HIV Funding: the Rising Tide That Rewards All Collaborators

It's not uncommon to come across articles arguing that funding for HIV is not adversely affecting funding for other health areas and even that funding for HIV is benefiting other health areas. Less common are articles about the basic conditions in the hospitals and health facilities that ordinary people have to use, if they can afford to. While the former articles bear witness to the huge amounts of money being poured into what has become the HIV industry, the latter articles make one wonder what the money is actually being spent on.

In an article entitled "Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap", Renee Hsia and colleagues go through the sort of data collected by Service Provision Assessment reports from MeasureDHS that should be familiar to readers of this blog. Looking at the six areas of "basic infrastructure, equipment, medicine storage, infection control, education and quality control", the authors show that surgery may be available in many facilities in Ghana, Kenya, Rwanda, Tanzania and Uganda, but it's very unlikely to be safe.

Concentrating on infection control, which is vital for ensuring that healthcare is safe, the authors find that facilities with availability of infection control materials (soap, running water, sharp box, latex gloves and disinfectant) ranged from less than 30% in Rwanda to 0% in Tanzania. In fact, availability was lower than 5% in the other three countries. Appropriate collection and disposal of infectious waste was also low, ranging from less than 80% in Uganda to less than 30% in Ghana.

How willing would you be to be circumcised in any of these countries? Or, what seems like an easier option for some programs when it comes to recruiting, how willing would you be to allow your son to be circumcised? As a woman, would you like to give birth in such facilities? Would you even wish to have an injection, for example, to receive some vaccine or the Depo Provera injectable contraceptive that has been so aggressively promoted in African countries despite carrying a number of health risks?

The reason for raising issues like circumcision and Depo Provera so regularly is that there seems to be large amounts of money available for certain sorts of health program in African countries but no money at all for others. If, as claimed by a number of reports, HIV funding 'floats all boats', why are hospitals and health facilities in such terrible condition in some of the very countries that receive a lot of HIV funding? Ghana is the only country surveyed by Hsia and colleagues that is not a PEPFAR focus country. Kenya is one of the biggest recipients of PEPFAR funding (though levels of funding don't seem to bear much relation to the severity of each epidemic).

A recent article (which I can't find at the moment due to limited connection) claims that 750,000 lives were saved by PEPFAR and various other claims were made about how the fund improved health conditions relating to diseases other than HIV. Another one, entitled "A Controlled Study of Funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as Resource Capacity Building in the Health System in Rwanda", by Donald Shepard and colleagues claims that HIV funding does not undermine general health care. The article is well criticized by Victoria Fan of the Center for Global Development, however, the critique makes very bland and polite remarks in the end. Shepard's article is entirely self serving.

To be more accurate, it's the PR around Shepard's article that makes a lot of claims that are not borne out by the article. This does not exonerate Shepard and he is cited several times in the PR saying things that do not appear in the article. Interestingly, the article is partly funded by UNAIDS, who should be very happy with this sales pitch. But there's also mention of Abt Associated, who seem to play quite a strong publicity role in an article that appears in a peer reviewed journal. Perhaps they peer reviewed it themselves, you can never be too sure about academic credentials.

As if conditions in health facilities are not bad enough, and they are certainly bad enough to guarantee that many people visiting health facilities will leave with at least one extra disease they didn't have when they arrive, in Madagascar, Family Health International and other interested parties are promoting the use of Depo Provera, to be administered by non-medically trained workers. If the few trained healthcare workers are unlikely to be able to provide safe healthcare, why should community volunteers be able to do any better? And why is the money being spent on expensive, branded, injectable contraceptives when there are cheaper and safer alternatives?

Aside from the obvious commercial/financial interests in mass male circumcision programs, injectable hormonal contraception programs and extremely expensive vertical HIV programs, it is far more basic things that ordinary people are most lacking. What could be more basic in a health facility than soap and water, latex gloves, bandages, syringes and the like? But some of the countries receiving hundreds of millions of dollars a year from PEPFAR alone (between 2004 and 2010, Kenya has received almost $2.5 billion, Uganda and Tanzania over $1.5 billion and Rwanda $673 million) can not even guarantee the safety of the simplest medical procedures; many can't even provide these procedures. But it's hardly surprising if a rising tide would fail to float the leaky boats, is it?

[For more about non-sexual HIV transmission and injectable Depo Provera, see the Don't Get Stuck With HIV site.]