Assessing the HIV/AIDS MDGs: Does this look like success or even progress?

INTRODUCTION

As Kim et al. (2011) indicated, progress towards achievement of the Millennium Development Goals (MDGs) has been mixed. One of the MDGs is to reduce sexual transmission of HIV by 50 percent by 2015. New infections are outpacing scaled up treatment, basic knowledge about HIV is poor, only about 35 percent of those infected receive treatment, and only about 40 percent of people living with HIV know their status. AIDS has become and remains the leading cause of premature death in Sub-Saharan Africa. According to UNICEF (2015) Eastern and Southern Africa contain about 5 percent of the world’s population and about 48 percent of the world’s new HIV infections among adults. Nine African countries, discussed below, have adult HIV prevalence rates which are the highest in the world, over 10 percent. Of the 25 countries in the world with the highest HIV prevalence rate, 24 are African nations. This paper is only concerned with the HIV/AIDS objectives and does not address the other diseases included in Goal 6. It builds upon an earlier paper by Fry (2013), and extends the findings and conclusions of that paper from a single country, South Africa, to the African continent. To preview discussion and conclusions, some issues are raised and discussed that appear to have the potential to produce a better way forward for HIV prevention for all of Africa. These begin with the need to convince the average African citizen about the importance of the HIV/AIDS epidemic and the danger and threats to all Africans it actually represents. African governments must not only convince citizens about the importance of HIV/ AIDS but attacking the pandemic must become a national priority, with promotion of HIV/AIDS prevention as a top level priority. Also, HIV/AIDS must be made a separate issue, treated as a stand-alone disease, one that should not fall under the general rubric of health or be anchored in Health Departments.

In a seminal paper which highlights the first issue raised above, Caldwell, Orubuloye, and Caldwell (1992) pointed to what they called the under-reaction of those parts of sub-Saharan Africa most affected by the HIV/AIDS epidemic; this included both the public and private reaction to the seriousness of the HIV/AIDS phenomenon. One major theme in the subsequent studies has been that ordinary citizens in sub-Saharan Africa were more concerned with basic issues like jobs and poverty, and did not want governmental resources diverted to HIV/AIDS related programs (Whiteside et al., 2002). The title of Justensen’s (2011) paper made that point abundantly clear. “Too poor to care: the salience of AIDS in Africa.”

Justesen also indicated that over time HIV/AIDS in Africa has transformed from being mainly a health issue to being a major human and economic development issue, one with devastating effects on the lives of millions of Africans. Justesen also noted that in the African countries included in what are known as the Afrobarometer Project surveys, it would be easy to conclude people who mention “AIDS” and those who mention “health” issues are essentially describing the same problem. Yet this would miss some important subtleties. For instance, Afrobarometer surveys find that to the extent that people see the epidemic as meriting government action, they tend either to see it as an AIDS issue, or as a health issue, but not both. When asked to select their own country’s top three priorities, those people who mention health are less likely to cite “AIDS”; and national samples of respondents that collectively prioritize “health” are much less likely to prioritize AIDS.

In the earlier paper, Fry (2013) echoed what others have noted that may be called citizen under-reaction in their public as well as private reactions to the HIV/AIDS epidemic. The surprising finding was that the choice of health was such a strong predictor of not selecting HIV/AIDS as a national priority. The suggestion is that the placement of HIV/AIDS programs under the health rubric has had a negative impact on promoting the importance of HIV/AIDS and the need is to promote the importance of HIV/AIDS to all Africans as a major concern of government.

As Nattrass (2014)) suggested, Millennium Development Goal (MDG) 6, ‘to combat HIV/AIDS, malaria and other diseases’, is unique among the MDGs because it emerged in the context of unprecedented prior international mobilization, especially around HIV/AIDS, thus both reflecting and facilitating an expanding international health agenda. MDG 6 built on the idea of “health as development”, originally articulated at the 1978 conference on primary health at Alma-Ata, but was profoundly shaped by the political traction and fund-raising successes of AIDS activism and the international AIDS response. This underpinned the expansion of MDG 6 targets to include antiretroviral treatment, helped forge partnerships to reduce the prices of antiretroviral treatment and essential medicine, thereby contributing to MDG 8 (“building partnerships for development”) and, in high HIV-prevalence regions, also to MDGs 4 and 5 (maternal and child health).

The UN High-Level Panel on the post-2015 development agenda recommends setting country-level health targets to achieve healthcare for all. Targets can help citizens hold governments to account by providing a focus for mobilization and a yardstick to measure progress. The data collection and policy monitoring pioneered by UNAIDS, and the involvement and support for civil society organizations achieved through the AIDS response, must be continued for this broader health agenda to succeed.

