Challenging Dogma


...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

The War Against HIV/AIDS: The 3 by 5 Initiative and its Failure to Consider the Barriers That Limit Treatment-Reena Doshi

It is estimated that 42 million people are now infected with HIV, while 30 million people have already died from the virus (23). In developing countries, 6 million people are in need of antiretroviral therapy (ART), though only 8% receive it (23). Today, the HIV/AIDS pandemic is the world’s most pressing matter, one that is destroying communities and health care systems, while taking away futures. Projections have indicated that if the pandemic continues at its current rate sub-Saharan Africa may face economic collapse. And in Asia the pandemic, which was more recently introduced, has skyrocketed with 1 million new infections in the Asia Pacific Region alone (16). It is a disease without boundaries, killing nurses, teachers, and civil servants alike, those most pivotal in stopping this disease, at a faster rate than replacements can be trained.

The World Health Organization saw ART as the simplest solution to the current HIV/AIDS pandemic and in 2003, with UNAIDS, released an extensive plan to treat 3 million HIV sufferers in 50 developing countries with antiretroviral therapy by 2005. The strategy, called the 3 by 5 initiative focused on devising more simplified and standardized tools of delivering ART therapy, including the creation of a new service, which would guarantee the necessary supply of medicines, intertwined with a strong global partnership (23).

In 2007, two years after the goal was to have been reached, only 33% of the 3 million have actually received treatment (1). The World Health Organization pledged much and gave little, since more than half of the 33% were treated with other initiatives such as the pharmaceutical industry's Accelerated Access Initiative, donations from the European governments, and U.S. donations toward the Global Fund, as well as President George W. Bush's initiative (1). Although, it unfair to declare the initiative a complete failure, one can wonder why the 3 by 5 initiative was so far from reaching its goal. Offering treatment to HIV/AIDS sufferers in developing countries is not a simple task and may have been more successful had the intervention considered the barriers that often limit an individual’s treatment access. Although the 3 by 5 initiative acknowledged that various barriers preventing treatment existed, the initiative failed to incorporate specific strategies to target these areas. The shortage of healthcare facilities and healthcare workers in the target countries is a pivotal blockade to a successful treatment plan. In addition, the narrow focus of initiative targeted a smaller population, those who need immediate antiretroviral therapy instead of focusing on the total population and including those at risk of infection. Moreover, the intervention failed to address the stigma and discrimination surrounding HIV/AIDS.

An Inadequate Infrastructure Cannot Support a Large Scale Treatment Intervention

“Health for All by the Year 2000,” pledged the World Health Organization member nations in 1978 at the Alma-Ata (22). Six years later, the current health situation in a majority of these countries is as appalling in the rural areas as it was before the 1978 pledge. When developing countries barely have the capabilities to treat their population with the basic health care package including prenatal care, family planning, and immunizations, treating 3 million with antiretroviral therapy by 2005 seems like an impossible goal. If a country is unable to provide its people with the simplest form of health care, how can it possibly treat HIV/AIDS? According to Ruger, combating HIV requires the improvement of a country’s basic infrastructure (17). A large majority of the targeted countries suffer from poor management, inadequate training of healthcare workers, low numbers of healthcare facilities and absenteeism, due to a large failure in the integration between health services and economic and social development (9). These critical concerns make it next to impossible to treat such an extensive number of people, providing a large barricade to treatment. Treating large numbers of patients requires large numbers of facilities with well-trained healthcare personnel, an issue the 3 by 5 initiative failed to recognize.

For example, 10% of the world’s population resides in Africa, a continent which carries 64% of the total HIV population, yet is home to only 1.3% of the world’s healthcare workers (3, 4). Estimates in Africa suggest that more than 100,000 healthcare workers are missing due to AIDS related death, emigrations, and better paid work (16). In Malawi, the only College of Medicine produces less than 70 new graduates each year, many of which move on to more westernized nations (14). Of the graduates that do practice medicine in their own country, they typically opt to stay in more urban settings, leaving the clinical care in rural areas to be provided by medical assistants. The primary care facilities that do service rural areas typically do not have the expertise or the materials to provide patients with the necessary treatments (21). Antiretroviral therapy is not simply a form of treatment we can hand out to the masses, it requires a life long commitment, with well-trained healthcare workers monitoring patient status. This is something that the targeted countries simply do not have. Without adequate numbers of healthcare facilities and well-trained healthcare workers, ART treatment will never be distributed efficiently and effectively. The 3 by 5 initiative was unable to reach its goal by 2005 because WHO created an unrealistic target without addressing one of the forefront barriers that limit access to treatment. Treatment cannot be thrown into a country and utilized successfully when the targeted countries do not have the manpower nor facilities to treat such a massive number of individuals. Treating three million patients in two years is an enormous number of people in a short amount of time. The initiative ineffectively addressed one of the key reasons surrounding the increasing HIV/AIDS pandemic. Before such a large-scale treatment plan can be implemented, it is critical that we focus on creating a stronger healthcare infrastructure, one that can realistically treat this magnitude of patients.

