World AIDS Day is a time to celebrate successes in tackling the HIV/AIDS epidemic. The global response has achieved reductions in the numbers of AIDS deaths and of new infections which we might once have thought impossible. Globally, over 20 million people are receiving antiretroviral therapy (ART) and the annual number of AIDS deaths has halved from around two million in 2004 to one million in 2017. The number of new infections has dropped from three million in 1997 to under 1.5 million in 2018.
However, it is also a day to recognise that huge numbers of people are still dying and becoming infected with HIV. So, while the potential to end AIDS as a public health emergency is there, achieving that will still take concerted effort and resource allocation.
Central to success will be the achievement of the goals of the 90-90-90 Fast Track strategy and the 2016 Political Declaration on HIV. These aim for high levels of HIV testing, antiretroviral treatment access, and successful viral suppression, as well as intensified HIV prevention, underpinned by elimination of stigma and discrimination affecting people affected by HIV.
Some regions and countries face particular challenges. In western and central Africa only around 40% of people living with HIV/AIDS (PLWHA) are aware of their status, compared to 70% or more in most other regions. In eastern Europe and central Asia, an estimated 70% of PLWHA know their status but less than half of those are on treatment. By comparison, in eastern and southern Africa, around 80% of PLWHA know their status and around 75% of those are on treatment.
Achieving ambitious global and country targets requires countries to scale up existing interventions to achieve scale. But progressing the next few percent towards targets increasingly requires innovations. These need to fine tune standard interventions, and also to supplement them with new models that can serve harder-to-reach populations and address more challenging risks and needs. In addition, responses need to use available resources more efficiently to ensure efficiency, affordability, and sustainability within available resources.
OPM has for some time been supporting the HIV and AIDS response. This has included its work on many aspects of strengthening health systems and improving financing for health care. In addition, OPM has worked in key areas such as financing options for HIV responses and health, and improving efficiency of the HIV response and services.
In OPM’s current work, several challenges to controlling the epidemic and its effects are prominent.
In the current funding environment, particularly in countries transitioning from Global Fund support, countries need to investigate and start developing customised, evidence-based sustainability roadmaps and plans with stakeholder agreement. A number of countries are engaging in National AIDS Spending Assessments, investment cases, and costings and efficiency analyses to define resource requirements and more efficient ways of using available resources. However, best practices in planning for transitions and sustainability are still being established.
Achievement of targets is particularly difficult in certain contexts and customised approaches are required. Innovative, differentiated models for delivery of services to communities must deal with financial and capacity constraints and make service more accessible.
Challenges to scale up in west and central Africa are a particular concern in current work to support the regional catch-up plan. New understanding of epidemics in the region, as well as new evidence on the effective models and approaches and targeting of interventions in responding to the epidemic, have been emerging, and can accelerate impact of responses. Consideration is being given to analysing bottlenecks, implementing new more accessible models for service delivery, and potential to enhance the role of civil society to deliver services and deal with issues such as barriers related to stigma and discrimination.
The Global Fund (GF) is a critical contributor of resources for achieving Political Declaration and 90-90-90 targets. Maximising the impact of those resources often requires support to help country-level implementers to overcome bottlenecks, including stigma and legal barriers to services effectiveness, and improving management systems and capacity of implementers. Strong monitoring and evaluation, and effective use of strategic information is required to track impact of GF-supported programmes on fast-track targets, to inform both management and planning to expand effective delivery models for greatest impact, and to ensure more effective responses to key populations.
The number of HIV-infected people who need care and treatment continues to accumulate. The Global Coalition on HIV Prevention has emphasised the need for greater momentum and strategic investment in HIV prevention. This will require more effective coverage of proven, effective interventions including condoms, circumcision, ART, prevention of mother-to-child transmission, and harm reduction. But ending AIDS will also require a combination of these with enhanced intervention models, and innovations such as PrEP, to provide people with a menu of options which responds to their diverse needs and risks.
UNAIDS has launched a Technical Support Mechanism (TSM) to provide quality technical support to assist its partners at country, regional and global levels to achieve priority HIV programme results. OPM has been appointed to manage the Technical Support Mechanism for UNAIDS. You can read more about it in our dedicated project page.
