Low Cost Production Of HIV-related Healthcare By grassroots CBOs in South Africa, Zimbabwe, and Uganda; What It Means Exactly.

“The world must increase the amount of resources available for HIV by US$1.5 billion each year between 2016 and 2020, a situation that is looking increasingly unlikely. New HIV infections are falling, but more antiretroviral drugs are needed. The huge mobilisation of resources for the global HIV and AIDS response over the course of the epidemic has been unprecedented in the history of public health. The challenge of funding HIV treatment, prevention and care in middle- and low-income countries has been characterised by vocal advocacy, unique and innovative funding mechanisms, previously unseen levels of bilateral (direct government-to-country) aid, and philanthropic donations whose scale have rivalled those of donor governments and multilateral institutions,” (Avert, 2018).  For more on this see funding for HIV and AIDS, 

Healthcare is a merit good and individual countries must devise means to provide resources in form of money, integrated social services and engaging a populace in self care. “Nowadays healthcare is commonly considered a ‘merit good’ – a commodity which is judged that an individual or society should have on the basis of need rather than ability and willingness to pay, “(Esteban Ortiz-Ospina and Max Roser, 2018). For more read their paper titled “Financing Healthcare.”

Following reduction in funds for maintaining a supply chain for ARVs, there are tried and tested practices the three countries can pursue to sustain a roll back effort. Knowledge of the new trends and empowering communities to access prevention and care tools will enable HIV Service providers in Africa to provide low cost HIV-related healthcare. Low cost, because this will be an opportunity to show case value for money results.  This will mean a people living with HIV-centered programming. I use the Politics, People, Prevention and Planet Model to elucidate this. 

This model relies on collaboration within countries, at international levels and maintaining partnerships which helps mobilize resources to establish prevention and care infrastructure. Some examples in crude: EGPAF, Case Western, Johns Hopkins, Medical Research Council, Harvard AIDS Institute, CDC, Bill and Melinda Gates and Clinton Foundation which speed the development and implementation of effective and sustainable medical/public health interventions. The Global Fund cut annual AIDS-related deaths by nearly half and new infections by 39 percent. Of 36.7 million people living with HIV, nearly 21 million are on antiretroviral therapy – 11 million through Global Fund-supported programs. Other partnering organizations offer primarily technical expertise, such as the Clinton Foundation, which played a leading role in designing treatment plans and negotiated much cheaper prices on a generic ARV regimen that those programmes may use (See:Keith Alcorn,). PEPFAR is a mechanism with multi-country wherewithal and through its influence the negative role of stigma can be addressed if Africa is to roll back the HIV epidemic. This position paper has been generated for you using materials from different underscored sources. 

Politics: The Economic, legal, cultural and social context 

South Africa was the first country in sub-Saharan Africa to fully approve PrEP, which is now being made available to people at high risk of infection. It is also a country with many of the non-nationals coming different African countries. There is need to institutionalize efforts to combat racial discrimination and ethnic violence.

People: Knowing how many are involved in order to engage

South Africa has the biggest HIV epidemic in the world, with 7.1 million people living with HIV. HIV prevalence is high among the general population at 18.9%.

South Africa has made huge improvements in getting people to test for HIV in recent years and is now almost meeting the first of the 90-90-90 targets, with 86% of people aware of their status.

Prevention: Making prevention a best-practice

The country has the largest ART programme in the world, which has undergone even more expansion in recent years with the implementation of ‘test and treat’ guidelines. 

Planet: The idea of universalizing and synchronizing best practices

An understanding of frameworks promotes internationally acceptable standards of care and reduces on complexities. One such standard in the HIV care world is the use of fixed dose combination of Stavudine (d4T), Lamivudine (3TC) and Nevirapine and Efavirenz-containing combinations that include AZT/3TC or d4T/3TC as a fixed dose tablet (Keith et Al, 2004). International HIV organizations play a key role in advocating for strong targets and indicators by which to measure progress. For example, those focussing on equal access to HIV services for all, call for global indicators to properly include key affected populations. UNAIDS’ Fast Track targets for 2020 include:

90% of people living with HIV know their status; of whom 90% are on treatment; of whom 90% are virally suppressed (90-90-90)

Fewer than 500,000 new HIV infections annually (a 75% reduction since 2010).

Those working in the field of HIV, including policy makers, programmers, governments and community-based organizations operate within the framework of global HIV targets.