A Narrow Intervention is Not Sufficient

The 3 by 5 initiative aimed to treat 3 million HIV/AIDS infected people with antiretroviral therapy by 2005. The interventions target: those already infected with the virus, ignoring those at risk of developing the disease. This narrowly focused intervention failed to consider the total population, focusing solely on those already HIV positive. But where does that leave those at risk of acquiring the infection? Currently, worldwide ignorance is common, with surveys around the world indicating that awareness and comprehension of HIV is low (3). The numbers of infected individuals is rising steadily. In 2005 alone, an estimated 4.1 million new infections occurred (4). Numbers in the youth population are also quickly rising, with estimates of 6 to 7 thousand new youth infections daily and 11.8 million already infected (3). In the United States, sexual education and life skills are incorporated into school curriculums, however, this is not the case in poor countries where HIV is spreading most rapidly.

Education involving factual and uninhibited knowledge is critical for both the HIV negative and the HIV positive population of all ages, helping to further prevent transmission by providing people with information about the disease, transmission, and how one can protect oneself. Education has also shown to be effective in improving the quality of life of HIV positive individuals, including teaching those infected, the importance of not passing the virus. Finally, education is critical if we hope to reduce the stigma and discrimination surrounding the pandemic, probably the most significant barrier preventing treatment. Without educating, allocating treatment becomes difficult. Those unaware of the problem and the virus effects will simply not be willing to accept treatment.

Additionally, the 3 by 5 initiative suffered from a funding gap of over 5.5 billion dollars, yet in spite of that, hoped to achieve an enormous goal (23). Consequently, implementing the most cost effective interventions, which target the greatest number of people, are critical to the program’s success. In a study conducted at the School of Public Health at the University of California, Berkeley researchers estimated that prevention interventions including education are almost 1000 times more cost-effective than treatment with antiretroviral therapy, even when the medications were provided at no cost (11). This is not to say that antiretroviral treatment should not be utilized, however, it does indicate that treatment alone will not solve the global problem.

The 3 by 5 initiative was unable to reach its goal because of its failure to incorporate broader development strategies into the invention. The initiative addressed only one issue-treatment-while ignoring those at risk of infection. A successful intervention must focus on providing people with the information to expand their understanding of the disease, as well as the tools to protect themselves and others. They must understand how the disease is transmitted, how it is prevented, the severity of the problem, and how it is treated. They must also understand that the disease is not biased against gender, age and economic status. The 3 by 5 initiative failed to take into account the fact that the HIV/AIDS crisis is multi-faceted, without the having the appropriate knowledge, treatment can only provide limited protection. The initiative’s core values were narrowly centered on treatment alone. Before offering treatment, awareness must be created. As the number of new HIV infections continues to escalate is it important that we speak to the entire population, whether infected or at risk. A fair public health intervention must protect the rights of those infected as well as those that are uninfected.

Stigma and Discrimination Pose a Threat to Treatment

At the 10th meeting of the Joint Nations Programme on HIV/AIDS, Peter Piot, the Executive Director of UNAIDS described the need to combat stigma as one of the five most pressing matters in the global community (15). However, when the 3 by 5 initiative was announced in 2003, the desire to combat stigma seemed long forgotten. The word Stigma dates back to ancient Greece, where it was defined as “a mark or spot on the skin that bleeds as a symptom of hysteria” (2). Today, it is no longer considered a “physical” mark, but a theoretical one. Sociologists define stigma as a symbolic mark, indicating severe disapproval for someone or something that is not within cultural norms” (6). This disapproval may be caused by an illness, deformity, behavior or a social group. Stigma often leads to discrimination or “unfair treatment of a person or group on the basis of prejudice by individuals, communities or society” (2). Characterized by rejection, denial, underrating and social distance, HIV/AIDS is considered to be the most stigmatized medical condition in the world (10). This stigma often impedes treatment, prevention, and diagnosis.

