In this revolution, what needs to be put up against the wall?
In my last blog post I gave an example of how people in charge of HIV prevention programmes can very easily bias things very badly. I suspect the same issues appear in other types of development work, and in health service provision in wealthy countries. Nonetheless I think it’s an important reminder because it’s the sort of practice-related nuance that isn’t reflected in the journal articles we rely on for evidence-based programming. I also think HIV prevention programming is particularly vulnerable to this sort of problem because it’s invariably about sex, and often about types of sex that people find it hard to discuss. When UNAIDS talks about an HIV prevention revolution I think that these micro-issues related to the behaviour of practitioners, managers and trainers are among the most important things that need to be addressed. However, there are also quite a few macro-level problems and challenges.
What are they? There are many but here are some of the ones that I don’t think get talked about enough. They’re mainly about prevention of sexual transmission of HIV :
Even when we do know what to do, a lot of people – people who influence these things – don’t like it. Because despite close to 30 years of the fight against AIDS; despite huge advances in how AIDS is treated; the availability of levels of funding unprecedented for a single health problem: the ways HIV are transmitted remain for many inextricably tied to morality. Stigma against the virus may be ebbing, but stigma against sex remains as intractable as ever, and many decision makers aren’t prepared to pay the price of addressing this.
Some are even prepared to do exactly the opposite. What is wrong about abstinence-only policies on HIV prevention isn’t the notion that more people abstaining from sex will help reduce the transmission of HIV – of course it will. What’s wrong is imagining the best way of achieving this is to say to people: “Forget everything else! Abstain from sex!”. See also, programmes in the sex industry which discourage and disable sex workers having a say, or even that are complicit in human rights violations.
Poorly allocated funding
In many of the countries I’ve worked in, AIDS is associated with money. It is unfortunate that in some health policy circles AIDS is seen as privileged “over-funded” because the reality is that there probably isn’t enough money for AIDS, and there certainly isn’t enough money for health generally. I think this is one of the reasons that there is often an “entitlement” based rather than an evidence-based approach to using AIDS funding. As someone who helps develop national AIDS plans and funding requests, I’ve frequently been leant on to “share” the money out among different groups because it doesn’t look good to focus resources on “undeserving” groups like sex workers, men who have sex with men or drug users. As well as being judgmental, it is an absurd to define fairness purely in terms of who gets what money spent on them – since most health problems affect some people more than others, and the cost of tackling different health problems varies considerably.
Poor allocation of HIV prevention funding may also be related to the fact that historically, the epidemiology of vulnerability to AIDS has been something of a free-for-all, where people are defined as being at risk on the basis of worst-case scenario guesswork rather than proper analysis. This blog post provides a good example.
Planning, continuity and financing of HIV prevention programmes
HIV prevention efforts face a particular problem because they are not primarily or wholly implemented by the formal health systems. While health systems are used to working according to norms and there is a good understanding of the roles of different types of health care worker and health care facility, there is rarely anything of the sort in the nongovernmental or community organisations that are the mainstay of community HIV prevention efforts. There is often no clear, common standard of what needs to be done and how to do it. Moreover, the mechanisms for funding these initiatives are often based around short-term grant support, with no guarantee of continuity and often with an expectation that after a few months or years, they’ll magically become sustainable enough for no more funding to be needed. To understand the absurdity of this one only needs to look at how we approach health systems: we don’t imagine health facilities can be funded for a few years and that then they will run themselves.
Continuity of services is also vital to their effectiveness. This recent example from Zimbabwe, describing a reduction in condom use among trial subjects very soon after the end of a programme, gives a very good illustration of the problem. What makes it worse is that while it generally takes a long time to see positive outcomes of HIV prevention efforts (because things like safer sex, and acceptance of HIV testing and STI treatment improve incrementally over time), the negative effects of halting prevention efforts can appear very quickly: if you stop a service all of a sudden, use of that service drops straight away.
There is as much an ongoing need for HIV prevention-related services – whether it’s outreach, condoms, social support, or clinical services – as there is for maternity, vaccination, or health emergency services. A major re-think is needed on how community programmes are funded – this goes not just for HIV prevention, but also for community based HIV care and support, and probably for health more generally. I’ve discussed this in more detail here and here.
The bigger picture
One of the major successes of the AIDS movement has been to show how AIDS is associated with all manner of other health and development problems, and with human rights. Unfortunately HIV prevention programmes are still very often implemented in an isolated way. This isn’t always inappropriate, but HIV prevention outreach programmes are often narrowly focussed on communicating about the mechanics of HIV transmission, rather than on making links with related health concerns – in particular those related to sexual and reproductive health and, for stigmatised groups, those related to issues such as violence and human rights. Many of these problems are aggravated by HIV and AIDS, but they exist independently. Moreover, it looks like we’re approaching a phase of the fight against HIV that is going to be increasingly characterised by technological solutions such as male circumcision, microbicides, pre-exposure treatment, and even vaccination. These will reduce transmission of HIV but will not remove it altogether – so HIV will still be a problem, just not such a big one. It is vital that if and when these are implemented as HIV prevention strategies, attention continues to be paid to the broader issues: the millions who still need treatment, and the many millions who will still face poor sexual and reproductive health, and those who face abuses of human rights, irrespective of whether they have HIV or not.
Just… get cracking
There is not much in what I have said that is particularly revolutionary. People have been saying most if not all of it since long before I got involved in HIV work. This is why I’ve been slightly unsure of the whole concept of a “prevention revolution” – to me, and to many practitioners I talk to, it is incredibly frustrating to know that we have had the theory and the tools for years but that not much has happened. In a sense, too many HIV prevention efforts haven’t ever really had the opportunity to succeed at a large scale. The biggest revolution will be to use what we know more ambitiously and more effectively than has been the case until now.