HIV and Health System Strengthening in Fragile States: Improving HIV Prevention, Care and Treatment

AIDS 2012 Fragile States panel

Panelists at the session HIV and health system strengthening in fragile states, July 26 at AIDS 2012 conference. (Photo credit: S. Holtz/MSH)

MSH in collaboration with the International Rescue Committee (IRC) and Physicians for Human Rights (PHR) sponsored a lively satellite session at the XIX International AIDS Conference in Washington DC discussing, “What are the keys to working on HIV & AIDS in fragile states?” Moderated by Susannah Sirkin of PHR, the session included an exciting interchange among panelists and delegates in the audience.

MSH President Dr. Jonathan Quick led off the discussion with a number of observations on fragile states, which included the point that a state which is not functioning effectively, (inadequate services, high levels of violence, etc.) — regardless of the cause — could be considered fragile. Each fragile state is unique, but all face similar challenges in that access to health services is difficult; often the population, at least in certain regions, must cope with considerable violence and insecurity.

The panelists, Peter Mutanda and Aminul Islam of IRC and I, contributed insights into the many vexing questions posed by dealing with HIV in fragile states where governments and society are overwhelmed by other problems and challenges that at times seem to dwarf the issue of HIV. In some fragile states, the prevalence of HIV is relatively low. These countries need to balance the immediate crises they face and the large numbers of preventable maternal and child deaths with the need to deal with HIV now to forestall a more serious epidemic down the road.

Members of the audience brought up fascinating examples of work that NGOs and ministries have done trying to deal with HIV in such fragile states as Democratic Republic of the Congo and Somalia. The discussion included these key issues:

  • What can we learn from fragile states where, despite overwhelming problems, some health programs are effective?
  • How should fragile states prioritize HIV amid other concerns?
  • What should be done when data are poor or non-existent?  How high a priority should fragile states place on obtaining better epidemiologic and surveillance data versus other pressing needs?
  • In fragile states where donors provide most health funding, how can country ownership of health programming be obtained? Who is ultimately responsible for deciding on health priorities, given the fact that ministries of health in many fragile states are barely functioning?

While we didn’t necessarily provide answers to these challenging questions, the discussion was stimulating and thoughtful for all who attended — and gave all of us a lot to think about as we return to work on strengthening health systems for HIV in fragile states.

Steve Solter, MD, MPH, is MSH’s country lead and technical lead on fragile states. MSH is currently working with partners in several fragile states, including South Sudan, Democratic Republic of the Congo, Afghanistan, Haiti, and Liberia.

 

Global Post Covers MSH Satellite Session on HIV and Non-Communicable Diseases

MSH’s satellite session on HIV and Non-Communicable Diseases is featured among the Global Post‘s highlights from AIDS 2012.

Learn more about the session:

The session included opening remarks by MSH’s President and CEO, Dr. Jonathan Quick, and Global Post reporter John Donnelly. Donnelly also authored the MSH 40th anniversary book, Go to the People: 40 Years of Improving Health.

The Vision for Success Beyond MDG 6: Chronic NCDs, Health System Strengthening, and UHC

2012 July 22 AIDS 2012 Satellite Session: Beyond MDG 6

Panelists at AIDS 2012 Satellite Session: Beyond MDG 6, July 22, 2012. (Photo credit: S. Holtz/MSH)

On Sunday, July 22, 2012, Management Sciences for Health (MSH) hosted a satellite session, Beyond MDG 6: HIV and Chronic NCDs: Integrating Health Systems Towards Universal Health Coverage at the XIX International AIDS Conference (AIDS 2012). The session panelists were (left to right): Dr Ayoub Magimba, Till Baernighausen, Dr Jemima Kamano, John Donnelly (moderator), Sir George Alleyne, Dr Doyin Oluwole, and Dr Jonathan D. Quick

This week at the XIX International AIDS Conference — as panelists and pundits debate whether an AIDS-free generation is actually possible — we must not neglect the other chronic diseases that remain an emerging and alarming threat to both aging HIV-positive and sero-negative populations in these settings. Today, chronic non-communicable diseases (C-NCDs), including cancer, lung and heart disease, and diabetes, kill over 28 million people annually in low and middle-income countries, many of whom are HIV-positive.