Since, the 1980’s, when AIDS made its first appearance, the belief that AIDS sufferers were “contaminated and tainted” was created and continues to prevail (18). The fear of transmission typically leads to social isolation, loss or rights, reduced access to services, and fuels transmission of the disease. The severity of the illness and its association with illegal and sensitive behaviors such as prostitution and drug use intensify the stigma associated with the disease (20). Consequently, it is often felt that HIV is a product of poor personal choices, infecting those with no moral values; therefore it is one’s own fault if they acquire the disease (20). One study, in South Africa, reported that two out of three men who have sex with men had not been tested for HIV, suggesting that stigma surrounding HIV/AIDS was preventing their need to get tested (18). In another study conducted in South Africa, 63% of those with HIV, claimed to be embarrassed by their status, while 74% claimed it was difficult to tell others their HIV positive status (18). Moreover, the stigma surrounding the virus does not only lead to embarrassment, but can be debilitating to one’s occupation or societal place. For example, in South Africa, 29% indicated that they would not buy food from an HIV positive vendor, while 20% wished that HIV positive children would be kept away from other children. And 41% suggested that HIV positive people should have their freedoms restricted (18). We have known for some time that the HIV virus is transmitted sexually or via blood, however, large percentages of people are admitting that they do not feel comfortable being near those infected. And how can we blame them when society is constantly telling them they are correct? Why would one admit to having the disease or accept treatment if they are to become social outcasts? Thus, even if treatment is placed in front of them, the population is not always going to take advantage of it.

In many developing countries, women are already often at a great disadvantage socially, culturally, and economically, making stigma and discrimination profound. Most already do not have equal acess to treatment or education, and if discovered to be infected are socially distanced from their communities. Mothers in Botswana, fearful of stigma, discrimination and possible abandonment, risk the lives of their infant children to protect themselves with 50% of the women indicating that they do not feed their babies with formula in hopes to cover their true HIV status (21). In India, for example, a husband abandoning his infected wife is not uncommon, even if he was the one to infect her. Even violence is not rare, and in 1998, Gugu Dhlamini, a South African social activist, was beaten and stoned after speaking publicly about her HIV status (3).

Stigma and discrimination discourage HIV testing, counseling, and prevention services. People are less likely to disclose their HIV to a sexual partner, women are less likely to practice safer infant feeding practices, and unnecessary stigmatization is conferred to family and friends. Stigma and discrimination are in truth the most severe barriers that limit treatment. If disclosing one’s HIV status or accepting treatment creates a risk of abandonment, social distancing, or death, it becomes clear why treatment alone is ineffective. The World Health Organization’s goal of supplying three million patients with antiretroviral therapy overlooks the main factor fueling the HIV/AIDS pandemic! The intervention failed to recognize that the HIV/AIDS problem is not solely based on a lack of treatment, but is intrinsically intertwined with the societal values. (17). Providing ART treatment will not rid society of the stigma and discrimination that persists. Creating an intervention which creates awareness and specifically targets stigma and discrimination is crucial. It is clear that large numbers of HIV sufferers in developing countries desperately need ART therapy, but therapy becomes ineffective when infected individuals are unwilling to utilize the treatment. Everyone deserves equal access to the drug, but with stigma and discrimination present, patients are not going to take advantage of the treatment that is placed in front of them. Jonathon Mann, Director of the World Health Organization’s former Global Programme on AIDS, claimed that the third phase of the AIDS pandemic was the most explosive. This phase, characterized by discrimination and stigma “are as central to the global AIDS challenge as the disease itself.” (15).

In 2007, we all agree on one thing, that the HIV/AIDS pandemic has progressed to a world-wide emergency. We can no longer sit back and watch the virus conquer our world. To combat the disease the World Health Organization created the 3 by 5 initiative, which hoped to provide antiretroviral treatment to 3 million HIV/AIDS patients by 2005. Sadly, the intervention did not reach its goal due to its failure to incorporate strategies targeting the barriers that limit treatmeant. The initiative failed to take into account that many of the target countries had poor infrastructures with severe shortages of healthcare facilities and healthcare workers. Additionally, the narrow focus of initiative targeted those needing immediate antiretroviral therapy, while excluding those at risk of infection. Finally, the intervention failed to address stigma and discrimination and its effect on acquiring treatment. Although, the 3 by 5 initiative was unable to reach its goal, it was not a complete failure. We learn from our mistakes and hopefully this aggressive treatment intervention can be incorporated into a more comprehensive plan that targets the underlying factors that have not only inhibited the success of the 3 by 5 initiative, but have been critical in fueling the pandemic.

REFERENCES

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19. Teixeira, P. The 3 by 5 Initiative-What it Wants to Achieve, the Challenges and the Role of NGOs and International Institutions. Swiss platform and International Cooperations. 2004.

20. Thomas. BE., Rehman, F., Suryanarayanan, D., Josephine, K., et al. How Stigmatizing is Stigma in the Life of People Living with HIV: A Study on HIV Positive Individuals from Chennai, South India. 2005;17(7):795-801.

21. World Bank. Raising the sights for India’s health system. 2002. http://Inweb18.worldbank.org/sar/sa.nsf/Attachments/one/$File/hCh1.pdf. Accessed April 1, 2007.

22. World Health Organization. http://www.who.int/countries/ind/en/. Accessed April 6, 2007.

23. World Health Organization. 2003. Treating 3 Million by 2005, Making it happen, The WHO Strategy. 2003. http://www.who.int/3by5/en/. Accessed April 1, 2007.

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