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.
Showing posts with label funding. Show all posts
Showing posts with label funding. Show all posts
Monday, February 22, 2010
Friday, January 15, 2010
Uganda Won't Allow Mere Principles to Compromise Foreign Aid
Uganda's President Museveni is not known for being forbearing or fair minded, especially when it comes to men who have sex with men (or, presumably, women who have sex with women). But he has decided to distance himself from David Bahati's bill, which proposes the death penalty for certain offenses relating to homosexual behaviour and prison sentences for others who fail to report homosexual behaviour. It even proposes life imprisonment for persons engaging in same sex relationships.
This is not an instance of Museveni suddenly becoming softhearted, either. There are existing Ugandan laws against homosexuality with very long prison sentences. The country that claims to have had so much success in fighting the HIV epidemic continues to fail some of the people most at risk of becoming infected with HIV and of infecting others. Bahati's bill was certainly heading in the wrong direction but Museveni needs to do a lot more than oppose the work of a power crazed bigot.
Sadly, the Bahati bill had a lot of popular support in Uganda. Other East African countries have similarly punitive laws and there was the fear that if Uganda passed such a law, other countries would follow. It's frightening that most African countries outlaw homosexuality but even more frightening when you hear about the level of persecution homosexuals and those suspected of being homosexuals must put up with from the public, professionals, officers of the law and just about anyone else.
Museveni is said to have been reacting to international protests, especially from countries from which large amounts of donor money come. He mentions pressure from Canadian, American and British leaders and refers to the bill as a 'foreign policy issue', which it clearly is not. It's good that Museveni has decided to question the bill, but it would be more heartening to hear that he had some objection to persecution of and discrimination against homosexuals.
However, earlier on in the debate, people like Bahati said the country should forgo some foreign aid if donors objected. The debate has moved on a little and there was probably never any danger of Uganda refusing foreign aid. Their HIV efforts, and those of most high prevalence African countries, are almost totally dependent on foreign donations. But even some of the American fascist evangelists who originally supported the bill have now started to criticize it.
The best we can hope for right now is for Museveni to succeed in persuading Bahati to withdraw the bill or in persuading people not to support it. That would put Uganda back in the position it is in now with regard to homosexuality. That's not good, but it could be worse. But more pressure is needed, like the pressure against the Bahati bill, in order to ensure that the rights of homosexuals and other minority groups are recognised.
All the talk about Ugandan's and other Africans being so Christian, right minded, conservative and the rest is just so much posturing when you view it alongside people's attitudes towards those who are seen as somehow different. There's something scary about a religion whose adherents seem to behave in ways that are directly contrary to the religion's preachings.
To the Ugandans and other Africans who argue that homosexuality is an export from the West, it could be pointed out that the sort of double standards that allow avowed Christians to persecute their fellow human beings may actually be the worrying export from the West. These double standards are doing and will continue to do a lot of damage; unlike homosexuality, which has always existed in all known human societies, including African ones.
And Museveni has the cheek to talk about not compromising the country's 'principles', while at the same time taking into account 'foreign policy interests', presumably referring to hundreds of millions of dollars of aid money. Yes, it would be totally unchristian to do otherwise.
This is not an instance of Museveni suddenly becoming softhearted, either. There are existing Ugandan laws against homosexuality with very long prison sentences. The country that claims to have had so much success in fighting the HIV epidemic continues to fail some of the people most at risk of becoming infected with HIV and of infecting others. Bahati's bill was certainly heading in the wrong direction but Museveni needs to do a lot more than oppose the work of a power crazed bigot.
Sadly, the Bahati bill had a lot of popular support in Uganda. Other East African countries have similarly punitive laws and there was the fear that if Uganda passed such a law, other countries would follow. It's frightening that most African countries outlaw homosexuality but even more frightening when you hear about the level of persecution homosexuals and those suspected of being homosexuals must put up with from the public, professionals, officers of the law and just about anyone else.
Museveni is said to have been reacting to international protests, especially from countries from which large amounts of donor money come. He mentions pressure from Canadian, American and British leaders and refers to the bill as a 'foreign policy issue', which it clearly is not. It's good that Museveni has decided to question the bill, but it would be more heartening to hear that he had some objection to persecution of and discrimination against homosexuals.
