HIV and AIDS in South Africa: what is an appropriate public health response?

Ninety-eight cases of acquired immune deficiency syndrome (AIDS)were reported in the Republic of South Africa by the end of1987, and 166 by mid-December 1988. By 12 February 1990, 353cases of AIDS had been reported: 326 in South Africans and 27in people from either elsewhere in southern Africa or abroad.The South African patients comprised two main groups: whitemen with the pattern of infection typical of homosexual andbisexual men; and heterosexuals exhibiting the pattern commonin much of central and southern Africa. There have been a smallnumber of people with haemophilia affected with AIDS, but onlyone injecting drug user with AIDS to date. There is evidenceof considerable spread of the epidemic into the South Africanblack population; migrant labour, the high prevalence of sexuallytransmitted diseases and suspicion of government-directed familyplanning programmes have all contributed to this. Seropositivityrates in South African blacks are noted to be rising rapidlyand the doubling time is considered to be about 8.5 months.The government and some employers have adopted discriminatorymeasures to control the disease, including the screening ofmigrant workers and the repatriation of those found to be seropositive.Public health leadership from the state authorities has beeninappropriate. We argue for greater involvement of homosexual,worker, community and public health personnel in developingpolicies of control for human immunodeficiency virus (HIV) infectionin South Africa, if the response is to be ethical, non-discriminatory,sensitive, prevention-orientated and effective.     

An approach to addressing ethical issues in a community-based risk assessment for HIV: a case from Chennai, India

Community-based assessment of HIV prevalence and behavioural risk factors is the basis for deciding priorities of prevention and care programmes. Here, upholding the human rights of participants in assessment is of utmost importance. The objective of the paper was to describe the process of implementation of an epidemiological survey to assess HIV-related behavioural and biological factors in Chennai city in South India and to suggest an ethical framework for conducting similar assessment activities in developing-country settings. A survey was conducted with participation from residents (n=1,659) of low-income urban communities (slums) as part of a community-based HIV/STD-prevention trial. Administration of the survey was preceded by extensive community contact and household visits to inform community members about the trial and assessment activities. Formative research further strengthened rapport with community, highlighted community concerns, and identified HIV-related risk behaviours that informed questionnaire design. The process of obtaining informed consent began before assessment activities and provided an opportunity for individuals to discuss participation with their families and friends. Privacy during assessment, comprehensive follow-up care for those who tested positive for HIV/STDs, such as nutritional and prevention counselling, referral services for opportunistic infections, and antenatal-care options for pregnant women increased trust and credibility of the project. The sustained availability of trial staff to facilitate access to resources to address non-HIV/STD-related felt-needs further strengthened participation of the community members. These resources included liaison services with local government to obtain public services, such as water and electricity and resources, to address concerns, such as alcohol abuse and domestic violence. Based on this experience, an ethical framework is suggested for conducting HIV epidemiological risk assessment in developing countries. This framework discusses the role of community participation, transparent and comprehensive informed consent, timely dissemination of results, and access to follow-up care for those living with HIV/STDs.     

The impact of the HIV/AIDS epidemic on hospital nurses in KwaZulu Natal, South Africa: nurses' perspectives and implications for health policy

During a stay in South Africa in 2002-2003, we learned that public sector nurses dealt with serious community and workplace impacts from the HIV/AIDS epidemic; and were reluctant to report occupational exposures to HIV or take a short-course of antiretroviral post-exposure prophylaxis to prevent HIV infection. In May 2003, in South Africa's KwaZulu Natal province, we explored perspectives of 34 public hospital nurses in nine group interviews on workplace safety; the impact of HIV/AIDS on nurses' work environments; and, hospital and government policy. The information they provided illustrates that the views of nurses are vitally important to policy-making. We conclude that seeking nurses' views and involving them in policy processes could contribute to worker health, to addressing the dramatic shortage of nurses, recently identified as the largest threat to providing HIV/AIDS treatment in sub-Saharan Africa, and to improving quality of care.     

