Geneva Health Forum Archive

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Primafamed: An Institutional Network for the Development of Family Medicine in Africa

Author(s): M. M. Flinkenflögel*1, J. De Maeseneer1
Affiliation(s): 1Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium
Keywords: Family medicine; African universities; primary healthcare; institutional network
Background:

Facing the challenges of high rates of infant and maternal mortality, HIV/AIDS, TB infection, endemic malaria and pervasive poverty, countries in Africa, need to develop an accessible, high quality comprehensive primary healthcare system. Nowadays, specific community based training of future family physicians is lacking in most of the African countries. WHO - World Health Report 2006 ‘Working together for health’ emphasises the need for primary healthcare-training in the local community in order to tackle actual ‘brain-drain’.

Summary/Objectives:

Primafamed is a 2 year project, coordinated from Ghent University, funded by Edulink, a programme from the European Union. 10 African Universities in 8 different Sub-Saharan countries are participating in this project. Primafamed is establishing an institutional network between departments and units of family medicine and primary healthcare in African universities, focussing on South-South cooperation, in order to:
1 – strengthen development of departments of family medicine/primary healthcare in African countries;
2 – create a forum for international cooperation to enhance the quality of programme content, educational methods and training in family medicine;
3 – encourage research collaboration in family medicine and primary healthcare education;
4 – insert motivated and locally well-trained generalists or ‘African family doctors’ into the primary healthcare systems;
5 – contribute to improvement of access to quality primary healthcare, especially for the most vulnerable communities in Africa.

Results:

The Primafamed-network, Ghent University and the 10 African partner institutions, has started and is working on the implementation of its mission to set up family medicine education in Africa to create a sustainable quality primary healthcare system in Africa, accessible and affordable for all.

Lessons learned:

Primafamed embraces the principle of South-South cooperation, encouraging the sharing of unique knowledge and wisdom between African institutions. By motivating, stimulating and supporting these institutions in the set up of family medicine training, primary healthcare systems in Africa can improve.

A Gender Perspective Study of HIV Positive Cases Attending Voluntary Counselling and Testing Center (VCTC), Vadodara

Author(s): M. G. Shaikh*1, S. Mishra1
Affiliation(s): 1Preventive and Social Medicine, Medical College Baroda - Maharaja Sayajirao University, Vadodara, India
Keywords: HIV/AIDS, gender, VCTC
Background:

A semi-structured and pre-tested pro-forma is used to interview HIV positive patients attending VCTC located at SSG Hospital, Vadodara. Prior verbal and written consent was taken before starting each interview. This cross-sectional study included HIV positive 50 male and 50 female (>13 yrs) cases attending VCTC during April-July 2007. Analysis is done by Epi info 6.04 d statistical package.

Summary/Objectives:

1 – To understand the epidemiological profile of HIV positive patients attending VCTC;
2 – To find out the possible high risk behaviour of having acquired HIV/AIDS among HIV positive patients studied;
3 – to understand the social support system and gender discrimination if any, in HIV positive patients;
4 – to find out health-seeking behaviour and ability to access health services in HIV positive patients.

Results:

Study found, almost 60 % of married HIV positive patients with significant higher percentage of males (58 %) as compared to females (42 %). Whereas total no. of widow/widower found is 23 % with almost 87 % of females as compared to males (13 %). Majority of female patients (80 %) were housewives while majority of males were involved in high risk occupations like truck driving, auto driving, call centre job, sales work etc. In 45 % cases, spouses were HIV positive while 31 % cases didn’t know of the HIV status of their spouse. 26 % HIV positive patients had a past history of Blood transfusion. More males presented with history of premarital sex (83 %), extramarital sex (64 %), multiple sex partners (84 %) and sexual activity (85 %) even after HIV infection. More number of females experienced careless behaviour/neglect (65 %) after HIV status disclosure to their spouse while 71 % females experienced careless behaviour from their family. Out of 9 % cases 75 % females were the culprit of domestic violence. Majority of males (59 %) had contacted private clinic/hospital initially for their health problems while 70 % female patients contacted government hospital for their problems. 3 females were forced to contact quack by their spouse.

Lessons learned:

Males were mainly involved with high risk occupations while females in household work. More males were presented with premarital, extramarital sex and multiple sex partners and females were more vulnerable. Health seeking behaviour of females was affected by male dominance and their economic dependency on others.