However, earlier on in the debate, people like Bahati said the country should forgo some foreign aid if donors objected. The debate has moved on a little and there was probably never any danger of Uganda refusing foreign aid. Their HIV efforts, and those of most high prevalence African countries, are almost totally dependent on foreign donations. But even some of the American fascist evangelists who originally supported the bill have now started to criticize it.
The best we can hope for right now is for Museveni to succeed in persuading Bahati to withdraw the bill or in persuading people not to support it. That would put Uganda back in the position it is in now with regard to homosexuality. That's not good, but it could be worse. But more pressure is needed, like the pressure against the Bahati bill, in order to ensure that the rights of homosexuals and other minority groups are recognised.
All the talk about Ugandan's and other Africans being so Christian, right minded, conservative and the rest is just so much posturing when you view it alongside people's attitudes towards those who are seen as somehow different. There's something scary about a religion whose adherents seem to behave in ways that are directly contrary to the religion's preachings.
To the Ugandans and other Africans who argue that homosexuality is an export from the West, it could be pointed out that the sort of double standards that allow avowed Christians to persecute their fellow human beings may actually be the worrying export from the West. These double standards are doing and will continue to do a lot of damage; unlike homosexuality, which has always existed in all known human societies, including African ones.
And Museveni has the cheek to talk about not compromising the country's 'principles', while at the same time taking into account 'foreign policy interests', presumably referring to hundreds of millions of dollars of aid money. Yes, it would be totally unchristian to do otherwise.
Friday, January 8, 2010
Will PEPFAR Become a Fund for Health?
It sounds as if PEPFAR (President's Emergency Fund for Aids Relief) is about to change a bit under the Obama administration. These changes are all long overdue. For a start, Aids is no longer to be seen as an emergency. It wasn't an emergency before PEPFAR started, so this is good to hear.
The 'exceptionalisation' of Aids, treating it as if it is a disease that is separate from health in general, should have its own institutions and funding, is to disappear. Again, this move is long overdue, but still welcome. Hopefully, it will mean that some of the huge sums that have been raised for Aids will be spent on health services. Those who think Aids issues will lose out needn't worry, people with Aids also have general health needs. So everyone will gain.
The head of PEPFAR, Eric Goosby, is at last questioning the sustainability of putting everyone who is HIV positive on drugs that they will need for the rest of their lives. Of course, HIV positive people should be treated, but with far more people becoming newly infected for every one put on treatment, something really has to be done to reduce the number of new infections as well.
So HIV prevention should return to the agenda. The question is, what kind of prevention programmes will be funded by PEPFAR? In the past, prevention has included little but lecturing people on their sexual behaviour. There are few prevention programmes that have had much impact on HIV transmission. Of course, most well funded programmes will tell you that they have been very successful and show evidence that whatever mindless drivel they repeated to all and sundry can be trotted out at the ring of a bell, or whatever.
But rates of HIV transmission remain high in many countries, including the US, despite these questionable programmes. Does PEPFAR have anything new to bring to the table? If they don't, it would be good to hear that they are willing to talk about using condoms and employing other harm reduction approaches to HIV. For example, clean needle and syringe distribution and greater advocacy and support for sex workers, men who have sex with men and other vulnerable populations.
Another change proposed is that PEPFAR funds go to governments rather than, primarily, to NGOs. While it's true that NGOs may not have done very well in many cases, I'm not sure about the wisdom of handing large amounts of money to governments. Kenya has had a particularly bad history when it comes to administrating large amounts of money intended for HIV treatment, care and prevention (or any kind of funding). Time and time again, investigations have found administration of funds wanting, only for the money to flow in again once the row has died down. PEPFAR recently announced a doubling in Aids funding, amounting to 2.7 billion dollars over the next five years.(A Ugandan writer also worries about these changes ito PEPFAR.)
Disbursements of US aid for HIV don't relate to a country's need. The HIV epidemic in Kenya is by no means the worst in Africa, even in Sub-Saharan Africa but they are one of the top recipients of funding. No, disbursements seem to depend more on how cozy a country's relationship is with the US and for Kenya, the relationship has been very cozy since independence. Perhaps questions about how much of that money actually benefits people with HIV are irrelevant to PEPFAR, as long as cozy relationships remain, who knows? But let's hope the changes take place and my fears are not realised.
