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Tag Archives: Tanzania

Choke on it: Peak Free Lunch at HIV Inc?

There have been several mentions recently of significant cuts in HIV funding, including PEPFAR and the Global Fund for Aids, TB and Malaria. It is said that funding could be cut by several billion dollars per annum, even as much as one third of all funding. Should we be worried?

According to UNAIDS, funding available for low and middle income countries has grown from $4.8 billion in 2000 to $19.5 billion in 2016. During that time, deaths from Aids have dropped from a peak of 1.9 million people in 2005 to 1 million in 2016.

The number of new infections has gone from about 4.7 million in 1995 to 1.8 million in 2016 and the number accessing treatment has gone from 685,000 people in 2000 to 19.5m people in 2016. The fear is that the number of deaths will cease to drop, or even increase, as the number of people on treatment flattens out or drops.

The gains over the last 15 years are certainly impressive, especially the increases in funding. But the correlation between increases in funding and improvements in HIV indicators is not so clear. Drops in rates of new infections had started many years before, and even death rates had peaked and started to decline before funds such as PEPFAR and GPATM would have had much impact.

In fact, figures for new transmissions in some high prevalence countries started to drop in the 80s (Uganda) and 90s (Kenya and Tanzania), long before big funding and large treatment programs were available. By the 2000s, several countries with serious epidemics were already seeing a substantial downward trend (Zimbabwe), with only an occasional upward blip, such as that experienced in Uganda.

Here are some ways that a lot more could be achieved with a lot less money:

  • Trace the possible source of every new infection; every new infection is potentially the source of more than one further infection, so failure to trace sources represents one of the biggest missed opportunities of the last 30 years of providing HIV services
  • Offer non-HIV healthcare services to those who test negative (as an incentive to testing), eg, free treatment for conditions other than HIV, including STIs
  • Re-examine the relative contributions of non-sexual and sexual infection routes for HIV, which must vary considerably from country to country, even within countries
  • Re-integrate HIV clinics and services into other health facilities, getting rid of expensive parallel HIV-specific structures
  • Distribute funding at a level closer to people on the ground, such as HIV positive people and those providing services
  • Re-direct some of the remaining funding to improving safety in certain service areas, eg, maternal health
  • ‘No blame’ investigations into serious outbreaks, especially among those whose risk should be low, eg, maternal health beneficiaries, virgins, infants, etc
  • Drop failing programs, such as abstinence-only and other behavioral programs that are aimed solely at sexual behavior
  • Listen to leaders who are calling for positive change, for things to be done differently, for a re-think of some of the strategies that have been failing for a long time

Big reductions in HIV funding could be used as an opportunity to make positive changes in the way the remaining funding is spent, and allow each dollar to go much further. Country leaders need to think differently, rather than chaining themselves to strategies that have been failing for years. Massive HIV NGOs and other institutions are too far removed from individual epidemics to be able to see differences between countries and within countries.

What we should worry about is stasis: static thinking in HIV institutions, static research focus in universities, static behavior in health facilities, static attitudes that have not moved on from the sensationalist finger-pointing of the 1980s. Static or falling funding is irrelevant so long as HIV spending remains independent of what’s happening on the ground. A radical drop in funding may bring about the very changes that have been wanting for decades.

Hepatitis, TB, HIV and Ebola: Healthcare Associated Epidemics?

It is sometimes claimed (by UNAIDS and others) that if HIV was frequently transmitted through unsafe healthcare in sub-Saharan countries, then hepatitis C (HCV) would also be common in the same countries, because HCV is usually transmitted through unsafe healthcare (dental procedures, surgery, stitches, etc). Indeed, HIV prevalence is often higher in countries that have low prevalence of HCV; and the high HCV countries tend to have low HIV prevalence.

However, given that it is well established that both viruses can be transmitted through unsafe healthcare, and that unsafe healthcare practices are probably very common in most (all?) African countries, the non-correlation between HIV and HCV prevalence seems like a very weak and unappealing argument. Because we don’t know the relative contribution of HIV transmission through unsafe healthcare, neither do we know how much transmission is a result of heterosexual sex.

Blaming high rates of HIV transmission almost exclusively on ‘unsafe’ heterosexual behavior has a number of dangerous consequences. For a start, it stigmatizes those who are already infected. It also results in people who don’t engage in ‘unsafe’ sexual practices failing to recognize their risk of being infected. More serious still, it means that public health programs aiming to influence sexual behavior will be relatively ineffective.

HCV prevalence in Egypt is the highest in the world and HIV prevalence is low. But a recent survey concludes that “Invasive medical procedures are still a major risk for acquiring new HCV infections in Egypt“. It sounds like measures to reduce transmission have not yet been completely successful. More worryingly, another paper finds that “there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities“.

What about countries where HIV prevalence is extremely high, such as South Africa? HCV prevalence is very low, so the UNAIDS argument above would suggest that unsafe healthcare does not play a significant role in HIV transmission. But does that mean unsafe healthcare is unimportant? After all, resistant strains of TB have been transmitted in hospitals in South Africa and this has even spread beyond South Africa, to surrounding countries, and even to another continent.