Current targets are geared towards ending AIDS as a public health threat by 2030.

South Africa has the biggest and most high profile HIV epidemic in the world, with an estimated 7.1 million people living with HIV in 2016. South Africa accounts for a third of all new HIV infections in southern Africa.

In 2016, there were 270,000 new HIV infections and110,000 South Africans died from AIDS-related illnesses.

South Africa has the largest antiretroviral treatment (ART) programme in the world and these efforts have been largely financed from its own domestic resources. In 2015, the country was investing more than $1.34 billion annually to run its HIV programmes.

The success of this ART programme is evident in the increases in national life expectancy, rising from 61.2 years in 2010 to 67.7 years in 2015.

HIV prevalence remains high (18.9%) among the general population, although it varies markedly between regions. For example, HIV prevalence is almost 12.2% in Kwazulu Natal compared with 6.8 and 5.6% in Northern Cape and Western Cape, respectively.

The role of independence, need for labour, contribution by other countries ensuring a post-Apertheid, Apertheid, Black-White Economic inequality, masculinity, femininity, status of children, orphanhood due to wars and HIV, and other historical experiences are intertwined in the self determination of individuals, democratization and notions of sexuality in South Africa. Reading Isak Niehaus (2010), Maurice Dunaiski (2013) and many authors one sees the character and typology of where the barriers to ending HIV in South Africa lie. Labourers or foreign nationals with/without South African stay permits, Women, young girls, men and young boys need the protection of law in case they face any form of violence/violations which may also be a precursor to HIV transmissions, STIs, unplanned pregnancies, maiming and deaths. Secondly, the need for individuals to be empowered in reporting abuses within the existing structures and a guarantee to be heard without shaming. Third, there has to be a system of referral and retention in clinics in case one has acquired HIV or faced physical or mental trauma. Fourth, there has to be a system of safe homes or havens to care for orphans, vulnerable children escaping rituals such as circumcision gone wrong, female genital cutting and gender-related persecution. These same spaces must cater for those living with HIV. The government must invest in structures to support rights of both citizens and non-citizens. In the case of HIV care for orphans the matrikin and older female siblings as benefactors is one good example which must be supported.  For more see: HIV and AIDS in South Africa. 

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Politics: The Economic, legal, cultural and social context 

For Zimbabwe, 86%-90% funds still comes from international donors. The National HIV and AIDS strategy is driven by three tiers: organized White community with connections to the Western world through kinship relations; the Central government; and private citizens. The central government promoted adoption of a Combination Prevention Strategy policy, which focused on a number of areas to prevent new infections. This approach includes prevention of mother-to-child transmission, voluntary medical male circumcision, behaviour change communication, condom programming and STI management. Homosexual acts are illegal in Zimbabwe for men who have sex with men (sometimes referred to as MSM), but legal for women who have sex with women. As a consequence of this punitive law, national statistics are rarely available. Zimbabwe, joined South Africa and Kenya to increase HIV prevention services and investment. 

The Zimbabwean government collects an AIDS levy, which is made up of 3% payee and corporate tax which contributes considerably to the domestic share of funding for the national HIV response. Although this is still low compared to the prevention and care needs. The White community and private citizens many of whom are staying outside of Zimbabwe remit money to help families in what is known as the extended family care system.

People: Knowing how many are involved in order to engage

In Zimbabwe, among young women, HIV prevalence increases with age, with 2.7% of women aged 15-17 living with HIV, increasing to 13.9% of women age 23-24. Among young men, HIV prevalence holds steady at around 2.5% until the age of 23-24 when it increases to 6%.

However, as only 64% of young women (15-24) and 47.5% of young men have ever tested for HIV, prevalence among this group could be significantly higher.

Zimbabwe is one of those countries in Africa dealing with a higher child-related TB. This demography competes with many other population demographies for attention and resources. 

The White Zimbabweans and the other Zimbabwe nationals staying outside are two groups who are a second engine driving prevention and care continuum in Zimbabwe.

Polygamous relationships and Gender Based Violence in domestic settings, are commonplace in Zimbabwe. These contribute to inability of women and girls in homes to engage in quality sexual reproductive and healthy living practices.

Prevention: Making prevention a best-practice

In Zimbabwe, masculinity norms inhibit men from getting tested and engaging in treatment. In 2016, 75% of people living with HIV knew their status. A large discrepancy between men and women exists, with 76% of women and girls living with HIV aware of their status, compared to 68% of positive men and boys. 