The 'exceptionalisation' of Aids, treating it as if it is a disease that is separate from health in general, should have its own institutions and funding, is to disappear. Again, this move is long overdue, but still welcome. Hopefully, it will mean that some of the huge sums that have been raised for Aids will be spent on health services. Those who think Aids issues will lose out needn't worry, people with Aids also have general health needs. So everyone will gain.
The head of PEPFAR, Eric Goosby, is at last questioning the sustainability of putting everyone who is HIV positive on drugs that they will need for the rest of their lives. Of course, HIV positive people should be treated, but with far more people becoming newly infected for every one put on treatment, something really has to be done to reduce the number of new infections as well.
So HIV prevention should return to the agenda. The question is, what kind of prevention programmes will be funded by PEPFAR? In the past, prevention has included little but lecturing people on their sexual behaviour. There are few prevention programmes that have had much impact on HIV transmission. Of course, most well funded programmes will tell you that they have been very successful and show evidence that whatever mindless drivel they repeated to all and sundry can be trotted out at the ring of a bell, or whatever.
But rates of HIV transmission remain high in many countries, including the US, despite these questionable programmes. Does PEPFAR have anything new to bring to the table? If they don't, it would be good to hear that they are willing to talk about using condoms and employing other harm reduction approaches to HIV. For example, clean needle and syringe distribution and greater advocacy and support for sex workers, men who have sex with men and other vulnerable populations.
Another change proposed is that PEPFAR funds go to governments rather than, primarily, to NGOs. While it's true that NGOs may not have done very well in many cases, I'm not sure about the wisdom of handing large amounts of money to governments. Kenya has had a particularly bad history when it comes to administrating large amounts of money intended for HIV treatment, care and prevention (or any kind of funding). Time and time again, investigations have found administration of funds wanting, only for the money to flow in again once the row has died down. PEPFAR recently announced a doubling in Aids funding, amounting to 2.7 billion dollars over the next five years.(A Ugandan writer also worries about these changes ito PEPFAR.)
Disbursements of US aid for HIV don't relate to a country's need. The HIV epidemic in Kenya is by no means the worst in Africa, even in Sub-Saharan Africa but they are one of the top recipients of funding. No, disbursements seem to depend more on how cozy a country's relationship is with the US and for Kenya, the relationship has been very cozy since independence. Perhaps questions about how much of that money actually benefits people with HIV are irrelevant to PEPFAR, as long as cozy relationships remain, who knows? But let's hope the changes take place and my fears are not realised.
Thursday, December 10, 2009
The One Trick Pony That Can't Defy Gravity
When debates become polarized there can be a danger that neither side can accurately characterize the view of their opponent. Thus, Gregg Gonsalves of the International Treatment Preparedness Coalition characterizes a particular view as the 'Aids backlash' and lumps together a number of views that may not even be held by any particular person or group. He characterizes the backlash thus:
The belief that "the fight against AIDS has misdirected our energies towards broader goals in health and development; the provision of antiretroviral therapy is a folly, it's too expensive and isn't worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea".
Personally I think there is probably not enough money put into the fight against Aids and that much of that money is not being used very well. In particular, I think too little of the money is being spent on prevention and almost all of that is not being used very well. True, it took some time for the international community to face the threat that Aids presented but when they did face it, they came up with a level of funding that has never been matched by campaigns against other diseases or disease groups (such as sexually transmitted infections, water borne diseases, etc).
I don't think the provision of antiretroviral therapy (ART) is a folly and I don't think people who hold the sort of sceptical view I've expressed in the last paragraph necessarily do either. The fact that there are many more people becoming infected than there are being put on ART is not an argument to reduce ART programmes, rather, it is an argument for finding out why HIV prevention is being ignored and rectifying this situation urgently. There is little point in spending nothing on people until they become infected with an incurable illness if something could be done to prevent them from becoming infected.
But also, there is little point in treating people for HIV and leaving them to die of something else. There are many preventable and treatable diseases that are killing people, including people who are HIV positive. I think that this is, in part, because of poor health facilities and services and an acute shortage of personnel. But also, there is a lack of funding that goes back several decades.
I am in complete agreement with Gonsalves when he points out that poor health services are not a result of the Aids pandemic. This is clearly true in Kenya and many other developing countries, where poor health services date back to the early 1980s, when Aids existed but hadn't been identified and certainly hadn't even begun to wreak the havoc that came later. Aids didn't help these ailing health services and certainly decimated the health workforce, as well as the workforce as a whole. But in short, Aids was just another nail in the coffin for public services in general, not just health.