Health care capacity and allocations among South Africa's provinces: infrastructure-inequality traps after the end of apartheid

Objectives. We assessed the determinants of health care funding allocations among South Africa''s provinces and their effects on health care from 1996 through 2007.Methods. We performed multivariate regression of funding allocation data against measures of disease burden and health system infrastructure by province.Results. Disease burden was increasingly negatively correlated with funding allocations and explained less than one quarter of the variation in allocations among provinces. Nearly three quarters of the variation in allocations was explained by preexisting hospital infrastructure and health care workers. The density of private hospitals in the preceding year was associated with greater government allocations (b_private = 0.12; 95% confidence interval [CI] = 0.08, 0.15), but public hospital density in the preceding year was not (b_public = 0.05; 95% CI = −0.02, 0.11). Greater allocations were associated with a higher number of doctors (b = 0.54; 95% CI = 0.34, 0.75) but fewer nurses (b = −0.37; 95% CI = −0.72,−0.25) in the same year.Conclusions. Regions with a greater capacity to spend funds received more funding and created more infrastructure than those with greater health needs. Historical infrastructure inequalities may have created an infrastructure–inequality trap, in which the distribution of funds to those with greater “absorptive capacity” exacerbates inequalities.

“Freedom for South Africa has brought the opportunity at last to address the basic needs of our people. It allows us not only to attend to immediate health needs, but also to begin to eradicate the legacy of poverty and inequity that is the greatest threat to our public health.”—Nelson Mandela^1a(p375)

When apartheid ended in South Africa in 1994, many saw it as an opportunity to redress inequalities that underpinned the country''s health care system. As a middle-income country, South Africa had provided world-class care for White elites, including the world''s first heart transplant, while denying many in the majority populations access to appropriate health care services.^1b Spatial segregation between populations was a prominent method to sustain inequality, with racially biased policies leading to the creation of “Black homelands” that detached the poorest areas from regions with better health care infrastructure (Figure 1).Open in a separate windowFIGURE 1South Africa''s provinces.Source. http://en.wikipedia.org/wiki/File:Map_of_South_Africa_with_English_labels.svg.In the late 1980s, South African health care researchers called for a needs-based formula to redistribute health resources more equitably.² But it was not until Nelson Mandela and the African National Congress came to power in 1994 that the national government explicitly addressed health equity and access for the majority population. Health care was enshrined as a constitutional right, and over the next few years the government constructed new health care facilities, provided free maternal and child care, and created new programs for water, nutrition, and welfare.³However, South Africa''s economic growth slowed toward the end of Mandela''s presidency, turning negative by 1998. Hard economic times reduced the resources available for redistribution just as health services faced increasing demands from patients with HIV/AIDS. The government introduced programs to improve efficiency and reduce budget deficits.⁴Despite the government''s commitment to health equity, some analysts expressed concerns that poorer provinces were unable to manage the funds allocated to them.⁵ In response to this criticism, 2 significant reforms in the late 1990s changed how health care funds were distributed. First, instead of the Minister of Health allocating earmarked health resources to disadvantaged regions, the Department of Finance disbursed block grants for general social spending to each province on the basis of the Treasury''s “Equitable Shares” formula. Provincial ministers then allocated the majority of funds for health care spending within each province out of this block grant,⁶ although conditional grants for specific diseases (e.g., HIV/AIDS) were also made available for disadvantaged provinces. Critics of this reform held that poor provinces had less spending autonomy because the Equitable Shares formula rewarded provinces according to economic output, rather than exclusively basing allocations on need; thus, poor provinces relied more heavily on conditional health grants to address their high burden of disease.⁷Second, the government introduced a growth, employment, and redistribution (GEAR) strategy that emphasized privatization and fiscal austerity. Comprehensive implementation of GEAR reforms began after Thabo Mbeki assumed the presidency in 1999.⁸ The change in administration coincided with declines in public health spending and a substantial increase in private-sector investment in health care, particularly in the wealthiest provinces.⁹When health policy aims to maximize efficiency, as intended by GEAR, it may be logical in the short run to distribute more resources to rich provinces with better health infrastructure¹⁰ because the regions can use the available funds more rapidly to meet health needs. In the long run, however, resource-deprived settings would benefit more from the additional funds required to develop new capacity. If health spending was distributed to those areas with the most capacity, this would create a self-perpetuating cycle of inequality, or what we call an infrastructure–inequality trap. According to this logic, the inequitable distribution of health infrastructure during apartheid would continue to affect distribution of health funding today.To determine how South Africa''s historical inequalities in health care resources may have been affected by these economic and administrative changes, we used multivariate regression to examine how health spending patterns among South Africa''s provinces have related to system capacity and disease burden since the end of apartheid.     

Equity and efficiency in HIV‐treatment in South Africa: the contribution of mathematical programming to priority setting

The HIV‐epidemic is one of the greatest public health crises to face South Africa. A health care response to the treatment needs of HIV‐positive people is a prime example of the desirability of an economic, rational approach to resource allocation in the face of scarcity. Despite this, almost no input based on economic analysis is currently used in national strategic planning. While cost‐utility analysis is theoretically able to establish technical efficiency, in practice this is accomplished by comparing an intervention's ICER to a threshold level representing society's maximum willingness to pay to avoid death and improve health‐related quality of life. Such an approach has been criticised for a number of reasons, including that it is inconsistent with a fixed budget for health care and that equity is not taken into account. It is also impractical if no national policy on the threshold exists. As an alternative, this paper proposes a mathematical programming approach that is capable of highlighting technical efficiency, equity, the equity/efficiency trade‐off and the affordability of alternative HIV‐treatment interventions. Government could use this information to plan an HIV‐treatment strategy that best meets equity and efficiency objectives within budget constraints. Copyright © 2009 John Wiley & Sons, Ltd.     

云南艾滋病防治专项经费分配影响因素分析

目的深入了解中央专项经费分配过程中的影响因素,为完善分配决策提供科学依据。方法采用定性调查的方法,对云南省德宏州芒市、红河州建水县、蒙自县及保山市龙陵县各级从事艾滋病防治中央专项经费管理的相关人员进行深入访谈,并对结果进行分析。结果资金拨付时间过长,统一物资招标采购过程漫长等因素影响中央专项经费的拨付;二次分配使得基层对经费信息掌握不全面,计划工作量与实际工作量的差异导致经费不足,预算制定缺少后勤保障经费将直接影响防治活动的实施,工作中临时增添的活动缺乏相应的经费支持等因素影响中央专项经费的使用。结论解决艾滋病防治中央专项经费分配存在的问题,需要合理制定计划工作量和经费预算,激励地方财政投入配套经费,紧密结合基本公共卫生服务等。     

The costs of HIV/AIDS care at government hospitals in Zimbabwe

According to official figures, HIV infection in Zimbabwe stood at 700 000-1 000 000 in 1995, representing 7-10% of the population, with even higher expected numbers in 2000. Such high numbers will have far reaching effects on the economy and the health care sector. Information on costs of treatment and care of HIV/AIDS patients in health facilities is necessary in order to have an idea of the likely costs of the increasing number of HIV/AIDS patients. Therefore, the present study estimated the costs per in-patient day as well as per in-patient stay for patients in government health facilities in Zimbabwe with special emphasis on HIV/AIDS patients. Data collection and costing was done in seven hospitals representing various levels of the referral system. The costs per in-patient day and per in-patient stay were estimated through a combination of two methods: bottom-up costing methodology (through an in-patient note review) to identify the direct treatment and diagnostic costs such as medication, laboratory tests and X-rays, and the standard step-down costing methodology to capture all the remaining resources used such as hospital administration, meals, housekeeping, laundry, etc. The findings of the study indicate that hospital care for HIV/AIDS patients was considerably higher than for non-HIV/AIDS patients. In five of the seven hospitals visited, the average costs of an in-patient stay for an HIV/AIDS patient were found to be as much as twice as high as a non-HIV/AIDS patient. This difference could be attributed to higher direct costs per in-patient day (medication, laboratory tests and X-rays) as well as longer average lengths of stay in hospital for HIV/AIDS patients compared with non-infected patients. Therefore, the impact on hospital services of increasing number of HIV/AIDS patients will be enormous.     

Gradations of researchers' obligation to provide ancillary care for HIV/AIDS in developing countries

Three principal factors affect the stringency of medical researchers' obligation to provide antiretroviral treatment to participants in non-HIV/AIDS studies that are conducted in developing countries: (1) the centrality of HIV/AIDS to the study design, (2) the extent of the researcher-participant interaction, and (3) the cost relative to the study budget. I provide a basis for assessing the comparative stringency of the researchers' obligation to provide this type of ancillary care. Practically, given the range of possible responses to study participants' needs, calibrating the researcher's responsibility to provide ancillary care is a useful step in ethical analysis. Theoretically, a gradation of obligation suggests how research ethics committees or institutional review boards can take multiple, potentially conflicting ethical factors into account without undertaking spurious efforts to quantify their importance.     

‘It hurts,but I don't have a choice,I'm not working and I'm sick’: decisions and experiences regarding abortion of women living with HIV in Cape Town,South Africa

Research was conducted with 36 women living with HIV in Cape Town, South Africa, regarding their decision-making about, and experiences with, abortion of unwanted pregnancies in the public health sector. Abortion intentions and decisions were explored by investigating influencing factors; knowledge of abortion policy and public health sector services; and abortion perceptions and experiences. Findings reveal that many women face censure both for becoming pregnant and terminating a pregnancy, including by family, partners, community members and healthcare providers. Data suggest that abortion may be more stigmatised than HIV despite South Africa's liberal abortion law. Generally, however, study participants were satisfied with the abortion care received. Most would advise women living with HIV to think carefully about abortion, but to make a decision in their own best interests, including only seeking care early in pregnancy from an accredited clinic. Study implications include a need to integrate information and counselling on safe legal abortion within sexual and reproductive health services, especially in efforts to integrate sexual and reproductive health into HIV care, and to forge greater linkages between HIV and abortion services more generally to ensure continuity in follow-up of care for women.     

Male and female genital cutting among Southern Thailand's Muslims: rituals,biomedical practice and local discourses

This paper explores the manifestation of HIV‐related stigma in seven‐ and eight‐year‐old white South African children's responses to HIV and AIDS. Drawing from elements of ethnographic and interview data, it shows how young children's responses to HIV and AIDS are inscribed within popular accounts of contagion and articulate gendered, sexual, raced and classed discourses in South Africa. Rejecting static accounts of stigma, the paper shows how children resist and confirm power inequalities involving intense self‐regulation as well as inscribing within discourses of care and concern for others infected with HIV and AIDS. The findings have implications for scaling up educational efforts to address awareness of HIV and AIDS and stigma, but also to build on positive insights that young children demonstrate with regard to the disease.     

Public-private partnerships for equity of access to care for tuberculosis and HIV/AIDS: lessons from Pune, India

The private medical sector is an important and rapidly growing source of health care in India. Private medical providers (PMP) are a diverse group, known to be poorly regulated by government policies and variable in the quality of services provided. Studies of their practices have documented inappropriate prescribing as well as violation of ethical guidelines on patient care. However, despite the critique that inequitable services characterise the private medical sector, PMPs remain important and preferred providers of primary care. This paper argues that their greater involvement in the public health framework is imperative to addressing the goal of health equity. Through a review of two research studies conducted in Pune, India, to examine the role of PMPs in tuberculosis (TB) and HIV/AIDS care, the themes of equity and access arising in private sector delivery of care for TB and HIV/AIDS are explored and the future policy directions for involving PMPs in public health programmes are highlighted. The paper concludes that public-private partnerships can enhance continuity of care for patients with TB and HIV/AIDS and argues that interventions to involve PMPs must be supported by appropriate research, along with political commitment and leadership from both public and private sectors.     

Identifying and addressing the governance accountability problem

Successive global health crises – from HIV and AIDS to SARS and H5N1 to Ebola – highlight one of the most pressing challenges to global health security: the GAP – the governance accountability problem. Introduced in 2014 in the book entitled, HIV/AIDS and the South African state: The responsibility to respond, this article takes up Alan Whiteside’s challenges, in a book review in these pages, to offer a more comprehensive analysis of the GAP. The GAP [?ehovi?, A. B. (2014). HIV/AIDS and the South African state: The responsibility to respond. Ashgate Global Health.] posits that there is a disconnect between ad hoc, state and non-state interventions to respond to an epidemic crisis, and the ultimate guarantee for health (security), which remains legally vested with the state. The existence and expansion of such ad hoc solutions result in a negligence: a failure of re-ordering of health rights and responsibilities for health between such actors and the accountable state. The GAP aims to highlight this disjunction. This article first defines the GAP. Second, it asks two questions: First, what is the contribution of the GAP thesis to understanding the emerging health security landscape? Second, what can the GAP offer in terms of practical insight into viable solutions to the re-ordering of state/non-state-based responsibility and accountability for global health security?     

The South African national health insurance: a revolution in health-care delivery!

A brief overview of the Green Paper on the National Health Insurance (NHI) policy of South Africa is presented. It describes the intention of the NHI to ensure equity, address the inequalities presented by the current private and public health system and present an ambitious plan to change the face of the South African health care system over the next fourteen years. It provides the context of the currents system that provides the case for the change. It also provides some detail on the structure of the proposed new Re-engineered Primary Health Care system as well as the future financing of this bold new health care system for South Africa. The challenge will be in its implementation.     

The effects of an HIV project on HIV and non-HIV services at local government clinics in urban Kampala

Background

HIV/AIDS is a major public health concern in Uganda. There is widespread consensus that weak health systems hamper the effective provision of HIV/AIDS services. In recent years, the ways in which HIV/AIDS-focused programs interact with the delivery of other health services is often discussed, but the evidence as to whether HIV/AIDS programs strengthen or distort overall health services is limited. The aim of this study was to examine the effect of a PEPFAR-funded HIV/AIDS program on six government-run general clinics in Kampala.

Methods

Longitudinal information on the delivery of health services was collected at each clinic. Monthly changes in the volume of HIV and non-HIV services were analyzed by using multilevel models to examine the effect of an HIV/AIDS program on health service delivery. We also conducted a cross-sectional survey utilizing patient exit interviews to compare perceptions of the experiences of patients receiving HIV care and those receiving non-HIV care.

Results

All HIV service indicators showed a positive change after the HIV program began. In particular, the number of HIV lab tests (10.58, 95% Confidence Interval (C.I.): 5.92, 15.23) and the number of pregnant women diagnosed with HIV tests (0.52, 95%C.I.: 0.15, 0.90) increased significantly after the introduction of the project. For non-HIV/AIDS health services, TB lab tests (1.19, 95%C.I.: 0.25, 2.14) and diagnoses (0.34, 95%C.I.: 0.05, 0.64) increased significantly. Noticeable increases in trends were identified in pediatric care, including immunization (52.43, 95%C.I.: 32.42, 74.43), malaria lab tests (1.21, 95%C.I.: 0.67, 1.75), malaria diagnoses (7.10, 95%C.I.: 0.73, 13.46), and skin disease diagnoses (4.92, 95%C.I.: 2.19, 7.65). Patients’ overall impressions were positive in both the HIV and non-HIV groups, with more than 90% responding favorably about their experiences.

Conclusions

This study shows that when a collaboration is established to strengthen existing health systems, in addition to providing HIV/AIDS services in a setting in which other primary health care is being delivered, there are positive effects not only on HIV/AIDS services, but also on many other essential services. There was no evidence that the HIV program had any deleterious effects on health services offered at the clinics studied.