According to Till Baernighausen of the Harvard School of Public Health, the total number of HIV-positive people aged 50 years and older is likely to triple over the coming decades from 3.1 million in 2011 to maybe 9 or 10 million in 2040. “We would really expect dramatic increases for the need for C-NCD screening and treatment.”

TURNING THE TIDE THROUGH INTEGRATED HEALTH SYSTEMS

Once deemed a death sentence, HIV is now considered a manageable chronic condition through the use of lifelong antiretroviral therapy (ART). HIV-positive individuals are now living longer, particularly in resource-limited settings where HIV care and treatment were not previously available. In fact, through the global scale-up of HIV and AIDS services, health systems in low- and middle-income countries are now better prepared to tackle other C-NCDs — like cancers, diabetes, chronic lung diseases, and cardiovascular diseases — by leveraging the existing investments, infrastructure, and systems put in place in recent decades.

BUILDING ON THE SUCCESS OF HIV & AIDS PROGRAMS

Over a decade ago, many critics said that bringing life-saving HIV treatment to the most hard-to-reach areas would be impossible. Yet today, more than 8 million people have access to antiretroviral treatment in low-and middle-income countries. The same models used for lifelong ART can be adapted and used for managing and monitoring patients with other C-NCDs. MSH firmly believes we can apply the lessons learned from our experiences with HIV to the C-NCD epidemic. For example, service delivery models — e.g. scaling up of ART and prevention of mother-to-child transmission (PMTCT) — innovations in funding, health care financing models, pricing for drugs and laboratory supplies and equipment, and new technologies for care diagnosis, among other innovations, provide a model for chronic diseases in low- and middle-income countries.

While proven solutions to tackle such conditions exist, the global health community is only now starting to realize the importance of designing cost-efficient, integrated health systems. According to Dr. Jemima Kamano of AMPATH, “One of the hardest things for me as a practicing clinician in Africa is to sit at the HIV clinic and treat HIV patients, counsel them and give them drugs and see them improving. But the minute they develop diabetes or hypertension, then I tell them unfortunately I can’t help them.”

By integrating current health systems and leveraging the existing groundwork laid by HIV and AIDS intervention scale-up, we can leverage existing public infrastructure, pharmaceutical supply chains, and human resources management, among other developments, to benefit patients with chronic diseases.

HIV & AIDS, C-NCDS, AND UHC

HIV and other C-NCDs have serious socioeconomic consequences, often creating a financial barrier for individuals in need of proper care and treatment, and forcing them to pay high out-of-pocket fees. Despite advancements in service delivery, only twenty countries worldwide currently have Universal Health Coverage (UHC) plans in which everyone can receive basic health services.

While some advocates in the AIDS community may see UHC as a threat to the provision of HIV & AIDS resources, others see it as a solution. Sir George Alleyne from the Pan American Health Organization (PAHO) reminds us that UHC is “feasible, socially desirable, and economically possible.”

“We have acceptance that UHC is possible. It is a myth that poor countries cannot afford UHC. There is no country that cannot afford UHC,” Sir Alleyne says. “It is a matter of social justice.”

According to Dr. Jonathan D. Quick, President and CEO of Management Sciences for Health, “UHC is becoming the driving vision for prevention, care and treatment of, and assuring access for, HIV positive and HIV affected people. They live long enough to get chronic diseases and to care for children — and they need the services that are provided through universal health coverage programs.”

The long-term nature of chronic diseases, including HIV, poses many challenges for the health system, but it is crucial that the prevention, care, and treatment of chronic disease be integrated in order to save many more lives.

MSH believes that in order to effectively combat the rise of C-NCDs — and turn the tide against HIV and AIDS — we must strengthen current health systems while leveraging existing platforms and ensuring access at an affordable cost in the context of UHC.

For a more in depth discussion on this topic, watch the webcast of MSH’s recent panel at the International AIDS Conference (via Kaiser Family Foundation).

Gloria Sangiwa, MD, is Management Sciences for Health’s global technical lead for chronic non-communicable diseases and the director of technical quality and innovation in MSH’s Center for Health Services.