METHODS

This paper utilizes multiple data sources, to identify the HIV/AIDS status of specific countries included in the research ( indexmundi.com2015), specific health related issues (AVERT,2015; UNAIDS, 2015). These sources also include Afrobarometer, which is a collaborative research effort produced by social scientists from over 30 African countries. The present paper is based on data collected during the project’s Round 5 surveys which took place in 35 countries between 2011 and September 2013. Interviews were conducted with persons 18 years of age or older; these are face-to-face interviews and were conducted in multiple languages. The sampling frame is such that each country’s final sample supports estimates of the national population of all adults that is accurate to within a margin of error of plus or minus 2 percentage points at a confidence level of 95 percent. Sample sizes are targeted at 1,200 or 2,400 respondents. The sampling procedures used in all of the Afrobarometer surveys are explained in detail in Bratton, Mattes and Gyimah-Boadi (2005). The survey used the same questionnaire which contains identical or functionally equivalent items in all 35 of the current Afrobarometer countries. The interviewer asks the respondent a series of questions in a face-to-face situation and in a language of the respondent’s choice.

The African countries included in this paper were chosen based on the fact that each country has an HIV prevalence rate of at least 10 percent; each of these countries were included in Afrobarometer’s Round 5. One study variable is the selection of AIDS as an issue the government should address, and is measured by the following question: In your opinion, what are the most important problems facing this country that the government should address? This question was asked in the same form three times. As Justesen (2011) indicated, one advantage of the wording of the ‘most important problem’ (MIP) question is that respondents can only name up to three problems, which forces people to prioritize and select those problems they consider the most important. In this study, the importance of AIDS is coded as a dichotomous variable: If a respondent mentioned ‘AIDS’ as one of the three most important problems, the variable is coded as one (1), and if not, zero (0). The choice of health as an issue the government should address was created in the same manner as the choice of AIDS. Respondents that picked health as one of their three important problems government should address were coded as one (1) and if they did not pick health zero (0) was recorded. A final Afrobarometer question asked respondent to indicate: How well or badly would you say the current government is handling the following matters, or haven’t you heard enough to say? Fixed responses were provided as follows: Very Badly; Fairly Badly Fairly well; Very well; and Don’t know/haven’t heard enough. These data are reported in Table 1, along with the HIV/AIDS Prevalence and AIDS related deaths for each of the 9 countries included in Table 1

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Table 1 clearly shows that HIV/AIDS is not seen as a national priority in the 9 countries with the world’s highest prevalence rates. Swaziland is a good example. In the country with the world’s highest prevalence rate, only 3 percent of respondents listed HIV/AIDS as a priority and they had three times to register their choices. Health did rate higher as at 14.3 percent and over 92 percent indicated they thought the government was doing a good job combatting the epidemic. South Africa gave HIV/AIDS the highest priority rating and a lower approval rating for the role of government. Mozambique and Lesotho’s scores reflected a high percentage of do not knows.

Note that Zambia perfectly fits the model of the choice of health over HIVs as a priority. Out of 1,200 respondents, only 5 listed HIV/AIDS, 2 as their first choice and slightly over 40 percent picked Health as their priority.

DISCUSSION

While Table 1 is interesting, the real purposes of this paper is to address two issues highlighted in the call for papers. The first of these questions is whether Africans were effectively involved in the creation of the MDGs? Do limitations in this involvement explain the failures? At what level and how should Africans have been more involved? The question going forward is how can Africans be more involved? The second is whether it is possible to have one Global South voice, or even a single African voice? The rest of this issue was framed as, is it necessary to be heard in this process, in the hope of taking into account the real genuine aspirations of Africans, or is it always a fool's game?

The simple answers to both of those question is a resounding, NO, and there is the need to discuss how do Africans go forward from here? The literature review made it clear that the MDGs were implemented after the pandemic had struck Africa and, if there was African involvement in the creation of the HIV/Aids involvement, it probably was not of any consequence. It would appear that there have been successes, particularly regarding maternal and child health, but that raises the question as to whether those populations are as important as thought to the HIV/AIDS goals for all of Africa. This paper would argue that the maternal population falls within the scope of what should be the target of HIV/AIDS policy, but the adult older group of HIV positive citizens should be the target; they are the primary source of new infections.

To begin to address an answer as to how to go forward, there is the need to look at Uganda as the proper case-study to answer both of these questions (Wikipedia, 2015). Once portrayed as the shining light of African initiated HIV/AIDS policy, Uganda appears to have gone downhill more recently, the prevalence rate returned to former levels, and now whether the original optimism was justified has been severely questioned. In the beginning in Uganda, everyone seemed to work together quite well, and then politics entered the picture.

