Health and development

Seven months after launching the catch-up plan in western and central Africa, progress on increasing the numbers of people on antiretroviral treatment continues to lag in the region. Many countries will not reach key targets by 2020 if the current systems remain unchanged.

"Overall we saw a 10% percent increase of people on treatment, which is not enough," said UNAIDS Executive Director Michel Sidibé. "Now, there is even more a sense of urgency."

Mr Sidibé, however, pointed to the success in the Democratic Republic of Congo where there was a clear increase in the number of people living with HIV accessing ARVs. The reasons for the positive trend included civil society and political leadership working closely together as well as community HIV testing and the training of 11 000 health care workers.

"More than ever there is a need to rethink health systems and alternatives for people to access health care," he said.

The call to delegate patient care to communities was a major rallying call during AFRAVIH, the international francophone HIV and hepatitis conference held in Bordeaux, France, early April. Mr Sidibé briefly shared the stage at the opening ceremony with the civil society organisation Coalition PLUS. They declared that the key to success in ending AIDS involved joining forces between doctors and community health workers and giving more leeway to communities to respond to the local needs of their own people.

Under the banner, "De-medicalize" the organisation explained that doctors will never be replaced but that there were too few of them and people living with HIV didn't require acute care.

Coalition Plus' recent report states that governments and the medical practitioners should delegate more tasks to nurses and community health workers. In addition to allowing for more targeted prevention and faster access to treatment, delegation of non-medical tasks would lighten the load on overburdened health systems. West and central Africa represent 17% of the total population living with HIV but 30% of deaths in the region are from AIDS-related illnesses. This is a region, according to UNAIDS and its partners, that can truly benefit from community models of care.

What worries Médecins Sans Frontières (MSF) is the risk of a significant drop in resources for treatment will hamper recent improvements in west and central Africa. This concern stems from the fact that Global Fund estimates a 30% drop in fund allocations to the region for 2018 – 2020 compared to signed HIV grants in the previous allocation period. In 2016, MSF was among the first to sound alarm bells regarding the region's high HIV death toll and the up to 80% of children unable to access antiretroviral therapy. MSF HIV Policy Advisor and Advocacy Officer Nathalie Cartier said that they supported the west and central Africa catch-up plan but that it needed to be fully implemented. "Political will has been promising but now it's time to make it a reality on the ground so that people living with HIV can reap the benefits," she said.

Global Fund supported the catch-up plan and works closely with countries in order to maximize the impact of the investments. They believe that leveraging additional domestic financing for health is crucial to increase country ownership and build sustainable programs.

All the more reason to decentralize healthcare systems and capitalize on innovations to keep health costs down.  HIV self-testing, new medicines and high impact strategies involving communities are critical to improving efficiencies.  "With point-of-care (POC) testing in communities and homes, delays are minimal between diagnosis and initiating treatment," said Cheick Tidiane Tall, Director of Réseau EVA, a network of pediatric doctors specialized in HIV care. “In the long run, that's a lot of people and resources saved,” he added.

Côte d'Ivoire Infectious and Tropical Diseases professor Serge Eholié couldn't agree more.  "Flexible health care systems capitalizing on various innovations makes a lot of sense," he said. Turning to the Minister of Health in the Central African Republic, Pierre Somse, he asked, 'How do you respond?'

Mr Somse, also a trained doctor, said, "We doctors will stay doctors. However, there is a need for us to lean on communities and vice versa."  He added, "at the heart of the issue are patients and they are and should always be the priority."

Mexico has taken steps to strengthen access to health-care services by lesbian, gay, bisexual, transgender and intersex (LGBTI) people. A new Ministry of Health code of conduct aims to put an end to stigma and discrimination based on gender identity and sexual orientation in all health centres in the country.

Establishing guidelines and specific actions for the provision of health-care services, the code of conduct will be implemented throughout the national health system to guarantee effective access to health by respecting the dignity and autonomy of LGBTI people.

The code of conduct provides for health personnel from public health facilities to be trained in avoiding discriminatory expressions and attitudes and to respect the confidentiality of patients. Among various provisions, it clearly stipulates that so-called treatment to “cure homosexuality or transexuality” must be avoided. It establishes that health centres should maintain a policy of zero tolerance for discrimination and must investigate accusations of discrimination. Health centres should also promote ongoing sexual and reproductive health and HIV prevention campaigns focused on LGBTI people.

