HIV Industry Admits They Got it Wrong? Sort of!

The US has launched a new grant to help developing countries to strengthen their health systems. The term 'health system strengthening' has become quite fashionable recently. But it's usually used by defenders of the likes of PEPFAR (President's Emergency Fund for Aids Relief) and the World Bank's Global fund, who argue that their funds do not target HIV at the expense of other diseases or of health systems strengthening. Remarkably, the article about this new fund, the Global Health Initiative, flatly contradicts these claims and even reads like an admission that mistakes have been made. Such admissions are rare, but vital if serious diseases such as HIV are to be controlled.

In another article, it is noted that the amount of money spent on HIV in Tanzania has risen by over 2000% between 2001 and 2007, from 17 to 381 billion Tanzanian shillings (11.5M to 259M USD). And the author is encouraged that in the same period, prevalence has dropped by 1%, from 6.7% to 5.7%. Is that encouraging? Hard to say, but apparently "Some of the biggest challenges in the fight against HIV/Aids are embezzlement and mismanagement of funds." One wonders where prevalence would stand if the money hadn't been embezzled and mismanaged. In some sectors of the Tanzanian population prevalence has been increasing.

The article ends with the conclusion that HIV was not adequately addressed because the focus was on the health sector, whereas this disease in particular is not simply a health problem. But you could argue that diarrhoeal diseases and intestinal parasites are a matter of water and sanitation, respiratory diseases are a matter of environment and housing and malaria is a combination of all of these factors and perhaps some others. None of them are 'simply' health problems.

Yet, it is true to say that you can't just reduce HIV transmission by sending everyone to a clinic and giving them counselling and drugs if they are infected and lecturing everyone who is not infected about safe sex and perhaps giving them condoms. This has been tried and has failed. Amazing amounts of money have been thrown at HIV and the result has been a continuation of very high levels of transmission and a distinct lack of understanding of why some countries and parts of countries have such profound HIV epidemics and why some do not.

So, like other diseases, HIV epidemics are not just a matter of dealing with a particular pathogen, you must also consider the host and the environment. Looking at it (and other diseases) from this point of view, there are a lot of ways of spending 381 billion Tanzanian shillings aside from on health aspects alone. Many people are said to be more susceptible to HIV infection because they don't have a choice about when, how often or with whom they have sex. Others are susceptible because they have various health conditions that make them so, for example, malnutrition, intestinal parasites, sexually transmitted infections, TB, malaria, etc.

As well as dealing with host factors, then, money could be spent on environmental factors, water and sanitation, infrastructure, gender relations, equality, poverty and many other things. But anyhow, the claim is that the money was spent on the health sector, not on health systems (supply chain management, health worker retention, information management, etc). And it seems fairly clear that money has not been spent on health systems, pace the argument for the Global Health Initiative and contra the unconvincing arguments of Global Fund and PEPFAR proponents.

But here's a thing, you could argue that those tenets of epidemiology leave out something very important, perhaps most important when the epidemic is HIV: nosocomial infections. This is where the disease is spread by medical procedures. The pathogen is clearly being introduced into a host, but artificially so and the environment is a rarefied but highly risky one. Do nosocomial infections, to some extent, elude epidemiologists altogether (or just those who work for UNAIDS, WHO or CDC and a few other institutions that have a lot of influence in the HIV industry)?

Following the pronouncements of those august institutions, you would think that nosocomial infections hardly infect anyone in developing countries, with the rare exception of some of their own employees who happen to be working in those countries and have to use the same medical facilities as the natives. Don't worry, that has probably never happened, though that doesn't stop them from warning their employees.

Ignoring other diseases, health in general, water and sanitation, nutrition, environmental conditions and structural conditions in the fight against HIV has been unbelievably stupid. Equally stupid is the failure to ensure that there were adequate health structures in place to implement various HIV prevention and treatment initiatives, however misguided some of these may have been. In fact, in countries like Kenya, health structures were being dismantled from the 1980s onwards at the instigation of institutions like the World Bank (yes, the one that came up with the Global Fund!).

In admitting that health systems have been ignored, the HIV aristocracy may be getting just a little closer to admitting that their view of HIV transmission in developing countries is in bad need of reconsideration. They still tell us that HIV is almost entirely transmitted through heterosexual intercourse in developing countries. But it would seem very hard to maintain this view when the Global Health Initiative is admitting that health systems have been ignored and this has done a lot of damage and has wasted much of the money that has been poured into HIV so far.

Huge amounts of money have been and still are being spent on trying to get people into medical facilities, to be tested and/or treated for HIV and many other diseases. Pregnant mothers are encouraged to go to clinics and to bring their babies and infants to be vaccinated. Men are being encouraged to go to clinics to be tested and/or treated for HIV and sexually transmitted diseases and even non-communicable diseases. But if health advocates want people to go to health facilities, they would need to make sure those health facilities are safe enough that people do not become infected with something as life-threatening as HIV. People need to be made aware of the risks they face in health facilities and those health facilities had better be improved quickly and thoroughly. I don’t think the admission that grotesque mistakes have been made was intended but it has certainly let the genie out of the bottle, well, one of them.