The UNAIDS TSM is focusing on assisting countries to maximize impact of financial support from the Global Fund (GF), in line with the Fast-Track Strategy and the Political Declaration on HIV (2016). The UNAIDS TSM has a primary focus on three regions eastern and southern Africa (ESA), Asia Pacific (AP) and western and central Africa (WCA),
]]>Two interventions in India are considered particularly effective and scalable interventions. A number of studies on these is presented. Both of these programmes focus on community mobilisation, and involve female sex workers (FSWs), as well as other key groups.
The key messages identified are:
The review of the six simulation models found estimates of costs per HIV infections averted (HIA) between $150 and $900 in high HIV prevalence settings over a 10-year time horizon, and $100 to $400 when including infections averted to 20 year. Cost-effectiveness models from individual studies estimate (download the full report for references):
Value-added from male circumcision comes from reduction in other sexually transmitted diseases.
Cost-effectiveness estimates identified are promising but vary widely, making it difficult to draw conclusions. Estimates are sensitive to inputs such as costing of the MC and treatment averted, the protective effect, and HIV prevalence. Estimates are also likely to vary over time due to inflation.
]]>In a way the development of anti-retroviral (ARV) based prevention is a similar moment. We now know that when positive people take treatment it can reduce the amount of HIV in their bodies to non-transmissible levels. Pre-exposure prophylaxis (PrEP) for HIV negative people, unarguably has the potential to stop transmission on a scale that could play a significant role in ending the HIV epidemic.
But in another way it is a quite different moment. Rather than a single, self-evidently justified demand PrEP creates a complicated set of ethical, legal, policy and practical challenges. Many of these relate to gender, equity and rights. In the lead up to International Women’s Day it is worth considering how we might collectively meet these challenges and learn from them in relation to the creation of new health technologies.
For people living with HIV the preventive value of ARV medication is a side effect of lifesaving treatment whereas PrEP is taken by well people. In medical ethics it is accepted that the safety level required of medication for treatment differs from that for prevention. The issue is simple, if a drug that might cause damage in the long term saves the lives of patients it is ethical to approve it as treatment but not ethical to provide it to people who are not ill. Despite many studies that suggest that PrEP will, or will not, have harmful side effects, the fact is we don’t know what might emerge in millions of PrEP users over decades. Medical history is littered with such scenarios. This concern led the trials of PrEP to be closed in Cameroon and Cambodia, when sex workers who were the subject of study realised that if the drug damaged them in years to come they would not be eligible for any kind of support. In response to the complaint in Cambodia researchers offered compensation of $36 per participant, which sex workers unsurprisingly took as a deal breaking insult.
A further ethical complication is that since PrEP is not a contraceptive and does not protect from sexually transmitted infections there is potential forharm to come to users who replace a proven prevention technology, condoms, with PrEP. This generates obligations in respect of the messages and targeting of the medication to women. Most research is focused on men, and the most vocal demand for PrEP to be approved and subsidised comes from men. The product developed for ‘high risk’ women whose adherence to daily pills is likely to be poor is a microbicide ring which can be inserted into the vagina for a month at a time. Enthusiasm for the ring has come primarily from public health agencies rather than potential consumers who are keen to lower their HIV risk. Notably the efficacy of the vaginal ring appears to be far lower than for oral PrEP.
Useful, independent research and rich discussions about PrEP and women in various settings do not seem to be occurring. If insightful guidelines about who should, and should not, be prescribed PrEP are being developed this is not an open process. Nor are plans for the anti-discrimination measures or public health messages that will be needed if PrEP is to fulfil its potential. So far we are only seeing grand claims about ‘saving millions of lives’ of people classified as being at risk. These are based on epidemiology’s crude mega-populations – sex workers, men who have sex with men, sero-discordant couples and transwomen.