The code of conduct was developed through a broad participatory process that included the Coordinating Committee of the National Institutes of Health and High Specialty Hospitals, the National Center for HIV Prevention and Control, Specialized Condesa Clinic of Mexico City, the National Council for Preventing Discrimination and representatives of civil society and LGBTI organizations.

The next steps include a training process on its practical application, with the involvement of civil society and community-based organizations. The implementation will have a pilot phase and will begin in the largest cities in the country.

The Yuetan Community Health Centre is nestled on a narrow lane in an old residential part of central Beijing, China. Its yard is packed with bicycles, rather than cars—an indication that the centre is serving people close to where they live.

“Through our centre and nine affiliated community health stations, we provide services to 150 000 people living in the Yuetan area,” said Du Xue Ping, Director of Yuetan Community Health Centre. “In addition to providing medicine, we also undertake health promotion, encouraging people to lead a healthy life. We know that prevention is far better than cure.”

The centre blends state-of-the-art Chinese medicine and Western medicine, serving 420 000 patients annually. It supports the community’s rapidly ageing population, overseeing two senior homes and staff who conduct home visits for seniors and people with mobility problems.

The facility is part of China’s highly regarded multitiered medical system, which has successfully brought life-saving services to people across the country. In this system, major diseases are handled in large hospitals and routine services are treated in community health centres. According to Chinese data, in 2015 there were more than 34 000 similar community health clinics providing essential health services to 706 million people in China. “Community health centres are the first line of defence in protecting people’s health,” said Michel Sidibé, Executive Director of UNAIDS. “The family-centred interface and clear bond between staff and patients exemplifies people-to-people connections.”

Mr Sidibé visited the community health centre to learn more about its holistic and comprehensive approach and how China’s community health system could help to inform the 2 million community health workers initiative, which was recently endorsed by the African Union.

In the 1970s, China’s community-based doctors dramatically improved access to health care in rural communities and were an inspiration to many other countries. China exported the model, sending teams of doctors and nurses to Africa.

“I know from my own personal experience the contributions China has made to primary health care in Africa,” said Mr Sidibé. “Chinese doctors provided crucial medical services to people in Mali where I am from.”

“The world can learn a lot from the Chinese experience,” said Mr Sidibé. “I am very impressed by the professionalism I witnessed here today.”

China and Africa have come together to find new ways of improving access to health care. More than 30 Ministers of Health from across Africa joined the Vice-Premier of China Liu Yandong, and the Chinese Minister of National Health and Family Planning Commission Li Bin at the China-Africa Ministerial Conference on Health Cooperation. The event was held in Pretoria, South Africa on April 24 under the theme China-Africa Health Cooperation, From Commitments to Actions.

The Vice Premier of China talked about the long standing partnership between China and Africa in the field of health care and of China’s commitment to help build the health sector in developing countries and boost efforts for a broader future for China-Africa cooperation in health.

In his address, the UNAIDS Executive Director, Michel Sidibé, outlined three critical initiatives that need to be put in place. He said that, together with the African Union, partners should create a workforce of 2 million community health workers for Africa, learning from the Barefoot Doctors of China organization, which trains people on basic medicine to work in rural areas of China. Trilateral cooperation between China, Africa and UNAIDS should focus on disease surveillance for accelerating action to achieve Sustainable Development Goals 3. He added that UNAIDS will continue to support the scale-up of the local production of medicines and health commodities.

Following his speech, participants signed a five-point plan for China–Africa cooperation on health which focuses on improving access to health-care services through Chinese medical teams working in Africa and by strengthening public health preparedness and capacity-building, particularly through the African Centre for Disease Control. The plan also includes a special focus on key populations, women and young people and urges an increase in training opportunities for African and Chinese people. Increasing China–Africa cooperation, specifically around accelerated action for technology and local production, is also part of the plan.

During meetings with the Chinese Minister of Health, and the Uganda Minister of Health, Jane Aceng, Mr Sidibé emphasized how the China–Africa partnership can go beyond AIDS, to create sustainable solutions for social and economic development in Africa.

Economic experts and representatives of national AIDS programmes, health ministries and health professional organizations endorsed the creation of a global coalition of community health workers in UNAIDS-convened consultations in New York, United States of America, on 9 and 10 February.

Community health workers bring cost-effective services to communities and increase service access for marginalized people, who often struggle to access essential health services. More than 6 million community health workers are already in place across the world. However, many are unpaid and are typically not fully integrated into health systems.

The participants called for an urgent initiative to recruit, train and deploy at least 2 million community health workers over the next two years to drive progress towards the 90–90–90 targets—whereby 90% of people living with HIV know their HIV status, 90% of people who know their HIV-positive status are accessing treatment and 90% of people on treatment have suppressed viral loads—and to lay the foundation for sustainable health for all.

The consultations generated strong support for UNAIDS to establish a new international coalition of community health workers by mid-2017. This coalition will help to galvanize the creation of national associations of community health workers, support their harmonization and formalization, advocate for actions that support them and provide a unifying platform.

As a next step, it was agreed that UNAIDS will seek input from country-level community health workers on the vision, mission and structure of the coalition. UNAIDS will lead a global effort to mobilize resources for an emergency fund to support national initiatives for community health workers and to incorporate them as formalized, integral members of the health system.

Funding from Luxembourg supported the consultations. The Earth Institute of Columbia University and the International Association of Providers of AIDS Care were co-hosts.

Health services are being scaled up in many low- and middle-income countries. This has resulted in a substantial increase in the amount of personal health information collected in order to develop and maintain comprehensive health records of a person’s use of the services and to monitor and evaluate the use, cost, outcomes and impacts of programmes or services. Detailed personal health information is also needed to evaluate success towards achieving, for example, the 90–90–90 targets, universal health coverage and the Sustainable Development Goals.

However, if personal health information is not held confidentially and securely, people may be reluctant to use health services, owing to fear of being stigmatized or discriminated against. The confidentiality and security of personally identifiable information therefore has to be protected at all levels of the health system. In many countries, this will require the development and implementation of privacy laws and a confidentiality and security framework for protecting personal health information.

Based on the principles of privacy, confidentiality and security, UNAIDS and PEPFAR have developed an assessment tool and an user manual to support countries to assess the degree that the confidentiality and security of personal health information is protected at facility and data warehouse levels and whether national guidelines that include privacy laws exist.

Many countries are in the process of developing and implementing national health identifiers (NHIDs) to ensure that each patient has a unique identity within the health system. This facilitates the development of comprehensive medical records and allows users of services to be tracked across health-care sectors. The development and use of NHIDs in a country’s health-care system promotes the effectiveness and efficiency of data gathering, but their use further underlines the need to protect the confidentiality and security of personal health information.

While policy-makers and other stakeholders in several countries recognize the need to develop and implement policies for protecting the privacy, confidentiality and security of personal health information, to date few countries have developed, let alone implemented, such policies. A workbook has also been developed that can be used to perform the actual assessments in country to assess to what extent policies have been developed and implemented at facility, data warehouse and national levels. 

On 20 July, at the 21st International AIDS Conference, being held in Durban, South Africa, UNAIDS, the World Health Organization (WHO) and the Global Coalition on Women and AIDS launched a joint report, entitled HPV, HIV and cervical cancer: leveraging synergies to save women’s lives, as part of the work of the United Nations Interagency Joint Task Force on Noncommunicable Diseases. The report was launched during an informal panel discussion with representatives of UNAIDS, WHO and the International Community of Women Living with HIV, East and Southern Africa, moderated by Ebony Johnson of the Athena Network.

The burden that HIV places on women, particularly adolescent girls and young women from low- and middle-income countries, is compounded by the global burden of human papillomavirus (HPV) infection and cervical cancer. Every year more than 260 000 women die from cervical cancer—approximately 85% of whom live in low- and middle-income countries. Women living with HIV have a four to five times higher risk of developing cervical cancer, an AIDS-defining illness that is the second most common cancer among women living in low- and middle-income countries.

HPV is a major contributor to global morbidity and mortality each year, causing diseases that range from benign lesions to invasive cancers. Growing evidence indicates that HPV may also be an important cofactor in HIV acquisition.

Given the association between HPV, cervical cancer and HIV, synergies must be leveraged, and a focused and integrated approach to sexual and reproductive health, and saving women’s lives, must be taken.

The launch of the report engaged advocates, activists, researchers, service providers, the United Nations and development partners in a lively and informal dialogue. Princess Tessy of Luxembourg, Yvonne Chaka Chaka and Prince Africa Zulu of Onkweni attended the event.