A Qualitative Study to Explore Barriers Faced by Patients in Adhering to Antiretroviral Therapy at Lighthouse Clinic

Author(s):

K. R. Chikaphupha*1, F. P. Kachomoza1, L. J. Nyirenda1, G. T. Bongololo1, R. Weigel2, M. Boxshall2, S. Theobald2, I. M. Namakhoma1

Affiliation(s):

1REACH Trust, 2Lighthouse Clinic, Lilongwe, Malawi, 3Liverpool School of Tropical Medicine, Liverpool, UK

Keywords: ART, adherence
Background:

The major success of the antiretroviral therapy (ART) depends on maintaining high adherence levels among patients on ART. Lighthouse operates the largest ART clinic in Lilongwe District in Malawi and provides care to more than 4,000 patients on ART.

Summary/Objectives:

The objective of the study was first to understand factors that cause patients on ART to stop treatment or miss doses or clinic appointments. Secondly to determine whether or not some groups of patients e.g. women, face more barriers in adhering to ART.

Results:

Results:   The study revealed several impediments to ART adherence. Financial problems were reported as a major challenge leading to patients missing appointments or stopping treatment. Patients reported that they sometimes do not have money for transport to travel to and from the hospital. Financial constraints also led to problems in sourcing food in the home hence patients’ failure to strict observation of their dose time and appointment dates. Patients’ financial problems were aggravated as a result of loss of income and employment due to long illness. Travel outside Lilongwe for purposes of business and work for instance truck drivers and business people, also contributed to missing of doses and appointments. Belief that HIV could be cured through traditional medication and prayers caused some patients to stop treatment. Side effects from ARVs and co-infection with TB that demanded an interruption of ARVs to start TB treatment also led some patients not to restart ART.

Lessons learned:

Poverty which leads to lack of food was a major impediment to the retention of patients on treatment. Hence exploring ways of supporting patients with food is necessary to enhance adherence to treatment. The TB/HIV co-infection in patients has implications for the individual and the health system hence need for better ways of addressing the problem. Further, health facilities need to improve on reporting system to curb mis-defining patients as defaulters. Early recognition of risk factors for poor adherence supported by follow up of patients could help to communicate targeted health messages to these groups to encourage treatment adherence and retention in the ART programme. Most of the patients who had defaulted from treatment are willing to continue taking up the therapy.

Building Partnership between Mental Health Workers, Social Workers and Medical Professionals to Enhance Capacity for Effective HIV and AIDS Responses in the Western Balkans Region

Author(s): B. Schwethelm*1, L. Hsu1
Affiliation(s): 1Fondation Partnerships in Health, Céligny, Switzerland
Keywords: HIV and AIDS, capacity building, mental health workers, social workers
Background:

The Western Balkans region covers Albania, Bosnia and Herzegovina, Croatia, Macedonia, Montenegro, Serbia and UNMIK Kosovo. The political instability, combined with socio-economic transition and extensive stigma and discrimination against marginal populations heightens the HIV vulnerabilities of these groups. International assistance has previously ignored the region whose health system is now in the process of being reconstructed and modernized. Strengthening the capacities and updating knowledge of health, mental health, and social workers in HIV and AIDS diagnosis, treatment, work place protection while building partnership between the public sector and local NGOs can facilitate reducing stigma and discrimination and improving access to care and support for marginalized populations. Knowledge, attitudes and practice assessments were conducted with primary healthcare doctors and nurses, psychologists, community mental health workers and social workers. The assessments identified the double jeopardy of HIV vulnerabilities combined with mental illnesses facing marginalized populations. This programme responds to this gap by strengthening mental health, social work and infectious diseases services of the health systems in the Western Balkans.

Summary/Objectives:

Improved risk assessments, counselling and referral coordination to strengthen health system support to PLHIV and marginalized populations in HIV prevention, AIDS treatment, care and support

Results:

Needs assessments have been conducted in three countries involving nearly 400 health and 150 social workers in public community healthcare services. Survey results indicated fundamental gaps in HIV knowledge (e.g., modes of transmission, the ‘window period’ of infection, HIV status of the partner of the PLHIV, client rights to confidentiality). For example, few health or social service providers would maintain the client’s right to confidentiality, being particularly willing to share the client’s status with their family. Only a small proportion of these workers had experience with HIV positive clients, and few would feel comfortable in having any contact with an HIV positive client. The size and volume of service also influenced the attitudes of the respondents. While there was substantial interest to learn more about HIV and AIDS, most practitioners gained their knowledge from TV and to a lesser extent, from professional journals. Access to professional conferences and workshops is limited in these countries. A model HIV and mental health support training curriculum has been developed based on the assessment findings. Each country’s curriculum committee is composed of staff of the mental health department, the community social worker’s group, the National AIDS Coordinator and infectious diseases specialists.