HIV testing is critical to a new beginning to address HIV/AIDS in Africa. As Fry and Hernandez (1994) discovered, that means testing procedures that begin from the bottom up. The issue here is that even if taken, there is strong evidence that a number of those tested never return to receive testing results. The evidence suggests that the majority of Africans do not know their HIV status. Testing must be culturally sensitive and promoted by persons who understand the language and customs of targeted groups. Fry and Fernandez found that in the US, minority populations needed to be brought in to the testing process early, and not after the fact. There is a vast and growing literature about domestic violence and revealing HIV status. The role of testing is almost always neglected in that process, and can be the key factor in generating domestic conflict. In some cultures, the spouse may go home and say they took an HIV test, often at the request of treatment personnel. Some spouses believe that either you, the one tested, are accusing me of something (cheating) or you are admitting you did something, (cheating.) Africa, with its ethnic systems, makes the development of culturally appropriate testing even more difficult, but a ground up approach means working with indigenous persons, and promoting a self-help approach.

Again with Uganda as the example, the latest conflict regarding treatment approaches is self-help advocates and their anger over governmental policy. This approach actually negates a regional or even national approach, and cries out for local control, with maximum support from all government agencies and NGOs.

There is the need to learn from failures beyond the kinds of data presented in Table 1. Treatment programs fail because they are not implemented properly, and this depends upon whether programs were created based on proper planning. Simply this means back to the drawing board for HIV/AIDS programming in Africa. If that creates another fool’s paradise, the fools have the right to make their own mistakes.

* Lincoln J Fry holds Ph.D. degrees from the University of Southern California and Mississippi State University. He is currently an Academic Member of the Sociology and Health Research Units at ATINER (Athens Institute for Education and Research) Athens Greece) and has over 65 academic publications.

REFERENCES

1. AVERT, available at http://www.avert.org/africa-hiv-aids-statistics
2. Afrobarometer (2004) Public Opinion and HIV/AIDS: Facing UP to the Future.
3. Briefing Paper No. 12 (2005) AIDS and Public Opinion in South Africa. Afrobarometer
4. Briefing Paper No. 14 (2006) The Public Agenda: Change and Stability in South African’s ratings of National Priorities. Afrobarometer Briefing Paper no. 43
5. Bratton, Michael, Robert Mattes & E. Gyimah-Boadi (2004). Public Opinion, Democracy, and Market Reform in Africa. Cambridge: Cambridge University Press. (2008). ‘Poor people and democratic citizenship in Africa’. In Anirudh Krishna, ed., Poverty, Participation, and Democracy: A Global Perspective.
6. Caldwell, J. & Orubuloye, I. & Caldwell P (1992) Underreaction to AIDS in Sub-Saharan Africa. Science and Medicine, 34, 1169-1182
7. Fry, L. (2013) Continuities in the HIV/AIDS Policy Debate in South Africa. African Journal of Infectious Diseases 7 (2): 21-26. & Fernandez, R. (1994) HIV prevention: Factors that predict compliance with testing and counseling procedures. Journal of The American Osteopathic Association, 94, 525-530.
8. Granich, R., Gilks, C., Dye, C. ,Decock,K. ,and Williams, B.(2009) Universal Voluntary HIV Testing with immediate antiretroviral therapy as a strategy for elimination of HIFV transmission: a mathematical model. The Lancet 373 available at http://www.the lancet.com/journals/lancet/article/PIISo140-6736
9. Justesen, M. (2011) Too Poor to Care? The Salience of AIDS in Africa. Afrobarometer Working Paper no. 133
10. Mattes, R., Bratton, M. & Davids, Y. (2003) Poverty, Survival, and Democracy in Southern Africa, Afrobarometer Working Paper N
11. Whiteside, A., Mattes,R., Willan, S. & Manning, R. (2002). ‘Examining HIV/AIDS in Southern African through the eyes of ordinary Southern Africans’.Afrobarometer Working Paper No. 21.
12. Wikipedia, HIV/AIDS in Uganda. Available at http://en.wikepedia.org/wike/HIV/AIDS_in_Uganda
13. Wouters, E., van Rensburg, H. & Meulemans, H (2010) The national Strategic Plan of South Africa: what are the prospects of success after repeated failure of previous AIDS policy? Health Policy and Planning 25: 171-185

ACKNOWLEDGEMENTS

Afrobarometer Data, Swaziland ,Botswana, Lesotho, South Africa, Zimbabwe, Namibia, Zambia, Mozambique and Malawi">, [Round 5)">, [Years 2011. 2012, 2013)">, available at http://www.afrobarometer.org

World Health Ratings, Swaziland, Botswana, Lesotho, South Africa, Zimbabwe, Namibia, Zambia, Mozambique and Malawi. Primary data sources: WHO, World Bank, UNESCO, CIA and individual country databases for global health and causes of death. Avalable at www.worldlifeexpectancy.com/world-health-rankings

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