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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility Summary In many African1 countries, where the burden of HIV/AIDS is the greatest in the world, the number of new infections is growing more rapidly than the availability of treatment. Unless this trend is reversed, HIV/AIDS can be expected to continue at a high rate of transmission for many decades to come. Despite the recent mobilization of donor funds, resources are strained, and the capacity of the region’s health care systems to absorb the increasing treatment load is precarious. Ensuring adequate institutional and human resources to meet the challenges of HIV/AIDS in Africa 10 to 15 years into the future will therefore require visionary strategic planning and investments in capacity building. In this context, the Institute of Medicine (IOM) tasked a committee of experts to recommend affordable, sustainable strategies that both African nations and the United States can implement to address the long-term burden of HIV/AIDS.2 The committee concluded that the burden of morbidity and mortality in Africa cannot be alleviated through treatment alone. Treatment can reach only a fraction of those who need it, and its costs are unsustainable. Therefore, greater emphasis must be placed on preventing new infections. 1 For purposes of brevity, unless otherwise noted, the term Africa denotes sub-Saharan Africa throughout the report. 2 The statement of task for this study did not call for, nor was the committee constituted to develop a social, behavioral, or biomedical science research agenda for addressing HIV/AIDS. The committee recognizes that advances in these areas could radically change the future of the epidemic.
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility THE BURDEN OF HIV/AIDS In 2009, approximately 33.3 million people globally were living with HIV; an estimated 2 million people died as a result of HIV/AIDS; and 2.6 million people, including 370,000 children, were newly infected (UNAIDS, 2010). Of those global HIV infections, 22.5 million were in Africa; this figure represents 68 percent of the global total, while the number of newly infected in the region represents 69 percent of the global total (UNAIDS, 2010). According to the World Health Organization’s (WHO’s) most recent guidelines, just 36 percent of those needing treatment are receiving it (WHO, 2010). Moreover, the committee’s projections indicate that the need for treatment will increase dramatically over the next decade. In addition to its toll on individuals and households, HIV/AIDS has had devastating impacts on four key sectors of African society: development, health, the state, and academia. The burden of the epidemic has compromised the achievement of key Millennium Development Goals in Africa and has led to declines in the growth of total gross domestic product (GDP) in the most affected countries. KEY FINDINGS AND CONCLUSIONS Local Responses to Global Solutions Although countries in Africa share many similarities, they also differ greatly in culture, history, politics, and education. As such, it is not surprising to find that HIV epidemics across Africa range from highly concentrated to highly generalized, and the responses by African nations have been equally varied, ranging from intense interventions to complete denial of HIV disease. Given this heterogeneity, as well as the diversity of African institutions and circumstances, the programs and policies recommended in this report require tailoring to local circumstances. The committee was not constituted to recommend specific actions for particular African countries; rather, in keeping with the theme of shared responsibility, the committee recommends approaches for African countries that can be adapted to their needs and priorities. The Future Impact of Current Decisions In 2020, the morbidity, mortality, and resource and financial burdens faced by the U.S. government and African countries for the ensuing decades will depend on decisions made today: Currently, people are becoming in need of treatment more rapidly than they are being placed on treatment. Therefore, although the death rate from AIDS has fallen, deaths among those in need of treatment will con-
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility tinue. There are two ways of closing the treatment gap: increase treatment coverage, and reduce incidence. The incidence (i.e., number of new cases) of HIV infection must be reduced before the burdens of treatment and mortality can begin to decline. Because treatment is a form of prevention, delaying initiation of treatment once it is recommended for an individual will also delay the realization of reduced need for treatment. If earlier treatment is expanded, of course, many more people will need to be on treatment in the short term. Moreover, the decline in numbers requiring treatment will be gradual, so that any reduction in incidence achieved in 2010 will only partially reduce the burden of HIV/AIDS by 2020. Thus the benefits of