     

Colonialism,Biko and AIDS: Reflections on the principle of beneficence in South African medical ethics

This paper examines the principle of beneficence in the light of moral and epistemological concerns that have crystallized in the South African context around clinical care. Three examples from the South African experience affecting the development of bioethics are examined: medical colonialism, the death in detention of Steve Biko, and the HIV/AIDS epidemic. Michael Gelfand's book [(1948). The sick African: a clinical study. Cape Town: Stewart Printing Company.] on African medical conditions captures the ambiguous nature of colonial medicine that linked genuine medical treatment with the civilizing mission. Biko's death was a key historical event that deeply implicated the medical profession under apartheid. The present HIV/AIDS epidemic presents the gravest social and political crisis for South African society. All three experiences influence the meaning and relevance of beneficence as a bioethics principle in the South African context. This paper argues for a South African bioethics informed by a critical humanism that takes account of the colonial past, and that does not model itself on an “original wound” or negation, but on positive care-giving practices.     

Americans' views on health policy: a fifty-year historical perspective

A review of data from more than 100 public opinion surveys conducted over a fifty-year period finds that the American public has conflicting views about the nation's health policy. They report much dissatisfaction with the health care system and with private health insurance and managed care companies, and they indicate general support of a national health plan. However, most Americans remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan. The review also finds that confidence in the leaders of medicine has declined but that most Americans maintain trust in the honesty and ethical standards of individual physicians.     

The Massachusetts HIV, hepatitis, addiction services integration (HHASI) experience: responding to the comprehensive needs of individuals with co-occurring risks and conditions

Categorical funding mechanisms traditionally used to fund public health programs are a challenge to providers serving individuals with complex needs that often span multiple service areas. Integration--a formalized, collaborative process among service systems--responds to the challenge by decreasing fragmentation of care and improving coordination. In 2000, the Massachusetts Department of Public Health (MDPH) received a one-year planning grant from the federal Substance Abuse and Mental Health Services Administration (SAMHSA) to evaluate opportunities for integrating HIV/AIDS programs and substance abuse treatment programs. The project was later expanded to include viral hepatitis programming. Outcomes include the development of a strategic plan, joint procurement initiatives, and an ongoing commitment to sustain inter-bureau integration efforts, even in the face of substantial budget reductions. Integrated approaches can promote greater efficiency, improving communication and coordination among clients, providers, and government funding agencies.     

CULTURAL AND GENDER ISSUES RELATED TO HIV/AIDS PREVENTION IN RURAL SWAZILAND: A FOCUS GROUP ANALYSIS

HIV/AIDS is a serious public health problem in Swaziland, a small land-locked Southern African country. The epidemic affects all subpopulations, but women are increasingly at risk for contracting the disease. Focus groups were conducted in a rural area to obtain qualitative information on the rural dimensions of HIV/AIDS, vulnerability to HIV/AIDS, and sociocultural factors influencing the spread of AIDS. Five themes were identified from analyses of the focus groups that are relevant in developing an AIDS prevention program for this population in Swaziland. Implications for future research and health care practice focus on gender-sensitive cultural research (e.g., women and men's roles and responsibilities in rural Swaziland society) and how social, economic, and cultural factors impact the spread of AIDS. Recommendations include reorienting and allocating resources for health, education, and social services to address the relative neglect of rural areas and strengthening policies and programs to achieve the equal participation of all women in all aspects of society's decisions. Specifically, policies related to economic and food security should result in programs to improve local access by women to all resources.     

Service management: an epidemiological model of health services organization

The New Zealand health system is undergoing a major paradigm shift. Services and programs have largely replaced hospitals and other institutions as the basic organizational framework, with each service having an epidemiologically defined responsibility for the provision of integrated personal and public health services for the population it serves. Primary health care as the infrastructure service is being implemented in some areas. These changes are being reinforced by the National Government's continuing reform process in which population-based and funded regional health authorities are purchasing all health services--primary, secondary, personal, public, acute and continuing--from a capitated and capped budget based on meeting the health needs of their populations.