It is certainly true that many of those most in need of access to PrEP live precarious lives but that precarity is driven by discrimination, violence and laws against drugs, sex work, and homosexuality that form a powerful barrier to any form of health care or preventative measure. The tension between public health and human rights on one hand, and punitive legal environments on the other, has been well documented in relation to HIV. But in many countries law has not kept up with developments in HIV so that the work of public health authorities and services to ‘key populations’ continues to be impeded by policy that reflects irrational fear and stigma. Criminalisation of HIV, sex work, adultery, abortion and the potential for civil legal actions remain a reasonable fear that drives barrier to the regular testing that must accompany PrEP.
One of WHO’s building blocks of the health system is ‘medical products and technologies’. Yet the example of PrEP demonstrates that the existence of an efficacious medication is only the starting point for the complex array of ethical and practical decisions that need to be made to improve health outcomes. And these decisions are molded by, and imbued with, questions of power, gender, and marginality. In the case of HIV sexuality, legal status, and poverty are particularly profound intersecting issues.
All too often we are lacking vital social science research that demonstrates – not that particular medication works – but the situations under which the introduction of a new technology can bring positive benefits, the unanticipated consequences of change, the beliefs and the preferences of particular ‘beneficiaries’ of interventions, and the motivation of those who seek to intervene.
Recent discussions about universal health coverage and its relation to human rights have highlighted that health policy change is not purely a technical, quick fix, driven by costing data alone. Rather there are political questions at play which are profoundly influenced by national and international law and the power and agency of citizens to demand their entitlements.
As discussions about PrEP move forward – and significant progress is being made quite rapidly – there is an urgent need for activists, health systems researchers and public health agencies to use their skills to ensure that due consideration is given to the health and human rights of women. Unless that happens the epidemic ending potential of ARV based HIV prevention will not be realised.
By Cheryl Overs, Research Fellow at the Michael Kirby Centre for Public Health and Human Rights at Monash University in Australia and the Institute of Development Studies in the UK
This blog was originally posted on Health Systems Global on 4 March 2016. Reposted with permission.
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Empirical data shows that, despite much higher mortality rates from NCDs, external funding for HIV is higher than for NCDs. From 2002 to 2009, funding totalled US$68,481,730 for HIV and US$32,910,778 for NCDs. External assistance for HIV activities in the Pacific in 2009 was more than US$18 million, while funding for NCDs in the same year was almost US$12 million.
Despite cooperation from many agencies, the funding data were difficult to gather, highlighting the need for greater transparency of funding information and more thorough record keeping. The external funding does not align with the disease and mortality figures, and further interviews suggested that donor funding decisions in the region are driven not by local priorities but by factors including a strong global HIV community, the commitment to the Millennium Development Goals (MDGs) and the lack of coherence in the way NCDs are presented to policy makers.
]]>DFID funding was allocated as budget support to the Government of Sierra Leone (GoSL), with disbursements released based on progress made against agreed milestones that were monitored by a joint donor Government Payroll Steering Committee (PSC). Over the lifetime of the project underperformance against some of the milestones led to 600,000 GBP of the funding not being disbursed.
The project was delivered through three outputs, aimed at increasing the uptake of health care by the most vulnerable. These included: (1) the efficient management of the payroll, (2) enhanced capacity of the Ministry of Health & Sanitation (MoHS) to manage the attendance and deployment of human resources for health (HRH), and (3) effective community oversight of the FHCI.
Overall, the project has scored an A as it has met expectations. The salary uplift has helped to attract, retain, and motivate health workers in the public health sector and to reduce absenteeism and moonlighting, despite increasingly heavy workloads as a result of the removal of user fees. The salary uplift has also attracted health workers back from the private sector.
The holding of PSC committee meetings and the frequency of monitoring visits to the districts decreased in the last year due to travel restrictions that were put in place because of the Ebola outbreak. This has meant that there is limited data to judge performance against the 2015 milestones. However key informants have reported that the support provided to salaries through this project, and the availability of motivated frontline workers contributed to the resilience of the health workforce during the Ebola outbreak and enhanced the GoSL’s response to it.
This project completion report provides details of programme performance, output scoring, and value for money and financial performance. It also provides a set of recommendations for the GoSL (particularly the MoSH) and DFID and other development partners.
