Tuesday, December 2, 2008

UNGASS and Others Floating on Top

In May of this year, the NACC (National AIDS Control Council) completed the UNGASS (United Nations General Assembly Special Session on HIV and AIDS) report that purported to indicate how Kenya was doing in the fight against AIDS. The report hails Kenya’s success in halving HIV prevalence, from 10% in 1997/98 to 5.1% in 2006. They report that there is “strong political will and commitment at all levels” and that some of the factors that contributed to Kenya’s success include “the improved harmonization and leveraging of resources with and among development partners and" various other technical jargon.

It was surprising that the UNGASS report should have come to these conclusions because the data to back them up was mostly incomplete or simply not supplied. In July of this year, the KAIS (Kenya AIDS Indicator Survey) found that HIV prevalence had actually increased between 2003 and 2007. Prevalence now stands at 9.2% for women and 5.8% for men, with a national prevalence of 7.8%. Rates are usually higher for women as they more easily become infected with HIV.

People working with HIV, including myself, were unsurprised by the KAIS findings. HIV increased in 6 out of Kenya's 8 provinces. It fell slightly in Nairobi and Central provinces. The biggest increases were in Coast and Rift Valley provinces. Increases, in general, are higher for men than for women, suggesting a real increase, rather than an apparent one.

Of more significance to a place like Mumias and the surrounding towns is the fact that the number of people becoming infected in rural areas is far higher than the number in urban areas (1 million people and 400,000 people, respectively). The percentage of infections is higher in urban areas but most Kenyans, around 75%, live in rural areas. Prevalence is 7% in rural areas and 9% in urban areas.

Even the UNGASS report notes that in Kenya, “rural populations continue to trail behind urban ones in the pace at which infection rates drop”. These authors go on to say that 60% of VCT sites are in urban or peri-urban areas and that ways of addressing that imbalance are presently being ‘promoted’. Whatever being 'promoted' means, I hope that after nearly thirty years of HIV, they will find a way of reaching the majority of the population, the same people who are also denied adequate levels of health, education and other social services.

Considering men are being infected in higher numbers now than they were in 2003, it is worrying that far more women test than men and the increase in testing among men has been disappointing. In fact, in both Kenya and Tanzania, I have talked to people who say that men will often get their wife or partner to test and then get tested themselves if the result is positive. In many couples, only one partner is positive, so these men are playing a kind of Russian roulette.

Similarly, apparently people sometimes ask other people, perhaps their partner, to collect antiretroviral (ARVs) drugs on their behalf. This has more serious consequences when both parties are infected as they then end up sharing the drugs, which runs the risk of drug failure and of building up resistance.

Those who are isolated from testing facilities, many rural dwellers, are also isolated from ARV facilities. Malaha, Shibale and Shianda are just three examples of that phenomenon. Because there is no VCT there, there is no outlet authorised to distribute ARVs.

It is not a well kept secret that many Kenyans live in rural areas, nor is it a secret that most VCTs, indeed most public services, are found in urban areas. The need for more voluntary councelling and testing (VCTs) is pressing but even more pressing is the need for mobile VCTs. That is, unless the government is going to pay for people's transport costs to visit a clinic and perhaps compensate them for loss of earnings. I don't see that happening.

UNGASS claims that there are almost 1000 VCTs in Kenya, but that is not enough for the Kenyan population, in excess of 38 million. Nor are the clinics distributed widely enough to be of benefit to most people. This would be the case even assuming that all VCTs are working to capacity, a very risky assumption.

UNGASS also claim that VCT, ARVs and TB medication are given free of charge in government facilities. But as we have seen in Western Kenya, access to those services and other costs are not free. Nor are the other things that people need when on ARVs or TB drugs, such as treatment for various illnesses and nutritional supplements.

(This is similar to the claim that all children are entitled to free primary and secondary education. There are many costs involved in education which are not met by the government and many children are not going to school or their attendance is not very high.)

World AIDS Day in Mumias was great, insofar as many people turned up. I hope the photographs speak for themselves. There was a number of organisations there of various kinds, a UN organisation promoting the AIDS vaccine initiative, the NACC, a big project in partnership with USAID called Aphia II, a Western Kenya based organisation and SAIPEH. The last two are the closest to the people on the ground, but they don't seem to see any of the millions of dollars that are said to go to Kenya every year. Yet they have been round for longer than most of the others.

There was a temporary VCT clinic and a real mobile VCT clinic. Which is wonderful, except that Mumias is the one place out of the four I visited that actually has its own permanent VCT clinic. Not so many people queued up to be tested yesterday, which is a pity, because I'm sure they had plenty of testing kits this time.

But on the subject of VCT, we have probably all heard about how confidential they are, and that's supposed to protect people against stigma and discrimination. Well, if you go to the VCT clinic in St Mary's Hospital, Mumias, you will notice that it is a separate building, outside the hospital compound. Everyone passing can see who is waiting in line outside the clinic and there is only one thing to go there for.

Eileen Stillwaggon, in her excellent book AIDS and the Ecology of Poverty, makes the point that when HIV and AIDS are seen as separate from health and welfare in general, this contributes to the stigma and discrimination suffered by people who are known to be HIV positive. In fact, there are many health conditions that have little or nothing to do with HIV, but that make people more susceptible to HIV.

Stillwaggon suggests that instead of setting up separate, standalone clinics for HIV, governments could set up clinics that treat others of the many conditions affecting people in developing countries. Only by improving health in general will sexual and reproductive health be improved. And reductions in the transmission of HIV will follow.

But more about this sort of argument another time. The top down approach to HIV in Kenya has failed and needs to be changed radically. There are many people who can advise on what sort of changes need to be made. It's time the government started talking to them.


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