I sympathize with Gonsalves to some extent, but when is money going to be spent on HIV prevention programmes that work, as opposed to programmes that promote purely political (including religious and pseudo-religious) ends? When is money going to be spent on the things that concern the most people, the many diseases and social problems that most people face? I needn't list the diseases or even the problems, Gonsalves would be more aware of them than most.
Some of the people that Gonsalves may gloss over as the 'Aids backlash' wonder how HIV positive people will benefit from a one trick pony health programme that can give them ART but nothing much else, perhaps not even the food they need to be able to take the antiretroviral drugs. They wonder why HIV positive people with certain diseases are more worthy of treatment than those who are dying of the very same easily preventable and treatable diseases. They wonder why those who are at risk of becoming infected with HIV are not entitled to very much, but if they become infected, they may receive a great deal.
But, more importantly, I think: what kind of HIV programmes can be implemented successfully in countries that have inadequate health services, along with poor standards of education, hardly any social services, very little infrastructure, lack of political leadership, governance, legal systems and levels of equality that would be required for these very expensive programmes to work? Even one trick ponies can't work without any solid foundation, as the Aids one trick pony amply demonstrates.
The belief that "the fight against AIDS has misdirected our energies towards broader goals in health and development; the provision of antiretroviral therapy is a folly, it's too expensive and isn't worth the money to continue its expansion; efforts against AIDS are destroying health systems and promoting unnecessary deaths from other simpler-to-treat diseases and conditions such as childhood diarrhea".
Personally I think there is probably not enough money put into the fight against Aids and that much of that money is not being used very well. In particular, I think too little of the money is being spent on prevention and almost all of that is not being used very well. True, it took some time for the international community to face the threat that Aids presented but when they did face it, they came up with a level of funding that has never been matched by campaigns against other diseases or disease groups (such as sexually transmitted infections, water borne diseases, etc).
I don't think the provision of antiretroviral therapy (ART) is a folly and I don't think people who hold the sort of sceptical view I've expressed in the last paragraph necessarily do either. The fact that there are many more people becoming infected than there are being put on ART is not an argument to reduce ART programmes, rather, it is an argument for finding out why HIV prevention is being ignored and rectifying this situation urgently. There is little point in spending nothing on people until they become infected with an incurable illness if something could be done to prevent them from becoming infected.
But also, there is little point in treating people for HIV and leaving them to die of something else. There are many preventable and treatable diseases that are killing people, including people who are HIV positive. I think that this is, in part, because of poor health facilities and services and an acute shortage of personnel. But also, there is a lack of funding that goes back several decades.
I am in complete agreement with Gonsalves when he points out that poor health services are not a result of the Aids pandemic. This is clearly true in Kenya and many other developing countries, where poor health services date back to the early 1980s, when Aids existed but hadn't been identified and certainly hadn't even begun to wreak the havoc that came later. Aids didn't help these ailing health services and certainly decimated the health workforce, as well as the workforce as a whole. But in short, Aids was just another nail in the coffin for public services in general, not just health.
I sympathize with Gonsalves to some extent, but when is money going to be spent on HIV prevention programmes that work, as opposed to programmes that promote purely political (including religious and pseudo-religious) ends? When is money going to be spent on the things that concern the most people, the many diseases and social problems that most people face? I needn't list the diseases or even the problems, Gonsalves would be more aware of them than most.
Some of the people that Gonsalves may gloss over as the 'Aids backlash' wonder how HIV positive people will benefit from a one trick pony health programme that can give them ART but nothing much else, perhaps not even the food they need to be able to take the antiretroviral drugs. They wonder why HIV positive people with certain diseases are more worthy of treatment than those who are dying of the very same easily preventable and treatable diseases. They wonder why those who are at risk of becoming infected with HIV are not entitled to very much, but if they become infected, they may receive a great deal.
But, more importantly, I think: what kind of HIV programmes can be implemented successfully in countries that have inadequate health services, along with poor standards of education, hardly any social services, very little infrastructure, lack of political leadership, governance, legal systems and levels of equality that would be required for these very expensive programmes to work? Even one trick ponies can't work without any solid foundation, as the Aids one trick pony amply demonstrates.
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