Crumbling, Staffless African Health Systems Bombarded With Drugs

With all the hubris about drugs and new medical technologies, you'd think that hospitals in East African countries are ready to save their whole populations if they could just get hold of the latest drugs. This is far from the truth.

Drugs that arrive in the country often don't get distributed and expire before they are used, they get distributed to the wrong people and disappear into the black economy, they are prescribed by people who don't know how to prescribe them properly, they are already useless because of widespread resistance, etc.

Even antiretroviral drugs have a bit of a mysterious time once they reach here. Some people are kept alive by them but the majority of people who need them don't yet get them. Another mystery is how many people die while on the treatment, or why treatment sometimes fails where it would have been predicted to succeed. And a huge number of infants are still infected by their mothers, despite promises that this phenomenon will soon be phased out.

Despite all the money being thrown at HIV, and very little else, health services just can't cope. There isn't the infrastructure or the level of skill required to ensure the health of most people and many, even those with HIV, are dying of easy to treat illnesses.

It's good to see an admission that the problem is at least partly with health systems but it would be even more comforting to hear that big funders are doing more to improve health systems than just talking about it. Strategies like PrEP, treatment as prevention, mocrobicides, etc, will be of little use if they don't get to people or if they are not used optimally when they do.

Which reminds me, why do countries that are so short of infrastructure, medical supplies and especially personnel think that mass male circumcision is so important when their health services are in crisis and have been for some time?

Apparently Tanzania has circumcised a few thousand men but so have Uganda and other countries. And Kenya claims to have circumcised 250,000 in a very short space of time. I'm glad I'm not one of the, having seen the state of some health facilities in East Africa.

Millions of Pills Haven't Worked So Let's Try Billions of Pills

The 'treatment as prevention' approach to reducing HIV transmission is getting airtime again, this time because the pioneer of the strategy has receive the Einstein award. Treatment as prevention is more of a hypothesis than a strategy or approach, really. But given the rarity of feasible HIV prevention strategies the HIV industry needs something to obsess about.

The hypothesis suggests that, because successful HIV treatment reduces the viral load to the extent that HIV positive people are very unlikely to transmit the virus, prevention programs could rely on this to significantly cut HIV transmission.

The number one flaw in the hypothesis is that it assumes that most HIV is transmitted sexually. This is a rash assumption in countries where health service provision is of extremely low quality. But the HIV industry has little interest in health or health service provision when they can sell lots of drugs. And it's a media friendly issue, with its combination of technical fix and the implication of illicit sex.

Of course, rolling out treatment to as many HIV positive people as possible when they need them is a good thing. But it may not have much impact on transmission rates. And ensuring that they didn't become infected in the first place would be preferable. It is hardly reassuring to those who are currently HIV negative that so little is going to be done to help them stay that way.

Another flaw is the assumption that a disease can be eradicated by some technical fix when the circumstances under which the disease became an epidemic are left pretty much as they are. So there is no need to improve health, education, infrastructure or social services? But these questions are not popular in the industry.

HIV testing has been around for some time now, in developed and developing countries. Most people never get tested, others test once and never again. But treatment as prevention requires the majority of people, or as near to 80% of people as possible, to be tested regularly, perhaps once a year.

It remains to be seen how many developing countries will be able to encourage such huge numbers of people to turn up for testing every year, or even how such programs will be administrated in countries where health services are so poor. High prevalence countries currently have a lot of trouble accounting for the HIV positive people they know about, a fraction of the total infected.

The above article on the award raises the issue of 'risk compensation', where it was feared that the availability of HIV treatment that also reduced infectiousness might result in increased risky sexual behavior. But where sexual behavior is not the main driver of HIV transmission, this is something of a red herring.

It's great to hear that treatment as prevention works so well in British Columbia. But I don't think the health problems in BC are anything like the health problems in East Africa. And I'm pretty sure the health systems (also education, social services, infrastructure) in BC are not like those in East Africa.

In short, the technology on its own is not the solution to an epidemic that has many determinants. This technical fix may have some impact in isolated pockets of East Africa, especially in randomized controlled trials, but people need a lot more than just pills to stay healthy. Far from obviating the need for decent health services now that some great technology is available, that technology requires adequate health services, and probably education, infrastructure and social services.