Lessons learned:

The strengthened collaboration and coordination between mental health and HIV service providers in the health system, with protection of client confidentiality, could improve access to the healthcare and social services for PLHIV and other marginalized populations, such as trafficked women, commercial sex workers, ethnic populations (Roma and other minority groups), men having sex with men, injecting drug users, and migrant workers.

Equity Assessment and Treatment Outcomes in Accessing Antiretroviral Therapy in Malawi

Author(s): T. I. Chilipaine-Banda*1, I. Makwiza-Namakhoma1, B. Nhlema-Simwaka1, J. Aberle-Grasse2, B. Hedt2,
E. Schouten3
Affiliation(s): 1Research for Equity and Community Health Trust, 2Centres for Disease Control, Malawi, 3Ministry of Health, Malawi
Keywords: Equity, treatment access, treatment outcomes, antiretroviral therapy
Background:

In Malawi, HIV prevalence among adults (15-49 years) is estimated at 14 percent. Though the number of people accessing ART is rapidly expanding, the goal of ART provision is to reach only 50% of the population becoming eligible every year. The Ministry of Health recognises the importance of equity in the national ART scale up as highlighted in the World Health Organisation’s Alma Ata declaration. Equity is defined as comprising elements of an assessment of vulnerability, in terms of HIV infection and access to care and treatment or ability to cope with the impact of the illness. Equity monitoring is crucial in ensuring that the disadvantaged and vulnerable populations are accessing treatment.

Summary/Objectives:

The study aimed at conducting an equity assessment to analyse who is accessing treatment by age and gender and compare if ART access is in line with HIV prevalence trends. Furthermore, the study established the effect of gender and age on the patient’s treatment outcomes. Data analysis used existing routine ART registers and focus was on all ART patients who initiated treatment in 2006 in the 5 districts of Malawi. Data was collected on the following variables; age, gender, area of location and also patient’s treatment outcomes.

Results:

Results show that 10,800 patients were enrolled on treatment in the 5 districts studied in 2006. Treatment access compared with HIV prevalence by gender shows proportionately more females accessing treatment than males. A comparative analysis of the age-sex distribution with HIV prevalence shows that the young age group of 15-19 had more men proportionately on treatment as compared to women. However, HIV prevalence trends show that prevalence in the 15-19 age group is higher in women than men. Also, uptake of treatment in the 30-39 age group showed that there were more women on treatment than men, yet HIV prevalence in this age group is higher in men as compared to women. Disparities in treatment outcomes by gender and age shows that men on ART are at more risk of dying as compared to women by 25% (Odds ratio= 1.25, P-Value=0.003). Furthermore, Men are 1.15 times more likely to default on treatment as compared with women (Odds ratio= 1.15, P-Value= 0.078).

Lessons learned:

In general, men are not accessing treatment as compared to women. Furthermore, there are also age specific differences in access to ART. Particularly, amongst the 15-19 age group for women and 30-39 age group for men. In order to make ART scale up provision equitable, it is imperative to target women in the 15-19 age group and men in the 30-39 age group for counselling and testing and also access to ART. This would enable increase in the uptake of treatment in these age groups. Furthermore, the treatment outcomes by gender suggests that there is need to understand the health seeking behaviour patterns amongst men in order to establish the confounding factors for the higher death rate and default rate in men as compared to women.

Gender Inequality and HIV/AIDS: Double Jeopardy of Women

Author(s): B. Joshi*1, B. Shahi1
Affiliation(s): 1Sociology and Rural Development, Tribhuwan University, Nepal, 2Community Health, All India Institute of Medical Sciences, New Delhi, India
Keywords: Gender, HIV/AIDS, women, vulnerability, rights
Background:

Current statistics indicate that 6.1 million people in South Asia are infected with Human Immunodeficiency Virus (HIV). HIV is an extraordinary kind of crisis. It requires an exceptional response that remains flexible, creative and vigilant on the one hand and on the other hand those who are affected need a multi-dimensional approach to their lives. Now HIV infection in Nepal has a female face because of it growing fastest in this subpopulation. How do gender and HIV/AIDS make women jeopardized? Gender is a crucial element in health inequalities in developing countries. Gender can be conceptualized as a powerful social determinant of health, which interacts, with other determinants such as age, family structure, income, education and social support and a variety of behavioural determinants. In a patriarchal system, men dominate women and exercise control over their lives including their sexuality and reproductive choices. Nepalese women’s vulnerability for HIV is further fragmented by a combination of factors such as biological, social- class, caste, urban/rural location, sexual orientation, culture, economic and legal factors, etc. These factors have an impact on women’s access to services, resources and information.