Planet: The idea of universalizing and synchronizing best practices

An understanding of frameworks promotes internationally acceptable standards of care and reduces on complexities. One such standard in the HIV care world is the use of fixed dose combination of Stavudine (d4T), Lamivudine (3TC) and Nevirapine and Efavirenz-containing combinations that include AZT/3TC or d4T/3TC as a fixed dose tablet (Keith et Al, 2004). International HIV organizations play a key role in advocating for strong targets and indicators by which to measure progress. For example, those focussing on equal access to HIV services for all, call for global indicators to properly include key affected populations. UNAIDS’ Fast Track targets for 2020 include:

90% of people living with HIV know their status; of whom 90% are on treatment; of whom 90% are virally suppressed (90-90-90)

Fewer than 500,000 new HIV infections annually (a 75% reduction since 2010).

Those working in the field of HIV, including policy makers, programmers, governments and community-based organizations operate within the framework of global HIV targets.

Current targets are geared toward ending AIDS as a public health threat by 2030.

The men in Zimbabwe are pivotal in rolling back HIV. The disadvantages of a masculinity epidemic can be turned around into a mobilisation advantage to fight HIV.  Zimbabwe has a high literacy rate and this could act to their advantage. Very good record keeping makes it a possibility to make reports cascading into the UNAIDS and a political dispensation which in turn ensures rights for all people needing services are upheld, a zero-tolerance to discrimination, it must be evidence based and commit to enabling institutionalized outreach services to all beneficiaries. This will entrench a possibility for grassroots to build the necessary critical mass for prevention and care tailored to unique needs but addressing the internationally agreed upon objectives. It should be noted here that by grassroots in Zimbabwe is meant all those structures consisting of all Black and White Zimbabweans and private citizens who together are resources of different kind. This will ensure the prevention and care continuum system exist including meeting objectives such as: encouraging taking medication and going to clinics for monitoring by those living with HIV. For more see: HIV and AIDS in Zimbabwe. 

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Politics: The Economic, legal, cultural and social context 

Uganda still relies on development partner funds to support most of its service sector. However, the new Country Economic Memorandum (CEM), jointly prepared by the World Bank Group and Government of Uganda shows that proceeds from oil could accelerate growth and reduce poverty. With commercial production in full swing, the Bank postulated that the country, could earn up to $3b ( about Shs7 trillion) in revenues from exports of up to 60,000 barrels of oil per day. These revenues have the potential to propel the economy between 7-10 percent forecast up from the current stagnation of 4 percent. The Memorandum offers a series of recommendations including policy and institutional strengthening, to regulate the sector, and ensure greater transparency as well as accountability. Stimulating manufacturing and industry, as well as private sector businesses, along with investing in health and education, would create a more skilled labour force capable of driving growth for the long term. The start of commercial oil production in Uganda, according to the World Bank, offers long-term prospects to diversify the economy and catapult it to upper middle income status by 2040 This has emboldened many in the government to  go ahead for instance to re-enact punitive laws. This creates an atmosphere of hostility toward say, key populations and a suspicion of NGOs and CBOs providing HIV-related service delivery. But, Uganda has been cautioned not to place much confidence in oil as a source of public revenue.

