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Health systems for HIV treatment and care


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Health systems for HIV treatment and care

  1. 1. Downloaded from on February 19, 2012 - Published by Editorial finally several are thoughtful opinionHealth systems for HIV treatment pieces. Two of the papers, written by authorsand care in the developed world, are particularly concerned about how to respond to (rela- tively) small numbers of infected people.Alan Whiteside Sherer writes about the future of HIV care in the USA. Against a backdrop of steadily but slowly increasing numbers, he argues patients are having less access to care andThis supplement is timely and important. The challenges facing us in the fourth the future of treatment is challenged.The original call for papers suggested the decade are new and considerable. They Apart from the financial problems facedissue would focus on topics such as: allo- centre around resources and priorities. It is by patients, there is a need for compre-cative and technical efficiency in drug clear that the impact of the AIDS hensive multidisciplinary HIV care. This isdelivery; health system studies on feasi- epidemic is not homogenous; the greatest especially the case since the number of agebility and outcomes of bringing treatment burden is African and specifically Southern related conditions are increasing, as wasto scale; studies of the integration of African. While being HIV infected is reflected at the Non-Communicableantiretroviral therapy (ART) programmes catastrophic for every individual (and Disease Summit held at the Unitedwith tuberculosis and the general health- family) who has the misfortune to be Nations in New York in September systems; and the political economy of in this position, the nature of the chal- Sherer makes a plea for a single payerdifferent models of ART delivery in lenge varies according to where in the system. The people falling through thedifferent countries. The articles that were world one is. This is well reflected in the cracks in the USA are those on thesubmitted, and make up this supplement, papers of the issue, which range from margins of society. The paper on the roleaddress these issues only to a limited Australia and the USA to China and of general practitioners in Australia isextent. Importantly, they open new Southern Africa. about even fewer patients, and peopleavenues of enquiry. It is extremely inter- The key question is how the response to who are in general immensely privileged inesting to see what has emerged from the the epidemic is addressed. As is shown by the care they get. This paper picks up oncall. These papers reflect where academics two of the papers, funding for AIDS will themes across the issue. Multidisciplinarybelieve current thinking and priorities are. at best remain static and at worst possibly care is crucial and at the core of good HIV HIV has been recognised for three decline. Grépin examines efficiency services is a relationship between patientdecades now. In the first decade of the considerations of donor fatigue, universal and care giver (in Australia usually generalepidemic, activities centred around access and health systems. Bärnighausen practitioners) that is built up over timeunderstanding the disease and its aeti- and colleagues look at the potential and is based on trust.ology, and the main interventions were change of funding from vertically to The issue of trust and quality of care isfocused on HIV prevention, both medical horizontally structured interventions and addressed in two papers from Southand behavioural. It is often forgotten that the effect this will have on evaluation Africa. The first is an ethnographic studyone of the important early successful HIV strategies. They begin this paper with the on access to ART and experience ofprevention strategies was the provision of assumption that funding will have to be patients in South Africa by Fried et al. Thissafe blood, and Zimbabwe was the third better accounted for, donors will want to paper shows that the major problems arecountry in the world to screen its blood see more ‘bang for their bucks’ and that poverty and the way the patients aresupplies. The second decade saw the this will probably mean little additional treated in the health facilities. Cleary et aldevelopment of triple therapy and a medi- funding to HIV. This is a key point for take the discussion further using datacalisation of the response particularly in health systems and of all the papers in the from four South African sites, two inthe developed world. The third decade supplement, it is, in my view, the most urban areas and two in rural settings.was a time of massive scale up of interest seminal. Here, a significant number of patientsin and funding for HIV and AIDS.1 The The papers could be divided into three report that staff did not treat them withamount of money available for HIV rose broad areas. The way the editors have respect; they spent considerable timefrom $3 million in 1996, the year UNAIDS chosen to divide them is: a description of waiting for services; and some felt stig-was established, up to $15.6 billion in the national and international issues; matised. The issue of stigma is critical and2008; there was a slight increase in 2009, service models; and patient perspectives should be better addressed. This is some-but the level of funding fell in 2010 and and experiences. There are other ways this thing that clinicians and others workingthe signs are that this trend has continued. could be done, and these are more inter- in the field of sexually transmitted infec-The Global Fund to Fight AIDS, TB, and esting for someone who has worked on tions have long experience of. Perhaps it isMalaria (GFATM) and the US Presidential HIV and AIDS for a quarter of a century. time for a learning across the fields: peopleEmergency Plan for AIDS Relief (PEPFAR) One such way is: developed world working in the field of HIV need to learnwere established in 2002 and 2003, perspectives; mobilisation of resources, from sexually transmitted infection expe-respectively, and both brought significant what is and what should be happening; riences, and genitourinary medicineadditional resources. reviews of issues; and data-driven assess- healthcare workers need to apply their ments. A second would be the source of experiences to HIV. the information: some papers are based on Interestingly, Cleary et al suggest that primary data collected through surveys; patients in rural areas have the greatestCorrespondence to Professor Alan Whiteside, Director,Heard, University of KwaZulu-Natal, Westville, Durban others are ethnographic; there are papers difficulty in accessing care, a finding that4013, South Africa; that claim to be systematic reviews; and is mirrored in the Australian study, albeitSex Transm Infect March 2012 Vol 88 No 2 73