]]>In March 2015, the Global Health Action produced a special issue on Gender and Health. One of the articles which I co-authored together with colleagues from Liverpool School of Tropical Medicine, Eleanor MacPherson, Sally Theobald and Esther Richards, highlights critical issues regarding sexual and reproductive health (SRH) in East and Southern Africa. We conducted a literature review on gender and health with the aim of identifying important issues for action.
The review found gender inequalities to be common across a range of health issues relating to SRH with women being particularly disadvantaged. Gender inequality is a critical structural constraint to development and improved health outcomes. Gendered social norms undermine women’s position in society leaving women with limited access to social and economic resources and impacting negatively on women and girls’ health and well-being. The ability of women to realise their sexual and reproductive rights is vital to achieving gender equity in health as well as the empowerment of women. SRH relates to the health and well-being of people in matters related to sexual relations, pregnancy, and birth. The ability of women to realize their sexual and reproductive rights is vital to achieving gender equity in health as well as the empowerment of women.
Eastern and Southern Africa have the highest burden of infectious diseases including HIV and AIDS. The high HIV prevalence could be a significant contributor to high mortality rates within this region. This region also has high maternal mortality rates. Comparison of data from the 16 ESA region between 1980 and 2008, actually showed worsening maternal mortality rates in Bostwana, DRC, Lesotho, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. Almost half of all maternal deaths occur during labour, delivery, or the immediate postpartum period. There is also a high unmet need of contraceptives which can lead to higher likelihood of unsafe abortions. Gender based violence is common and takes multiple forms – physical, sexual, psychological and economic. The data on gender based violence is shocking, for example in a study in South Africa, 27.6% of the men interviewed admitted to raping a woman; while estimates by the United Nation’s Children Fund reveal that 13-49% of women having been physically assorted by an intimate male partner.
Gender equity analysis is important
On Sunday March 8, we commemorated the Women’s International Day, which reinforced for me the importance of gender equity analysis. It is critical that the focus on gender analysis is not lost in health research in order to have better understanding of how gender impacts on health inequities and related health outcomes. The Research for Equity and Community Health Trust has been central to debates and research that is close to policy to put forward gender and equity perspectives. Studies have shown gender to be an important determinant in access to health services. Analysis of pathways to care seeking in Malawi shows that women take longer to report to health facilities than men. The delay period amongst TB patients showed that women took longer to be diagnosed with TB than men and had more repeated visits. An exploration of desire to give birth among people living with HIV showed that women often against their wishes, were under pressure from their partners and spouses to fulfill community expectations in having children. Access to family planning was hindered as some men perceived that the use of modern contraceptives negatively affected marital sexual relations. Gender also has impact on men living with HIV as often perceptions of masculinity affect access and retention to HIV services resulting in poor treatment outcomes.
Opportunities for advancing gender equity in health
Many researchers, like the ones in RinGs, are exploring ways to make health systems more gender-responsive and more gender-equitable. An issue that is important to me is the role of close-to-community providers, as I am the principle investigator for the REACHOUT consortium in Malawi. Effective community health worker (CHW) programmes have shown to have potential to better meet the needs of women, tend to be easily accessible, and minimize costs of care seeking. A study which investigated the impact of using CHWs to promote early diagnosis and referral for HIV, showed a 37% increase in new patients initiating antiretroviral therapy and 61% increase in uptake of HIV testing within a 12 month period. CHWs are strategically placed to understand the challenges women face in accessing care and how this relates to broader societal and infrastructural challenges including gender norms. However for CHWs to be effective, there is need for mechanisms that sufficiently support and motivate them such as a responsive referral systems, adequate training, supportive supervision, community engagement and good coordination among the different stakeholders working at community level. We hope to learn more about this as our REACHOUT work progresses.
By Ireen Namakhoma – Ireen Namakhoma is the Director of the Research for Equity and Community Health (REACH) Trust, Malawi.
Originally posted on RESYST on 30 March 2015.
RinGs (Research in Gender and Ethics: Building stronger health systems) is funded by DFID and brings together three health systems focused Research Programme Consortia (RPC): Future Health Systems, ReBUILD, and RESYST in a partnership to galvanise gender and ethics analysis in health systems.
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