People: Knowing how many are involved in order to engage

7.3% of adults age 15-49 in Uganda are HIV-positive. HIV prevalence is higher among women (8.3%) than among men (6.1%). Among women, HIV prevalence is higher in urban areas (10.7%) than in rural areas (7.7%). In contrast, HIV prevalence is the same (6.1%) for men living in urban and rural areas.Uganda’s open policy toward HIV in 1986 and mobilization drives to warn communities about it made it a household epidemic. This prepared communities to dismiss much of the negative information about HIV. The need to limit sexual intercourse to one uninfected partner was commonly known. There were no ARVs then like today. Private individuals paid exorbitant amounts of money for 5 liter jerrycans of herbal medicines. Those who did not have the money relied upon contributions of extended families. This strained family resources so fast and left families so destitute because many families had more than one person living with HIV. The word used then for people living with HIV was “victim.” This had a denigrating connotation! Family heads or breadwinners sold off real estates to pay for herbal medicines. The herbal medicines were more like oral rehydration salts, bitter plant combinations of mineral supplements and methylated syrups. These became the available costly  medicines against HIV. The herbalists reaped large sums of money but when the Ministry of Health initiated a drug efficacy test, many of these herbalists disappeared. Few HIV-related deaths were recorded then. Around early 2000s, ARVs became available to a select few who could afford them. By mid 2000s with Global Funding and PEFAR an integrated HIV Prevention and care infrastructure was made possible. Clinics were opened and this made ARVs accessible to people. Communities were mobilized and trained in primary prevention and care skills. Community Based HIV/AIDS Initiatives were formed and provided with money to establish care continuum services at village levels. This built a bottom up structure which connected with health facilities and other social services at sub-county and county levels. This made it possible for nine in ten respondents of either sex to know personally of someone with HIV or who had died of AIDS. It made it easier to establish reporting and referral systems. The structure became a docking platform into which an AIDS Control Project was built. This was coordinated multisectorally and it helped integrate HIV prevention and care in all spheres of service delivery. HIV prevalence and incidence were brought down. HIV service delivery emphasized Abstinence and monogamy. This was followed by a culture of criminalization, punitive laws and stigmatising attitudes and it turned out to be Uganda’s undoing of a success story. So, sexual minorities, sexually active unmarried people, children and sex workers were left vulnerable and not likely to engage with HIV services. As of 2016 around 33% of adults living with HIV and 53% of children living with HIV were still not on treatment. Persistent disparities remain around who was accessing treatment and many people living with HIV experienced stigma and discrimination. It is apparent, the need to expand the meaning of prevention, reach out to demographics most at risk and address other political and cultural barriers hindering effective HIV prevention programming in Uganda is paramount.

Prevention: Making prevention a best-practice

Voluntary Testing made Uganda a success story in the early 90s but other predictors of HIV prevalence were dismissed or neglected by policy, programming and planning. By 2016, an estimated 1.4 million adults and children were living with HIV in Uganda; it is estimated that there were approximately 52,000 new HIV infections and 28,000 HIV-related deaths during that year (UNAIDS 2017). The Ugandan government has been at the forefront of developing and implementing innovative public health strategies that address the HIV/AIDS epidemic. Beyond designing and being among the first countries in sub-Saharan Africa to implement Option B+, Uganda is also among the initial countries to include Test-and-Start and the 90-90-90 objectives for epidemic control within its National Strategic Plan. Uganda initiated Test-and-Start in November 2016 and has consistently adopted aggressive strategies in its HIV programming that have moved the country closer to controlling the epidemic.

Planet: The idea of universalizing and synchronizing best practices

In 2015, Uganda developed the 2015/2016-2019/2020 National HIV and AIDS Strategic Plan (NSP), which provides a new framework for the implementation of HIV programs that align with the UNAIDS 90-90-90 targets. The NSP focuses on case identification and promotion of access to antiretroviral therapy (ART), adherence, and retention (Uganda AIDS Commission 2015). National efforts and investments from donors and other partners have also focused on HIV prevention, knowledge, and behavioural interventions. The Uganda country program has been monitoring the impact of these programs through routine HIV program monitoring, Demographic and Health Surveys, Biological Behavioural Surveillance Surveys, and a Population-based HIV Impact Assessment survey. It is hoped these reports will be used to inform policy and programming.

Punitive laws, violence, stigma, discrimination and a concentration of duplicate primary prevention services in urban centers play an interference distortion in the end to HIV objective for Uganda. They mask effective roll back efforts, make it harder to generate disaggregated reports which in turn affects HIV prevention and care service delivery. Such best practices in which it is possible to capture those who drop out of the care continuum or categorical processes addressing optimal ARV adherence are missed. Concentrating HIV-related service delivery within political elite circles and urbanized settings makes HIV an infrastructure epidemic. This means refugees, those stigmatized, women and key populations may be served by whim and not strategy in a country known for resolve against HIV. Service delivery organizations in Uganda are pivotal in rolling back HIV if they have solid mechanisms to negotiate renewal of contracts to engage in new prevention and care initiatives such as: demand creation, community mobilisation, planning, programme management, monitoring and evaluation, safer male circumcision, condom use, lobby for funds for critical mass demand for male circumcision money, rally around a sustained ARV supply chain, supply chain, management and upholding of rights-based approaches. For more see: see HIV and AIDS in Uganda. 

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HIV/AIDS Statistics. Courtesy of Avert

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HIV/AIDS Statistics. Courtesy of Avert

HIV/AIDS Statistics. Courtesy of Avert