In reality, we don’t know that much about HCV in the Africa region. A review of research on the subject concludes that “Africa has the highest WHO estimated regional HCV prevalence (5.3%)” in the world. That’s a striking figure, because HIV prevalence across the whole sub-Saharan African region is also around 5%. There are two serious viral pandemics on the continent that may both be driven to a large extent by unsafe healthcare.

HCV concentrates in certain countries and in parts of certain countries. But so does HIV. Prevalence is relatively low in most of Kenya, for example, only a few percent. It’s high in the two large cities, Nairobi and Mombasa, and highest in three (out of 47) counties around Lake Victoria. The situation in Tanzania is similar, with three high prevalence areas. In Burundi and Rwanda prevalence is also low, except in the capital cities.

So the fact that most high HIV prevalence areas do not overlap much with high HCV prevalence rates is not a very convincing argument that the two viruses are transmitted in completely different ways, the former being mainly transmitted through heterosexual sex and the latter through unsafe healthcare. Comparing HCV and HIV patterns only makes the contention that HIV is mostly sexually transmitted look all the more infantile.

The good news, then, is that improving healthcare safety would reduce transmission of both HCV and HIV, and even a range of other diseases that don’t get anywhere near as much attention as HIV. Good healthcare is also safe healthcare, whereas indifferent healthcare, with low standards of infection control, results in alarmingly high rates of transmission of serious diseases.

Journalists have recently had their attention drawn to the potential drawbacks of neglecting healthcare; ebola is difficult to control in a healthcare environment (as opposed to a rural village, where it appears to die out quite quickly). But it has been shown that it is difficult to control in healthcare facilities because of unsafe practices, such as reuse of skin-piercing instruments, gloves and other disposable supplies, lack of infection control procedures, a shortage of skilled personnel, etc.

One newspaper article even made a connection between ebola and HIV, suggesting that because many West African countries had relatively low HIV epidemics, investment in healthcare was lower, hence the weakness of the response to ebola.

Their analysis is not very perceptive. HIV-related investment in Sierra Leone and Liberia has been high enough to ensure that more than 80% of HIV positive people are provided with antiretroviral treatment. Guinea is way behind them in this respect, with less than 50% of people receving treatment. But spending money on preventing supposedly sexually transmitted HIV, and on treatment, does nothing to address unsafe healthcare.

HCV, HIV, ebola, TB and various other diseases can be transmitted through unsafe healthcare, so this is an argument for strengthening all health facilities in all developing countries. A human right to health does not make any sense if healthcare is so unsafe that patients risk being infected with a deadly disease when they visit a health facility. So ‘strengthening’ healthcare must include making health facilities safer.

It is hardly surprising that people in Guinea, Sierra Leone and Liberia run from health authorities and hide family members who are sick. The prospect of having your house searched by people in hazmat suits, sometimes backed up by people with guns, is frightening enough. But if your property is dragged outside in broad daylight and burned in public, and your sick relatives are hauled off to a ramshackle, understaffed, undersupplied health facility, these must extremely traumatic experiences.

If health facilities are unsafe, healthcare associated transmission of serious diseases will only increase as more people are admitted to them. Transmission rates will not go down until safety is made a priority; this applies as much to HIV as it does to HCV, ebola, TB and other diseases. The additional assurance that people will not be exposed to life-threatening diseases through unsafe healthcare should also increase demand for healthcare.

What Kind of HIV Risks do Public Sector Employees Face? Sexual? Non-Sexual?

An article in the Arusha Times claims that public sector employees may be more vulnerable to HIV. This is not too surprising because HIV prevalence is higher among employed than unemployed people in Tanzania and a lot of other higher prevalence countries. Prevalence is also higher among urban dwelling people, wealthier people, and various other groups.

But the question is, why is their risk higher, often much higher? One of those cited in the article is said to have urged “married couples to go for tests on their HIV status without any suspicion on who among the two was to blame in case he or she tested positive”. Maybe neither are ‘to blame’. Many HIV positive people are married to or living with only one, HIV negative person. They don’t know how they were infected. However, the HIV industry insists that they were almost definitely infected through unsafe sex. Perhaps public sector employees face non-sexual risks, such as those from unsafe healthcare, traditional or cosmetic practices?

[There have been a number of unexpected infections in infants and young adults in Tanzania in the 1980s and 1990s and these may have been cases of healthcare associated HIV, but they have yet to be investigated.]

UNAIDS’ 3 Ones: One Disease, One Theory, One Solution

According to “more than $400 million [of donor funding] was committed to HIV and AIDS in 2007/2008“. However, less than a quarter of that funding, probably around 20%, was spent on ‘prevention’, with the usual assumption that almost all HIV is transmitted through heterosexual behavior. Around 60% is estimated to have been spent on treatment and care, say around $240 million.