Drop Everything, A Vaginal Gel Has Been Developed

Chi Mgbako writes an article entitled "International donors must fund female-controlled HIV prevention gel", but this raises a number of issues.


Is a vaginal gel, as Mgbako and others argue, female controlled? One would think that if it is, so are oral contraceptives. Yet, the majority of women in many developing countries opt for injectible contraceptives. They say their husbands object to them taking contraceptives, so they get an injection every three months, possibly running the risk of picking up some blood-borne infection at the clinic, perhaps even HIV. Will the same husbands that object to oral contraceptives ignore vaginal gels? Has this even been tested?

Also, this article mentions a number of things that are in need of change, such as domestic violence and gender inequality. These are in need of change regardless of HIV transmission. Is the author advocating that these and other social problems be ignored as long as vaginal gel is paid for by international donors and some (rather small) percentage of HIV infections are possible prevented?

I don't think the author is making the argument that these other social problems are insignificant or that HIV reduction should be chosen over other social problems. Rather, it needs to be made clear that that is something international donors do.

Numerous social problems have been alluded to as causing HIV transmission, allowing HIV transmission, assisting HIV transmission, etc. But most of these problems are independent of HIV, they existed before HIV and they won't just go away on their own.

But HIV programs have a tendency to ignore contexts to the extent that HIV testing clinics are set up in areas where people are dying of contaminated water related diseases, respiratory infections, intestinal parasites and other treatable and preventable conditions. HIV programs are, no matter how much those in the HIV industry would like to argue otherwise, deflecting attention from real and preventable problems.

And to what end? That we might be able to reduce HIV transmission by 39% (in ideal, trial related scenarios)?

Finally, if the gel is so good, why have funders not come up with the funding? Is there something they know that we are not allowed to know? Other HIV related drugs have made billions, why are international funders drawing back from this one?

Do Family Health International Care About Women or Funding?

A quick look at the HIV/AIDS and Malaria Indicator Survey for Tanzania (or any other African country) will show that 'HIV' always means 'sexually transmitted HIV'. The so called 'ABC' strategy (Abstain from sex, Be faithful to one sexual partner, use a Condom) is still about as far as the global HIV industry has got in terms of HIV prevention. Over 50%, often over 80% of people between the ages of 15 and 49 know about at least one of these methods of reducing the risk of sexually transmitted HIV.

It would be more comforting if a higher percentage of people knew about all the ways of preventing HIV, but that would need to include non-sexual transmission, as well. People answering questions about ABC are prompted but it takes a lot more prompting to get people to suggest non-sexual modes of HIV transmission. Such modes are deemed not to be important enough to include in the Survey. Some people know about them, rather surprisingly, but how many know how to avoid or prevent non-sexual HIV transmission?

PrEP and a handful of other interventions are also aimed at sexual transmission of HIV. While some drugs may also reduce non-sexual transmission, this is not their aim. And telling people they could take antiretroviral drugs to avoid being infected with HIV when they pay a visit to a health facility, a dentist's surgery or the hairdresser might not be the best way of selling the technology.

So gushing about vaginal microbicides "giving women a new tool to protect themselves from HIV infection" sounds like humbug when it comes from FHI's Ward Cates. If FHI gave a damn about women being able to protect themselves from HIV, why do they not take so much interest in non-sexual transmission? After all, they have received hundreds of millions of dollars to try to influence women's behavior, in relation to sex, reproduction and health in general. If they are not in a position to warn about non-sexual transmission, who is?

Of course, there is a set of questions about medical injections and about whether the equipment used was taken out of a sealed packet. But these matters do not usually make up part of HIV prevention programs and few programs mention either the risks from medical injections or the steps people can take to reduce the risks of infection with HIV or any other blood-borne viruses. None of the Aids Indicator Survey questions aim to establish how HIV positive people might have become infected.

The company that produces the drug used in the microbicide gel, Gilead, is one of the many multinational drug companies that sponsors FHI. It wouldn't do Gilead, or anyone else betting on sexual transmission of HIV, any good if non-sexual transmission were to play a significant role in the epidemic in African countries. But luckily, there's a whole pack of companies and even funders who have similar interests, which don't include nosocomial or iatrogenic HIV transmission. Who are they? Just take a look at FHI's list of funders.