  2. 2. Downloaded from on February 19, 2012 - Published by Editorialon a totally different scale. It is not surprising as this would seem like input from two of the major internationalhowever surprising or new to learn that common sense. It is another argument for organisations that should be prominent.rural populations tend to be disadvan- a move from vertical to horizontal These are the WHO and the World Bank.taged. Urbanisation is a feature of the programmes and strengthening health UNAIDS staff are coauthors on themodern world. We need to learn more systems. What is concerning though is important review of cost and efficiency.about it and the effects on rural popula- how few rigorous studies there are. The WHO is lamentably absent not onlytions with regard to many services, not There are gaps in both the special issue in terms of authorship but also in terms ofjust those related to HIV. and the papers that make it up. With the frequency with which it is cited. The Mobilisation of resources is the theme of regard to the papers, a concern is the World Bank has knowledge in this areaa number of papers. Globally people often failure to celebrate some of the successes and it is unfortunate it is not being sharedthink of donors leading the way in this. that we have seen. A major achievement here.However, Goldberg et al looking at indica- has been the development of and reduc- There are some important take hometors of political commitment in responding tion in the prices of the drugs that treat lessons from this supplement. It is timeto HIV do not find finance to be as central HIV. In 1996, these drugs cost tens of to integrate HIV into health systems. Thisas one would expect in developing coun- thousands of dollars per patient; today, is in the long run the most efficient andtries. Economist would hope that govern- they can be delivered for <$100 per person cost-effective way to go and it willment allocations would reflect their per year. There have been great successes improve the health of everyone inpriorities, although authors do recognise in providing interventions to prevent a nation. There is a lack of good data and‘crowding-out’, where outside funding mother to child transmission. Although we need more rigorous evidence-basedleads to a reallocation of national budgets. there are problems with the data, as was information, but these will be harder to This supplement highlights the chal- shown by Ferguson et al in their work on achieve. AIDS has been recognised forlenges facing those working in HIV and Kenya, the reality is that across most of 30 years, and it will take us a few moreAIDS. It shows how important it is to the world fewer infants are being born decades to deal with the disease. Healthintegrate the epidemic into national with HIV than was the case 10 years ago. systems have been and will be around forhealth services if the response is to be In some places, HIV-positive infants are very much longer. The challenge is toefficient and sustained. There are many virtually unheard of. That is not to say we make events like HIV work for thedifficulties in doing this. One major cannot do better, but we should recognise delivery of better health for all. Thisproblem faced in poorer countries, depen- what we have achieved. supplement points to some of the waysdent on international funding for the Only one of the papers talks about the this can be done.programmes, is that integrated horizontal impact of the disease on healthcareservices are not easy to evaluate as is workers. The reality is that in all sub- Competing interests None.shown by Bärnighausen et al. These Saharan African countries, health workers Contributors AW is solely responsible for writing thisinterventions simply do not fit in with have levels of HIV prevalence at similar article.what donors do best: that is fund clear levels to their professional peer groups. Provenance and peer review Commissioned;programmes for a defined time period. The They are falling ill and need care but the internally peer reviewed.key about building health systems is that stigma means that they have difficulties in Accepted 15 December 2011it is a horizontal and long-term project. accessing medical services. AIDS is not Sex Transm Infect 2012;88:73e74. Sweeney et al review the cost and effi- just a demand issue, it also has an effect doi:10.1136/sextrans-2011-050441ciency of integrating HIV/AIDS services on the supply side: by diverting resources,with other health services. They conclude as the supplement shows, and becausethat the limited available evidence health workers fall ill and die. REFERENCEsuggests that this gives value for money Missing from the papers and the 1. Smith JH, Whiteside A. The history of AIDSand better services. It should not be supplement is evidence of leadership and exceptionalism. J Int AIDS Soc 2010;13:47. PAGE fraction trail=1.7574 Sex Transm Infect March 2012 Vol 88 No 2
  3. 3. Downloaded from on February 19, 2012 - Published by Health systems for HIV treatment and care Alan Whiteside Sex Transm Infect 2012 88: 73-74 doi: 10.1136/sextrans-2011-050441 Updated information and services can be found at: These include: References This article cites 1 articles Email alerting Receive free email alerts when new articles cite this article. Sign up in service the box at the top right corner of the online article. NotesTo request permissions go to: order reprints go to: subscribe to BMJ go to: