Funding the fight against AIDS in Africa: You should have (Red) this

Here is an interesting argument from the former USAID HIV prevention advisor for southern Africa advocating a broader approach for healthcare in Africa by not merely throwing money at aids, but the need to strengthen basic health systems in Africa.

Many millions of African children and adults die of malnutrition, pneumonia, motor vehicle accidents and other largely preventable, if not headline-grabbing, conditions. One-fifth of all global deaths from diarrhea occur in just three African countries — Congo, Ethiopia and Nigeria — that have relatively low H.I.V. prevalence. Yet this condition, which is not particularly difficult to cure or prevent, gets scant attention from the donors that invest nearly $1 billion annually on AIDS programs in those countries.

I was struck by this discrepancy between Western donors’ priorities and the real needs of Africans last month, during my most recent trip to Africa. In Senegal, H.I.V. rates remain under 1 percent in adults, partly due to that country’s early adoption of enlightened policies toward prostitution and other risky practices, in addition to universal male circumcision, which limits the heterosexual spread of H.I.V. Rates of tuberculosis, now another favored disease of international donors, are also relatively low in Senegal, and I learned that even malaria, the donors’ third major concern, is not quite as rampant as was assumed, with new testing finding that many fevers aren’t actually caused by the disease.

Meanwhile, the stench of sewage permeates the crowded outskirts of Dakar, Senegal’s capital. There, as in many other parts of West Africa and the developing world, inadequate access to safe water results in devastating diarrheal diseases. Shortages of food and basic health services like vaccinations, prenatal care and family planning contribute to large family size and high child and maternal mortality. Major donors like the President’s Emergency Plan for AIDS Relief, known as Pepfar, and the Global Fund to Fight AIDS, Tuberculosis and Malaria have not directly addressed such basic health issues. The Global Fund’s director, Michel Kazatchkine, has acknowledged, “We are not a global fund that funds local health.”

The problem is not only from the government. In an article for Foreign Affairs last year, Laurie Garrett argued that while more money is being poured into public health from private donors, much of it is directed “narrow, disease-specific problems” and not tackling public health in general. From her article:

Moreover, in all too many cases, [health] aid is tied to short-term numerical targets such as increasing the number of people receiving specific drugs, decreasing the number of pregnant women diagnosed with HIV (the virus that causes AIDS), or increasing the quantity of bed nets handed out to children to block disease-carrying mosquitoes. Few donors seem to understand that it will take at least a full generation (if not two or three) to substantially improve public health -- and that efforts should focus less on particular diseases than on broad measures that affect populations' general well-being.

The Los Angeles Times, in a recent investigation, found that one unintended consequence of laser focus on a specific disease is that local health workers who specialize in AIDS are paid much more than their counterparts.

Here’s the takeaway lesson from the LA Times.

Because of the generosity of the foundation and other donors, millions of children have been protected against scourges such as malaria and measles -- and AIDS deaths in much of Africa are finally leveling off. Dr. Mphu K. Ramatlapeng, Lesotho's health minister, echoed health authorities worldwide when she said this would have been impossible "if it were not for the money from Bill Gates."

But because of the overwhelming nature of AIDS, wartime disruptions and poor governance in some nations -- and because of the priorities of global health groups, including GAVI and the Global Fund -- key measures of societal health have stalled at appalling levels or worsened.

Dr. Peter Poore, a pediatrician who has worked in Africa for three decades, is a former Global Fund board member and consultant to GAVI (formerly the Global Alliance for Vaccines and Immunization). He says they and other donors provide crucial help but overstate the impact of their programs. "They can also do dangerous things," he said. "They can be very disruptive to health systems -- the very things they claim they are trying to improve."

Three arguments making basically the same point. Only here at Africa Flak.

The Guess Who: UNAIDS and its small problem with statistics -- and the truth

UNAIDS, the United Nations coordinating organization to combat AIDS, admitted it overestimated the size of the world-wide HIV-AIDS epidemic and will drastically slash the reported number of people suffering from the disease.

The Geneva-based organization calls these reductions a “revision of estimates” made after reviewing its research and monitoring methodologies. The adjustments, however, are substantial, bringing into question a decades worth of AIDS advocacy.

UNAIDS admits it overestimated the number of people with new infections at 2.5 million, a cut of more than 40 percent from last year’s calculation of 4.3 million. More startling is the reduction of last year’s assessment that 40 million people were infected with the disease. This statistic now reads 33 million.

Also, according to the group, the number of people dying each year from HIV-AIDS dropped from an estimated 2.9 million in 2006 to a revised 2.1 million.

UNAIDS officials claim their reassessment of the disease’s reach in India led to the greatest reduction in its prevalence and mortality rates. The advocacy group also admitted that “important revisions of estimates” took place in Angola, Kenya, Nigeria and Zimbabwe.

Alarming issues
UNAIDS statistics have long been questioned by researchers and health care advocates. Today’s Washington Post provides a takeaway message from the group’s announcement:

Having millions fewer people with a lethal contagious disease is good news. Some researchers, however, contend that persistent overestimates in the widely quoted U.N. reports have long skewed funding decisions and obscured potential lessons about how to slow the spread of HIV. Critics have also said that U.N. officials overstated the extent of the epidemic to help gather political and financial support for combating AIDS.

"There was a tendency toward alarmism, and that fit perhaps a certain fundraising agenda," said Helen Epstein, author of "The Invisible Cure: Africa, the West, and the Fight Against AIDS." "I hope these new numbers will help refocus the response in a more pragmatic way."

Over the past decade, global spending on AIDS has grown by a factor of 30, reaching as much as $10 billion a year.

But in its role in tracking the spread of the epidemic and recommending strategies to combat it, UNAIDS has drawn criticism in recent years from Epstein and others who have accused it of being politicized and not scientifically rigorous.

For years, UNAIDS reports have portrayed an epidemic that threatened to burst beyond its epicenter in southern Africa to generate widespread illness and death in other countries. In China alone, one report warned, there would be 10 million infections -- up from 1 million in 2002 -- by the end of the decade.

Peter Piot, the Belgian doctor who formed UNAIDS in 1995 recently lashed back at critics who, he says, worry too much about his groups’ estimates, which diverts attention from solving the AIDS riddle.

In a recent speech, he claimed:

"The challenge is ... complicated by the mixed messages circulating around the world," Piot said. "Denialist statements such as that 'UNAIDS overestimates the size of the epidemic,' and 'There's too much money for AIDS' don't help, not least because there's clearly a massive gap between what's needed and what's available."

Methodological questions persist
The scientific community has long held misgivings about the methodology UNAIDS uses to gather its prevalence estimates. Throughout much of the past decade, the group primarily relied on sentinel surveys, which monitor the prevalence of HIV in women who attend: 1) prenatal clinics; or, 2) clinics for the treatment of sexually transmitted diseases.

By only tabulating AIDS rates of sexually-active patients who visit health clinics, UNAIDS researchers admitted they wanted to track the people or groups most likely contribute to the expansion of the disease. This will provide them with a leg up when combating a concentrated malady like HIV-AIDS. Another advantage of this system is that these surveys could be taken anonymously because the clinics are settings where blood is often drawn.

Critics point out that UNAIDS long ignored the common practice of household surveys, which make use of large survey sizes in discrete geographic regions. (One of the problems with STD clinics is they most often reside in large cities, although much of Africa’s population still lives in rural areas.) Because household-based surveys are more thorough and time consuming, they are not susceptible to the wild variations of the sentinel surveys.

An example of inconsistent results recently took place in Burkina Faso. UNAIDS, using 2001 sentinel studies from various health clinics around Burkina Faso, reported the national AIDS rate stood at 6.5 percent, a much higher rate than anyone predicted. The next year, UN researchers conducted a similar study and saw the rate fall to 4.2 percent. After repeating the study once again in 2003, UNAIDS reported the average tumbled down to 2.3 percent.

About the same time, a different group of researchers published the results from a household-based survey which estimated the national prevalence rate to be 1.8 percent. Another benefit of household-based surveys is they provide researchers with important geographical information on the spread of AIDS. The researchers found that only 1.3 percent (on average) of rural people are infected, along with 3.6 percent of people living in urban areas. Yet, even these numbers can be deceiving: In the predominately Muslim rural north, for example, only .1 percent of the population is afflicted with HIV-AIDS, while up to 3.7 percent of people in the far southern part of the country. The study also found that prevalence rate for AIDS in the capital Ouagadougou to be as high as 4.2 percent.

Looking deeper
While UNAIDS should be applauded for acknowledging its shoddy science, I still have serious reservations with the group’s announcement.

Most importantly, UNAIDS kept with its sentinel surveys long after the knew these methods provided exaggerated claims of the spread of the disease. According to its own publication, the 2007 AIDS Epidemic Update, the group continually overestimated AIDS prevalence rates in 25 different African countries. (These rates include all adults between 15 and 49 years.)

Some of the “overestimates” were minimal, like the UNAIDS .8 percent rate of prevalence for 2004 in Senegal while a household survey found a .7 percent prevalence rate.

Some figures were staggering.

• In Botswana, researchers reported the AIDS prevalence rate in 2004 to be 25.2 percent, one of the highest in the world. That same year UNAIDS claimed the rate to be 38 percent. In 2005, the UNAIDS said the rate fell to 24.1 percent;
  

• In Central African Republic, UNAIDS announced the 2004 prevalence rate to be 13.5 percent. A 2006 household survey predicted the rate to be 6.2 percent. In 2006 UNAIDS reduced its estimate to 10.7 percent;

• In South Africa, researchers claim that in 2005, some 16.1 percent of the adult population was infected with the disease. UNAIDS put that number at 20.9 percent in 2004 and 18.8 percent in 2006.

Reviewing this data, one can see the group had plenty of time to revise and update its methodology. A cynic may even point out that as researchers began to lob criticism at UNAIDS’ findings, the group slowly began downsizing its estimates. If that's true, why did it take until 2006 for this to begin happening?

This is a group responsible for a $2.6 billion budget (in 2006-07), an organization that refers to itself as the UN’s coordinating body in the fight against AIDS. One would think it would want the most thorough, most geographic and gender specific information available regarding the disease it purports to fight.

The problem with these high estimates is that UNAIDS also views itself as a major portal in AIDS fundraising. Of course, the group never referred to its questionable statistics when it had its jar out for donations.

That didn't stop officials from making wild claims. In 2005, UNAIDS released a report claiming a “looming funding gap of $18 billion for H.I.V./AIDS in developing nations between 2005 and 2007.” This shortfall, the group said, could hurt access to prevention programs against HIV transmission and would jeopardize the antiretroviral treatment to 75 percent of individuals clinically qualified to receive these medicines in 2008 and slow down the progress made in providing support for AIDS orphans and other children affected by the disease.

The short version: If we don't get you're money, people are going to die.

Data-free research
Regular readers of this blog (my mother and some guy in Minneapolis, Minnesota) will no doubt understand my obligation to puncture what I feel is time-honored, but reality-free stereotypes of Africa. One of the most hallowed of those myths is that the continent of Africa doubles as a hospice for AIDS patients. This legend, perpetrated in part by the media of all stripes and fashionable personalities of all shades, provides for the rest of us a perfect symbol of Africa: A continent full of emergencies like AIDS, the slow, silent killer, producer of death, leaving only widows and orphans in its wake. Yet the subtext remains the same: Africans are too dumb, too foolish, too conservative and too horny to understand what the rest of the world already knows: AIDS kills! Stay away from it.

From Africa to the rest of world, the message clearly remains the same: We are constantly in trouble and we could use some more help.

Of course, UNAIDS, a long perpetrator of this myth for its private gain, has come out of the darkness and (somewhat) begged our forgiveness. In the coming weeks and months we will judge the contrition of this most high-paid and well oiled group. I guess they could start by merely telling the truth and quit being so damned arrogant.

Update: Added link to Washington Post story

AIDS in Africa: Context, please

Two issues have stood out above others in my storied career as a press critic. One, I’ve called for more coverage of shark attacks, a wish the fourth estate is currently fulfilling. Second, I’ve called for providing readers more with context – more background information so they can better understand how an issue truly affects others. This is especially important for international stories, where readers may not have everyday understanding of the problems facing, say, Africans.

Here’s an example:

On the Oprah Winfrey show, Bono explains some of the bad news facing the continent: “Currently, 28 million Africans are infected HIV; approximately 1.5 million children.”

In a perfect world, Oprah would then whip out her laptop and pull up this website, and say to Bono: “Well, it says here that more than 922 million people live in Africa. That would be” – tapping on a calculator – “about three percent.”

Oprah would then look solemnly at the camera: “Three percent of Africans have AIDS. It’s a tragedy, a human tragedy. But the way you keep going on, Bono, you’d think that four out of five Africans were lying in huts waiting to die.”

This didn’t happen, of course. Oprah Winfrey is not in the business of fighting with too many guests. She's an entertainer. She is not responsible for vetting much of the information reported on her show.

But what can we say of our news organizations?

A recent New York Times story reported that according to a poll, 42 percent of Americans think that AIDS is the world’s most prolific killer of children under five. However, the disease is only responsible for three percent of the nearly 10 million deaths to children every year.

Also, nearly one in five of those polled felt malaria was the biggest killer. But the mosquito-born illness kills about 8 percent of children under five.

To the story:

The reasons for this misapprehension are varied, but they most likely include health advocates' recent success in focusing politicians and news organizations on the undeniably horrific toll from AIDS and malaria.

''It's based on what's in the news,'' said Nils Daulaire, president of the Global Health Council, an organization of health professionals, nonprofit groups and other institutions. ''And it's a vicious cycle. The things that get reported on are the things that people believe are important.''

Health advocates’ recent success focusing news organizations? Apparently, the New York Times takes no responsibility for these misconceptions. In fact, the story is placed under the following headline:

In U.S. Poll, Most Fail a Quiz on Global Causes of Child Deaths

Yet, a simple search of “AIDS + Africa” at nytimes.com yielded more than 250 stories (including one in the Home and Garden section) published within the past year. Conversely, a search for the words "diarrhea" + "Africa" landed only 24 hits. By the looks of it, those health professionals working with AIDS must have done a lot of arm twisting.

Yes, Americans may be ignorant about the cause children’s deaths (I know I am). But I’d like to think as journalists we could start looking for blame elsewhere for our readers’ lack of understanding.