Monday, February 20, 2012

Time To Rethink HIV and AIDS Spending

Back in March last year, in an article entitled "Aids to lose ‘special status’ in new plan", Dr Martin Sirengo of Kenya's National Aids Control Program said “HIV is no longer a big issue. It is just like any other disease because we now have the knowledge about it, we have the drugs, and nearly everybody knows about it”. Sirengo is perhaps exaggerating but more than 90% of Kenyans are not HIV positive and many suffer from diseases that could have been prevented or could be treated, if the government (and foreign donors) saw this as important enough.

Sirengo goes on to say that Kenya "is in the process of implementing a disease integration model that will eventually do away with emergency response to HIV/Aids and address it like any other chronic disease." Apparently the program was already underway then and was due to be fully implemented by 2012, resulting in the "demise of special rooms set aside for voluntary counselling and testing at health centres or even special pharmacies for HIV cases".

It's hard to know whether this 'integration' was driven by a desire to spend less money on HIV or if it was seen as a way to spread health funding beyond facilities that deal with HIV and pretty much nothing else. After all, HIV positive and HIV negative people alike suffer from and die from all sorts of conditions. But Sirengo says "These may be the first steps that could eventually lead to the dismantling of parallel, but expensive administrative structures set up to manage the pandemic."

At the time, Sirengo's comments were expected to meet with a lot of opposition from NGOs, government agencies and other parties benefiting from funding specifically for AIDS. He pointed out that specialist skills would still be needed, and that the approach was being gradually rolled out already. But sure enough, a whole group of institutions concerned with HIV and AIDS got together to protest.

It's worth looking carefully at the letter this group wrote, outlining why they see the proposed approach to HIV and AIDS as so objectionable and arguing that HIV is still an emergency. The letter is addressed to the Ministers for Public Health and Sanitation, for Medical Services and for Special Programs. It is pointed out how many people are estimated to be living with HIV, how many need treatment, how many receive treatment, numbers of new infections per year, deaths from AIDS, children born with HIV, etc.

The figures are frightening, but they don't immediately add up to an argument that the country, already starved of public sector spending on health for several decades, should spend so much money on parallel systems for one disease. The letter does not make it clear why testing people for HIV in one place and testing them for all or most other disease somewhere else is a good way of ensuring high levels of public health.

Rather, the big gap between what is required and what is available suggests a more urgent need than ever to use every shilling wisely. If a health facility can test for HIV, why should the same facility not also be able to test for other far more common diseases, including non-communicable diseases?

The letter mentions issues of stigma and discrimination, as if having parallel systems for a disease said to be between 80 and 90% heterosexually transmitted could in any way reduce these; on the contrary, separating HIV from other health issues is far more likely to fuel stigmatizing attitudes and discriminatory behavior. In fact, given that it is unlikely such a massive proportion of the disease really is spread sexually, treating HIV as different from all other diseases is a form of discrimination. People found to be HIV positive are effectively branded as being promiscuous.

However, the group is not opposed to some kind of integration. Rather than opposing the approach at all costs, they seem to interpret Dr Sirengo as using it as a smokescreen to reduce overall spending or as an excuse for continued underspending on health. They are right, sadly, in their claim that health is underfunded. But while HIV may not be overfunded, there appear to be a disproportionate number of institutions and facilities dedicated almost entirely to the virus when the majority of sick and dying people do not have HIV.

Anyhow, all this was before the Global Fund decided that it would be suspending disbursements for the next two years. And now, Dr Sirengo's comments have appeared yet again, this time in an article that says both donors and the government agree that 'downgrading' HIV's 'emergency status' is the way to go. It had been suggested that the Dr's remarks were his own and not representing those of the National Aids Control Program or the government; but even the Public Health and Sanitation Minister, Beth Mugo, is cited as being in agreement: "Integration is the way to go because it makes logistical and economic sense".

If there are about 110,000 new infections every year, and about 90,000 deaths, the costs of treatment and care will continue to rise. But one of the best ways of ensuring that the numbers of new infections go down is to identify who is at risk, what risks they face and what strategies most effectively reduce the risk. It will be painful for many groups working in the HIV and AIDS field to face up to the fact that it's not all about sex, but concentrating almost entirely on sexual transmission has failed; it's a good time to admit to being wrong.

Health facilities need to be safe places, where people don't pick up something worse than they had when they arrived, such as hepatitis or HIV. It would be inhumane to ignore the plight of those who are living with HIV; but it would be insane to continue to leave non-sexually transmitted HIV uninvestigated. And Dr Sirengo is wrong in one crucial respect; almost everyone does not know about non-sexually transmited HIV. If people don't know about non-sexually transmitted HIV, they will not recognize non-sexual risks and will no know how to avoid them.

[For more about non-sexual risks for HIV transmission, see the Don't Get Stuck With HIV site and blog.]


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