.

Meanwhile, the advocates of 'treatment as prevention' are back in the news. They claim that rolling out ART to everyone found to be HIV positive and testing every adult about once a year could prevent nine out of every ten infections. If this is true in practice, testing everyone regularly and treating everyone found to be positive would be even better than very high levels of condom use (levels that have probably never been achieved). Of course, the approach to funding would have to be completely changed as current funding would be nowhere near high enough to cover the costs of 'treatment as prevention'.

Another study claims that the sort of mass screening suggested above could allow HIV to be eradicated in 40 years (in South Africa). My reaction to these articles, and I'm thinking specifically of Kenya, is that if it were possible to test many millions of people every year, it may also be feasible to put millions on treatment. And if it were possible to successfully treat so many people, then transmission rates should drop radically.

But I would question the feasibility of testing most sexually active adults in Kenya every year. This is a country where health services are in very short supply and high quality services are only available to the very rich, if at all. Long term care for the chronically ill is in even shorter supply. Is the country really going to raise the money for and implement the vast improvements in health infrastructure that would be required just to make this level of HIV screening possible? And if this happens, will the country also develop its capacity to provide long term care to millions of HIV positive people for several decades to come?

Even if the money is forthcoming, I find it hard to believe that Kenya's levels of health care, education, infrastructure and social services will be raised sufficiently to make anything like these predictions about 'treatment as prevention' become a reality. Maybe it is true that 1.5 million people were tested in three weeks. And maybe the sort of funding required to eradicate HIV will be provided. But I can't help remaining highly sceptical.

My discomfort stems from reflecting on the fact that HIV spread rapidly in Kenya at a time of high and increasing levels of poverty and unemployment. Levels of health and education provision were low and are still decreasing. Health indicators, especially for maternal, child and infant health, were particularly poor and most have been disimproving since the 1980s. Gender inequalities have never been given very high priority and those among whom HIV spread most rapidly, women, commercial sex workers, men who have sex with men and intravenous drug users, are as vulnerable now as they were three decades ago.

If it is true that HIV transmission is related to the conditions in which people live and work, as I would maintain, provision even of astronomical levels of funding to test and treat millions of people will still fail to address these conditions. Therefore, I'm suggesting, HIV could still be a problem for countries like Kenya in 40 or 50 years time. In fact, we have hardly even started to address HIV transmission because we continue to ignore the conditions mentioned. But that's just my take on it.


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