Wednesday, March 23, 2011

Will Reduced Funding for UNAIDS Mean Less Prejudice?

My first experience of a HIV voluntary counselling and testing (VCT) clinic in Kenya was memorable for the fact that, among the bustle of people coming and going from the public hospital, those wanting anything to do with HIV turned left before the hospital gates. The would sit outside the standalone clinic, in full view of passers by.

This phenomenon, which is still the norm, is just one aspect of HIV exceptionalism and it clearly puts people off going to VCT clinics. It compounds the stigma that surrounds HIV, the fact that anyone who sees you at the clinic will know that you may be HIV positive. Those who are HIV positive face the even greater stigma of having to go to a Comprehensive Care Clinic, dedicated to those with HIV.

Now a pilot program in Western Kenya is trying out the idea of integrated care, where people turn up to see a health professional without being segregated into HIV and non-HIV groups. And aside from reducing the fear people had of being sneered at by other patients and even by health professionals, some are saying that it also frees up scarce resources.

It is good to hear that efforts are being made to see HIV as just one of many illnesses, because people also suffer from and die from so many diseases, often preventable and/or curable conditions. Those who defended the exceptionalization of HIV claimed otherwise, but it is widely felt that resources, including personnel, tended to be deflected away from less prominent conditions.

In fact, one of the groups most vulnerable to HIV, young women of child-bearing age, were unlikely to get much care aside from HIV related care. If they turned out to be HIV positive, they might get just enough care to ensure than their baby was not infected. But then they would be left to their own resources, ignoring the fact that the best way to ensure the health of an infant is to ensure the health of their mother.

Those who turned out to be HIV negative were even less likely to get the care they needed. But recently, there has been talk about putting a greater emphasis on maternal health. Some have even talked about strengthening health systems and improving health facilities, without reference to one, or a handful, of diseases. This may just be a way of reducing funding, but it may also be a genuine attempt to right the balence. I'm accepting that the two could be compatible.

Another of the effects of the exceptionalism of HIV was the way it was never really seen as the business of national governments in high prevalence countries. It was always something that donors controlled. The only interest that health (and other) departments would take seemed to be in the vast sums of money that HIV seemed to attract.

If it is true, as defenders of exceptionalism like to claim, that much of the HIV money was additional, on top of health funding, that's great. And if it is true, as they also claim, that HIV money has also helped strengthen health systems, that's great too. Though I have to say, I don't believe those claims for one moment. But all the better for health systems if they are right, because it's very likely that they will have to get by on a lot less if the pilot is scaled up across the country.

My worry is not that less money will be spent on HIV prevention. Very little is spent on prevention now and most of it is being spent on useless exercises. But if health facilities do not give some attention to levels of infection control, there is a danger that they will continue to expose patients to diseases such as HIV itself, as well as many others.

Conditions in Kenya's hospitals are appalling. Nurses in Pumwani, one of Kenya's busiest state run maternity hospitals, have gone on strike to complain about conditions, extreme shortages of personnel, equipment and medicines. Maternal, infant and under five mortality rates in Kenya are among the highest in the world as a result of these conditions. And yet UNAIDS still claim that HIV is almost never transmitted in health facilities. This is an area of HIV prevention that is in urgent need of attention.

Treatment and care for HIV positive people may suffer if funding for this is reduced. After all, though this amounts to little more than funding for drugs, they are inordinately expensive. But a reduction in donor money for HIV drugs may result in a reduction in the sort of prices that the market has never been able to sustain. And many HIV positive people don't even die of AIDS. They, in common with those suffering from AIDS, often die of preventable and/or curable conditions, despite levels of donor funding for AIDS drugs.

If HIV becomes less exceptionalized, perhaps it will also start to be looked at more realistically. The experience in Kakamega and other districts is, apparently, quite encouraging, especially in the way it has reduced stigma. If HIV is seen as just one of many diseases, it may also be recognised that it can be spread in health facilities, just like hepatitis, MRSA and lots of other diseases. And this would represent a paradigm shift in HIV prevention.


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