reduced incidence need to be considered over a period of decades. The burden of HIV/AIDS is extremely sensitive to alternative policies. The course of the epidemic, costs, and the lives of millions of individuals will be affected by decisions made today regarding, for example, early versus late treatment initiation, coverage with second-line versus first-line regimens, program quality versus quantity, and investment in treatment versus prevention. Implications of the Projected HIV/AIDS Burden in Africa for U.S. Interests With the launch of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, the United States established itself as a global leader in expanding care and treatment in the fight against HIV/AIDS in Africa. Through PEPFAR and support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States helped galvanize an extraordinary global response to a single disease and mobilize donor and private-sector resources on an unprecedented scale. Despite this momentum, the expected expansion of the epidemic in the coming decade portends significant challenges for the United States and the global community in sustaining these commitments. In the United States, the effects of a historic global financial crisis and a domestic deficit approaching $2 trillion will likely drive greater congressional scrutiny of spending on foreign assistance. Ironically, moreover, the success of the U.S. HIV/AIDS effort has increased attention to other African health challenges, which may drive competition in resource allocation among health priorities. Beyond health, the scope of U.S. development assistance in Africa has expanded dramatically in the last decade to include food security, climate change, and unemployment. As the United States seeks new forms of engagement in Africa that provide greater political and economic leverage than traditional development and humanitarian assistance, options are reduced because the commitment to support Africans on life-saving antiretroviral therapy (ART) cannot be withdrawn to advance diplomatic goals. As new HIV infections continue to outstrip the world’s ability to provide
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility ART to those in need, the costs of treatment alone will consume ever larger proportions of available resources. The combination of competing health and development demands, the rising cost burden of HIV/AIDS treatment, and continued resource constraints will force difficult choices for U.S. policy makers. As the largest single contributor to global HIV/AIDS resource flows to date, the United States will need to manage these choices in a way that does not compromise the global achievements in HIV/AIDS, advances U.S. interests, and strengthens global capacities to respond to HIV/AIDS and other global health challenges. One way for the United States to accomplish these goals while addressing its own fiscal concerns is to transition to a model for long-term sustainability based on shared responsibility with African partner states and the broader international community. By looking to African partners to assume increasing responsibility for leadership, management, and investment of resources in HIV/AIDS, the United States would be promoting a future of self-reliance and self-sustainability in the region. Under this shared-responsibility model, the United States would assist African partner states in developing the leadership, academic, medical, research, and other capacities necessary to assume that responsibility effectively. Countries with demonstrated political will, an emphasis on prevention, and efficient, transparent health management would receive stronger financial commitments with less oversight or intervention from the United States. Implementation of this model would necessitate greater accountability and transparency in the investments being made by each African partner state. The United States would need to set ambitious but realistic objectives for the next 10 to 15 years and place an urgent and consistent focus on prevention of new HIV infections. Strategies to Build Capacity for Prevention, Treatment, and Care of HIV/AIDS in Africa, 2020–2025 A major requirement if African states are to assume greater responsibility for responding to their HIV/AIDS epidemics is to strengthen health care systems in the region by building institutional and human resource capacity. Successful capacity building supports national health plans and health care system development. Host country partners would take the lead, since government capacity is itself crucial to the future course of the African HIV/AIDS epidemic. Strategies for Highly Affected Nations in Africa: Making the Most of Existing Capacities Given increasing numbers of patients, shortages of trained medical personnel, and financial constraints, treatment must be provided more efficiently, as is encouraged by the Joint United Nations Programme on HIV/AIDS (UNAIDS) Treatment 2.0 platform. The committee has identified a number of strategies for making the most of existing African capacities.
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility First, scale-up of HIV/AIDS prevention, treatment, and care programs must rely not just on health care professionals but also on management and support staff from outside the clinical health sector who can free up time for health care providers to perform clinical work. A second strategy—task sharing, in which physicians, nurses, dentists, and other health professionals delegate health care responsibilities and relevant knowledge to others, including community health workers—can make more efficient use of existing human resources and ease bottlenecks in service delivery. Sharing of responsibility may also involve the delegation of some clearly delineated tasks to newly created cadres of health workers who receive specific competency-based training. Harnessing the expertise and building the capacity of the informal health care sector is a third viable strategy. Informal health workers, such as untrained family members or friends, merchants and shopkeepers, and traditional healers, are found in every health care system; the weaker the formal sector, the greater impact they have. Where formal health care facilities are not easily accessed, this group of informal health workers is the first and most important point of call for people in search of health care services. A fourth strategy is to tap the potential of information and communication technology (ICT). Recent major advances have enabled applications such as teleconsultations, telereferrals, electronic patient records, and training of community health workers to support such aspects of health care as prevention, diagnosis, and patient management and care. A fifth strategy entails planning the African health workforce on the basis of projected needs. To this end, African governments will need to establish, strengthen, and maintain health personnel information systems that collect, analyze, and translate data into effective health workforce policies and planning. Existing African institutions also hold great potential for mitigating the future impact of the HIV/AIDS burden. In particular, partnerships and regional collaborations involving universities and other academic training programs in developing countries can be used to exchange technical assistance in HIV/AIDS prevention, treatment, and care through visits, training, and ongoing communication. African science academies can make important contributions to these efforts, providing balanced, multidisciplinary, authoritative, and evidence-based locally appropriate advice. Finally, coordinating core public health functions through national public health institutes and health resource partner institutions and networks can result in more efficient use of resources, improved delivery of public health services, and increased capacity to respond decisively to public health threats and opportunities.
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility Strategies for the United States: Supporting Partnerships and Other Capacity-Building Programs The U.S. private sector, nongovernmental organizations, militaries, and academic institutions can help build capacity for HIV/AIDS prevention, treatment, and care by participating in partnerships with African institutions. First, public–private partnerships can contribute to the fight against HIV/AIDS by enhancing the skills and capacities of local organizations; increasing the public sector’s access to the expertise and core competencies of the private sector; facilitating the scale-up of proven, cost-effective interventions through private-sector networks and associations; expanding the reach of interventions by accessing target populations (for instance, through workplace programs); and sharing costs and promoting synergy among programs. Second, faith-based organizations can make important contributions because they exist in cities, villages, and even the most rural regions of low-income countries, providing between 30 and 40 percent of health care services. Moreover, while governments and political climates change over time, communities of faith generally remain intact. Third, military partnerships can support the strengthening of local health care systems by building the partners’ capacity to provide needed services for HIV/AIDS. These services include behavioral interventions tailored to the risk factors faced by military personnel. Finally, academic partnerships, including “twinning” between universities and technical and vocational schools, are yet another means of building capacity. In the context of this study, twinning is defined as a bilateral, mutually beneficial capacity-building partnership formed to mitigate the effects of HIV/AIDS. Parity is an essential feature of such a partnership; new skills, processes, and knowledge should be acquired by both partners through the process. Strategies to Ensure an Ethical Decision-Making Capacity for HIV/AIDS Policy and Programming in Africa Decisions about HIV/AIDS policy and programming are made at three levels. At the macro level, governments determine the overall health budget and its distribution across categories such as human resources, hospital operating expenses, research, and disease-specific treatment programs. At the meso level, institutions such as ministries of health, hospitals, and clinics determine which services they will provide and how much they will allocate for such expenses as staff, equipment, and supplies. At the micro level, health care providers decide what expenditures to recommend for the benefit of each individual patient. At any of these three levels of decision making, when people whose needs exceed available resources have approximately the same clinical status or risk exposure, medical criteria are insufficient to guide resource allocation decisions. From
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility a moral point of view, then, the decision-making process for resource allocation must incorporate robust safeguards not only against discrimination but also against arbitrary or self-serving exercises of power. One safeguard is to identify and empower stakeholders in particular settings who should have far more influence in such decision making than they actually do (such as patients and the general public). A complementary approach is to identify relatively enduring processes through which resource allocation decisions are made and to enhance the ethical capacity of those already empowered. The range of such actors might include local health service providers, local health care system managers, HIV/AIDS program implementers, civil society (community-based and nongovernmental organizations), traditional community leaders, local public officials, academic institutions, national public officials, regional organizations, and the media (to promote responsible and balanced reporting of information so as to foster participatory democracy). The committee concluded that there is a need to build capacity for ethical decision making in Africa with respect to policies, programs, and resource allocation for HIV/AIDS in their populations. Core competencies for ethical decision making need to be defined in such areas as budgeting, management, evidence assessment, communications, and health policy analysis. Insufficient capacity may exist to deal with counterethical pressures from powerful actors. In many cases, government officials also need assistance in developing accountability and competence, particularly in priority setting and fair allocation of scarce resources. RECOMMENDATIONS The committee’s recommendations are a first step toward exercising the shared responsibility of the United States and Africa to prepare for the future of HIV/AIDS. These recommendations are in three areas: the future impact of current decisions, implications of the projected burden of HIV/AIDS for the United States and Africa, and strategies to prepare for the long-term burden of the epidemic. The Future Impact of Current Decisions Recommendation 2-13: Measure incidence. African countries, with the support of donors, should develop and implement cost-effective methods 3 The committee’s recommendations are numbered according to the chapters of the report in which they appear. Thus, for example, Recommendation 2-1 is the first recommendation in chapter 2.
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility for accurately measuring the level of and change in HIV/AIDS incidence to enable better planning and evaluation of HIV/AIDS prevention programs.4 Recommendation 2-2: Analyze trade-offs. The U.S. government should support countries in developing projections of the future burden of their HIV/AIDS epidemics and in assessing the implications of alternative national HIV/AIDS policies for human welfare, capacity, and resources so policy makers can make informed decisions on HIV/AIDS-related trade-offs. Implications of the Projected Burden of HIV/AIDS for the United States and Africa Recommendation 3-15: Emphasize a new contract approach that incentivizes shared responsibility. The Office of the Global AIDS Coordinator should emphasize, develop, and implement a more binding, negotiated contract approach at the country level. The contract should incentivize shared responsibility whereby additive donor resources are provided to a large extent as matching funds for partner countries’ investments of their own domestic resources in health. Such matching funds should not be a uniform ratio; rather, the ratio should vary based on each African partner’s ability to contribute. Recommendation 3-2: Develop a U.S. roadmap for HIV/AIDS in 2020. The White House and the Office of the Global AIDS Coordinator should develop a U.S. roadmap for HIV/AIDS in 2020 incorporating a model of U.S.–African shared responsibility that makes prevention a priority and balances bilateral and multilateral funding. The roadmap should: Give priority to prevention as a central tenet of a sustainable long-term response to the HIV/AIDS epidemic. To this end, steps should be taken to: strengthen country-level surveillance and monitoring of the epidemic to ensure adequate and reliable data with which to estimate incidence rates (see Recommendation 2-1); encourage the UNAIDS-recommended approach of targeted prevention strategies tailored to in-country priority populations, applying evidence-based public health approaches; 4 As described in Chapter 2, laboratory-based assays for the calculation of incidence estimates are in development and are urgently needed to provide important epidemiological data on trends of the epidemic and the effectiveness of interventions so that limited resources can be directed most efficiently to limit the epidemic’s further spread. 5 See counterpart Recommendation 4-3 directed to African countries.
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility increase access to and coverage of synergistic combinations of known effective prevention technologies; and expand research and investments in new prevention technologies. Strike an optimal balance between bilateral and multilateral mechanisms for HIV/AIDS funding. The United States should seek to capitalize on the strategic complementarity of bilateral and multilateral funding flows and engagement and work to strengthen multilateral institutions toward that end. U.S. policy makers should encourage greater involvement of emerging economic powers, including Brazil, China, Russia, and India, in international forums and activities on HIV/AIDS and in strengthening of South–South collaborations addressing the epidemic.6 Recommendation 3-3: Integrate health and development. Congress should support greater integration of U.S.-funded HIV/AIDS interventions with broader U.S. global health initiatives and African countries’ comprehensive development plans. As Congress contemplates an overhaul of the U.S. Foreign Assistance Act, it should seek to encourage greater flexibility in development funding to ensure that assistance for both health and development meets recipient country priorities. Recommendation 4-1: Develop 10-year country roadmaps. In parallel with the U.S. strategic planning called for in Recommendation 3-2, individual national HIV/AIDS coordinating bodies in Africa should develop, articulate, and update national 10-year roadmaps for combating HIV/AIDS. Each roadmap should take into account the implications of long-term projections of the national HIV/AIDS burden for institutions, communities, and resource requirements. As part of their roadmap, African governments should: invest sufficiently in HIV/AIDS prevention, following globally accepted best prevention practices; disclose national and subnational prevention outcomes and impacts and how they vary geographically and over time; and perform yearly evaluations to determine success as measured by change in HIV incidence data, as discussed in Recommendation 2-1. Recommendation 4-2: Develop and promote more efficient models of HIV/ AIDS care and treatment. African countries should invest in, evaluate, and 6 South–South collaborations involve a horizontal relationship between two or more developing countries in which technical assistance in HIV/AIDS prevention, treatment, and care is exchanged through visits, training, and ongoing communication.
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility apply more efficient models of HIV/AIDS care and treatment and promote those models through South–South learning exchanges. Recommendation 4-37: Establish a governance contract. African countries should establish a negotiated contract with U.S. agencies that includes programmatic targets and delineates each partner’s responsibilities and expectations within a shared-responsibility approach. African governments should fully maintain the role and function of leadership and stewardship for policies and program implementation in their countries’ health sector. Strategies to Prepare for the Long-Term Burden of the Epidemic Recommendation 5-1: Analyze and plan for meeting workforce requirements. African governments and international organizations should assess and plan for meeting national workforce requirements for responding to the long-term burden of HIV/AIDS. Recommendation 5-1a: Through partnership programs and other investments, African governments and institutions, along with U.S. private companies, academic institutions, foundations, and civil society organizations, should establish national databases and information systems for health care worker statistics, as well as bolster the analytic capacity of national planners for determining human resource needs. Recommendation 5-1b: African governments and institutions should create staffing models to optimize the impact of the health care workforce. Such models should include developing cadres of managers and support staff outside the clinical health sector, encouraging needs-based training and task sharing within the health sector, focusing on retention through compensation and other incentives, utilizing information technologies, and harnessing the informal health sector. Recommendation 5-1c: In Africa, governments and institutions should work together in planning the African health care workforce based on projected needs derived from national data and analyses of future human resource requirements. Such planning should involve ministries of health, education, finance, public service, and labor. The private sector and the academic and medical communities should also be brought to the table for such national human resource planning exercises. Recommendation 5-2: Utilize existing African capacity. African governments and international donors should recognize, invest in, strengthen, and 7 See counterpart Recommendation 3-1 directed to the U.S. Office of the Global AIDS Coordinator.
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility utilize currently existing capacity within African institutions and networks to provide local solutions for responding to the HIV/AIDS epidemic. This capacity includes South–South and regional partnerships, universities, African science academies, national public health institutes, and other networks within Africa. Recommendation 5-3: Develop government leadership and management in health. U.S. government agencies and programs, foundations, and academic institutions should invest in the development of African leadership and management in the health sector. Recommendation 5-3a: U.S. government agencies, such as the Health Resources and Service Administration (HRSA), the U.S. Agency for International Development (USAID), and the U.S. Centers for Disease Control and Prevention (CDC) and its global counterparts, should be actively engaged in leadership and management development, and the International Association of Public Health Institutes should be tapped as a resource for advancing these efforts. Recommendation 5-3b: U.S. foundations and academic institutions should invest in African leadership and management development through programs that educate African scientists and scholars who may then take on leadership positions in their own countries. Recommendation 5-4: Invest in innovative partnerships. Private-sector organizations, professional organizations, faith-based organizations, academic and research institutions, militaries, foundations, and civil society organizations should increase funding for and participation in meaningful, effective, and innovative partnerships designed to build African capacity now to address the full extent of the HIV/AIDS burden over the next 10 years. Recommendation 5-4a: New U.S.–African partnerships between local vocational or technical schools that train allied health professionals, laboratory technicians, informatics specialists, and/or health administrators should be explored and encouraged. Recommendation 5-4b: Innovative North–South and South–South partnerships that build human resources for health should be developed. In North–South partnerships, African counterparts should take the lead in developing and controlling the partnership agenda. Recommendation 6-1: Enable and reinforce capacity for ethical decision making. Donors and governments should help build capacity for ethical decision making by adequately funding education and training in the disciplines
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility of ethics, human rights, and pertinent aspects of the law. This training should include both educational and implementation components. Recommendation 6-2: Donors and governments should support civil society organizations where they exist and help develop them in other places over time. As a first step, the focus should be on procedural justice. Therefore, U.S. government agencies, including the State Department, USAID, and the Department of Health and Human Services, should provide technical and financial support to recipients of their health assistance for the establishment of effective mechanisms for procedural justice, including transparency, accountability, and responsibility. Recommendation 6-3: Professionals with training in ethics should be incorporated into multisectoral teams. To increase the capacity for ethical decision making at the national level, professionals with training in ethics should be incorporated into national government multisectoral teams that include ministries of health, finance, and education, as well as other government ministries whose work is relevant to HIV/AIDS; civil society organizations; educational institutions; professional organizations; and nongovernmental organizations. A CALL TO ACTION Just as Africa is a mosaic of countries and cultures, HIV/AIDS is a mosaic of different epidemics in different countries and regions in Africa and around the world, each with its own dynamic character; the politics, economics, and sociocultural drivers of HIV/AIDS are distinct in different settings. As a result, programs and policies should reflect local circumstances. Therefore, the recommendations in this report will need to be tailored to individual countries and their epidemics. Many of the recommendations imply a need to perform implementation and operations research8—as well as ongoing evaluation—of programs, partnerships, and interventions to combat HIV/AIDS in Africa. Such efforts can identify the optimal approaches for carrying out the recommendations in specific contexts. Moreover, no single strategy can meet the challenge of HIV/AIDS; countries will need to adopt multipronged strategies, tailored to local circumstances. It is the committee’s hope that this report will contribute to the global fight 8 Operations research seeks to identify and address barriers related to the performance of specific projects. Implementation research seeks to create generalizable knowledge that can be applied across settings and contexts to answer central questions (such as how multiple interventions can be packaged effectively to capture cost efficiencies and reduce the splintering of health systems into disease-specific programs) (Madon et al., 2007).
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Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility against HIV/AIDS in Africa and beyond. This report focuses on Africa, where the incidence and prevalence of HIV/AIDS are the greatest in the world and where the impact of the pandemic is most pronounced in all sectors of society. Nonetheless, the committee’s recommendations and the array of strategies identified in this report can and should be applied to the broader global context. REFERENCES Madon, T., K. J. Hofman, L. Kupfer, and R. I. Glass. 2007. Implementation science. Science 318(5857):1728-1729. UNAIDS (The Joint United Nations Programme on HIV/AIDS). 2010. Global report: UNAIDS report on the global AIDS epidemic 2010. Geneva: UNAIDS. WHO. 2010. Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector. Progress report 2010. Geneva: WHO.
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