Tuesday, October 11, 2011

RethinkHIV Demonstrates Failure of Vertical Health Interventions

RethinkHIV, in their great wisdom, have ranked 18 types of HIV prevention intervention, or eighteen interventions that have had HIV prevention powers attributed to them. Remember, these are all ranked on their presumed economic costs and benefits, not on any data about how well they might reduce HIV transmission, or any other consideration for that matter.

The top five are vaccines, infant male circumcision, prevention of mother to child transmission, making blood transfusions safe and scaling up antiretroviral treatment. Vaccines don't exist yet. But assuming that when they do they will actually be used where they are most needed, unlike most health resources, they might have some impact.

Infant male circumcision is idiotic as most infants don't have sex and circumcision only protects against sexually transmitted HIV, if it protects at all. The arguments for adult circumcision are dubious enough but those for infant circumcision are entirely without foundation. Whatever your stand on male circumcision, there is no reason for performing the operation 15 or more years before it might have some impact.

Mother to child transmission has been very successful in rich countries but in poor countries, and all high HIV prevalence countries are poor when it comes to health spending and quality, the women who are infected with HIV should never have been  in the first place. Many of them didn't get HIV from their sexual partner and the main risks they face are probably non-sexual, such as unsafe healthcare and cosmetic practices. If HIV infection in mothers was prevented, mother to child prevention would be taken care of.

Mother to child transmission programs often forget the 'mother' element, aiming to improve headlining child related (and Millennium Development Goals related) indicators and giving relatively little attention to the maternal indicators. One of the best ways to improve the health and welfare of a child is to do so for the child's mother first. Indicators are a means to an end, though you wouldn't think that sometimes.

Making blood transfusions safe is the august group's number five, which is good to hear. But most national AIDS strategic plans already claim to have achieved this. They haven't, but cost benefit estimates based on the questionable figures UNAIDS provides for HIV transmission through contaminated blood are not going to be reliable anyway. Similar remarks apply to their number six, making medical injections safe, which is only considered 'good', as opposed to the 'excellent' first five interventions.

But all 18 of the interventions considered, from the most cost effective to the least, suffer from the same problem: they all assume that HIV transmission occurs in a social vacuum. And the academics in question are supposed to be considering HIV as a sexually transmitted infection! No disease is independent of the people it infects, the hosts, no matter how it is transmitted (or even if it is non-transmissible). And no disease is independent of the environment in which it is transmitted.

A recent paper on the failure of 'vertical' approaches to health was discussed on this blog a few days ago. Every intervention examined, admittedly from a purely economic point of view, is of little or no use if there is barely any health infrastructure, low levels of education, high levels of inequality and the like, in the most affected countries. Vertical approaches have been failing for decades. Applying them to HIV has failed. But no one informed the Copenhagen Concensus Center.

The interventions that aim to reduce HIV transmission by making blood transfusions and medical injections safe would have an impact beyond HIV alone. This could also reduce nosocomial transmissions of hepatitis B and C, a large percentage of which is transmitted in hospitals and clinics. These measures could also reduce other nosocomial transmissions, such as bacterial infections.

But otherwise, the entire exercise carried out by Bjorn Lomborg, his Nobel Laureates and some other assorted geniuses seems like an expensive waste of time. Perhaps it's good that the Danish Government is cutting funding to their research. But let's hope they divert the funding to broader health projects, ones that certainly don't target a single disease or type of disease; perhaps they could look at health systems strengthening.

One of the biggest dangers of many of the most popular HIV and other sexual and reproductive health interventions is that they are carried out in badly equipped and funded health facilities, often staffed by badly paid and badly trained personnel. Worse still, many health procedures are carried out in makeshift facilities, by people with no training at all, or even in people's own homes.

Before health programs can be successful, health facilities need to be accessible and safe. There is a need for funding that goes way beyond that of HIV, or sexual and reproductive health more generally. But even HIV and sexual and reproductive health issues can not be addressed until health facilities are vastly improved.


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