It’s tremendous that a lot of money is being spent on treating and caring for people who have been infected with HIV. Not all HIV positive people are currently eligible for treatment. Perhaps UNAIDS’ claim that 60% of those who are eligible were on treatment at some time, although the figure, however many hundreds of thousands it may be, does not discount those who have died or who have been otherwise lost to follow up.

Around 95% of Tanzanian people are HIV negative. Out of the 1,470,000 people who are living with HIV, between one and two thirds may be on treatment. That’s 1-2% of Tanzanian people, at the most. So how do those who control the money decide how to spend the approximately $80 million in order to reduce transmission of HIV; what kind of prevention activities should be prioritized among those 46,300,000 Tanzanians who are still uninfected?

UNAIDS has a slogan (aside from their ‘three ones’ slogan alluded to in the title above) that goes ‘know your epidemic – know your response’. This makes it sound like UNAIDS believes that there are different epidemics in each country, and perhaps even different subepidemics within each country. But their response is always to treat HIV epidemics in Africa as if they are all virtually the same, although they may vary in intensity: but they are all assumed to be ‘driven’ by heterosexual behavior.

It’s not very clear how far $1.70 per head can go towards ‘changing people’s sexual behavior’, but that hasn’t stopped UNAIDS and other big players in the HIV industry (and some of them are very big players indeed) from trying. Billions have been spent on wagging fingers at rooms full of adults and children over the almost 20 years of UNAIDS’ existence.

Luckily there are a few things that can be done to help establish that HIV is probably not entirely heterosexually transmitted and that most finger-wagging exercises are a complete waste of money (their inherent paternalism is probably not considered to be a disadvantage; perhaps neither is their clearly demonstrated ineffectiveness).

For example, in Tanzania (and most other countries) there are only a few places where HIV prevalence is really high. Here’s a list of prevalence by region (the five with the lowest prevalence are the Zanzibar archipelago):

Njombe 14.8
Iringa 9.1
Mbeya 9
Shinyanga 7.4
Ruvuma 7
Dar es Salaam 6.9
Rukwa 6.2
Katavi 5.9
Pwani 5.9
Tabora 5.1
Kagera 4.8
Geita 4.7
Mara 4.5
Mwanza 4.2
Mtwara 4.1
Kilimanjaro 3.8
Morogoro 3.8
Simiyu 3.6
Kigoma 3.4
Singida 3.3
Arusha 3.2
Dodoma 2.9
Lindi 2.9
Tanga 2.4
Manyara 1.5
Mjini Magharibi 1.4
Kusini Unguja 0.5
Kusini Pemba 0.4
Kaskazini Pemba 0.3
Kaskazini Unguja 0.1

And there are further generalizations that can be made about HIV in Tanzania. Prevalence tends to be higher among females, urban dwellers, wealthier people, people with higher levels of education and employed people. It tends to be lower among men, rural dwellers, poorer people, people with lower levels of education and unemployed people.

UNAIDS tends to ‘analyze’ these features, which are shared by all high HIV prevalence countries, and conclude that wealthier, urban dwellers with jobs have bigger ‘sexual networks’ (etc) as if every person with HIV must have a ‘sexual network’ (etc). But there are other figures they could avail of when they are in an analytical frame of mind.

For example, while women are said to be more susceptible to HIV infection for various biological reasons, wealthier, urban dwelling, better edcated women with a job are also much more likely to attend ante natal clinics (ANC) and seek the assistance of some kind of trained health professional when they are giving birth.

Now, you might expect women who attend ANCs and have assisted deliveries to be less likely to be infected with HIV, but you’d be wrong. In many instances they are more likely to be infected, sometimes a lot more likely. Indeed, some countries with the highest HIV prevalence figures also have the highest ANC and attended birth figures, Swaziland, Lesotho, Namibia and Zimbabwe, for example. The contrary tends to be true of low prevalence countries in sub-Saharan Africa.

This is not to say that HIV is never transmitted through heterosexual sex, or that it is always transmitted through unsafe healthcare (even among women). It’s just a clear indication that we need to know exactly what contribution heterosexual behavior makes to epidemics, and what contribution may be made by non-sexual routes, such as unsafe healthcare, cosmetic care and perhaps other practices.

The whole concept of a UN agency set up to ‘fight’ one disease is bad enough. But it’s a whole lot worse if they and the rest of the industry continue to squander precious resources on poorly targeted and ineffective interventions. Resources need to be spent on health, defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (there’s no irony intended in citing WHO here).

Apparently one third of all aid in Tanzania is being spent on HIV, which leaves the other two thirds to be spent on other development areas. So perhaps some of that will eventually be used to address the many poorer, less well educated, jobless people living in rural areas with virtually no infrastructure or social services, but who are HIV negative. They will likely remain negative if even a fraction of available donor funding is spent on working out the relative contribution of unsafe healthcare to the worst HIV epidemics in the world and addressing this issue, however belatedly.