Summary/Objectives:

A study was conducted with PLWHA women during 2005-2007. To examine the complexity of HIV/AIDS and to learn more about the specific problems faced by women living with HIV - how the concept of gender & HIV/AIDS make their life vulnerable. Case studies and Informal Interviews with HIV infected women. Data was analysed with EPI info programme.

Results:

Case studies and interviews with women from the study illustrate that low status in family, sexual violence, economic and social problems such as poverty, lack of education are some of the primary reasons to get infection. Cultural orientation inhibits them to talk about sex to their partners, which results in infectious status. In the middle-aged women, after sterilization they do not practice regular use of condoms, because they think it is primarily for family planning. Among the newly-married women they know their status only at time of pregnancy, which results in psychological trauma and other related aspects. Most of them are widows and they know their sero status at a later stage of their partner’s HIV infected life. After the death of their partner, some of them are being expelled from their home and undergo various violations of human rights.

Lessons learned:

This study revealed the need to develop appropriate programme would be emphasizing the target communities. Due to illiteracy, poverty, gender inequality women and girls are facing with spousal battering, sexual abuse of female children, dowry related violence, rape including marital rape, traditional practices harmful to female, no spousal violence, sexual harassment and intimidation at work and in school, trafficking of women, forced prostitution, rape in war, female infanticide, constant belittling includes controlling behaviours such as isolation from family & friends, monitoring her movements, restrict her access to resources. Social workers can minimize these issues by giving empathy and psychosocial support, change behaviours and attitude providing medical treatment, offer counselling ,documents injuries and refer their clients to legal assistance and support services, family planning and other mental and reproductive healthcare. Peer-educators (healthcare workers and medical students) approaches for prevention of violence are cost effective, sustainable, easy access to-hard-to reach groups. Governments, NGOs, INGOs also have crucial role to work hand in hand on these issues by empowering women, law and policy, equal education and equal economic opportunities.

Prevalence of HIV Infection and Tattooing Behaviour among Injecting Drug Users in Chennai City, Tamil Nadu State, India

Author(s): C. Pauline Dinakar*1, R. Sundaralingam2
Affiliation(s): 1Dept. of P.G Studies and Research in Human Science, Justice Basheer Ahmed Sayeed College,University of Madras, Chennai, 2International Drugs Expert, ex-Interpol, India
Keywords: HIV infection, injecting drug users (IDU), incarceration, tattooing, contaminated sharps
Background:

Drug abuse is on the rise and is adding fuel to the HIV scenario in India. India has an estimated number of 3.1 million HIV infected population. Non –sexual transmission of HIV has been overlooked in developing countries as reported by David Guisselquist. The prevalence of IDUs in the southern states of India is rapidly increasing. Injecting Drug Usage (IDU) and needle sharing behaviour was found to be substantially prevalent among the incarcerated IDUs visiting the drop-in centres in Chennai city. The hot pursuit for illicit drugs is pivotal factor for the frequent incarceration and criminal records of the IDUs. The use of contaminated sharps by the IDUs behind bars has been analysed in the study. Tattooing exposures were observed. Tattooing was strongly associated with peer- substance use and constitutes a part of their lifestyle. The IDUs involve themselves in risk behaviours such as sharing equipments used for tattooing purposes or injecting drugs, unaware of transmission of HIV through contaminated needles. The ‘fresh-blood remains’ leftover in the ink pots used for tattooing was used for 3 or more clients and constitutes a major risk for HIV transmission.

Summary/Objectives:

Objectives: (1) To determine the prevalence of HIV infection in the selected IDU population in Chennai; (2) To determine correlates of HIV infection with body-tattooing behaviour of the IDUs in Chennai. Methods: 180 IDU were recruited from a drop-in centre and its neighbouring parks and streets in Chennai city. Participants were interviewed using a structured questionnaire regarding their socio-demographics and HIV risk characteristics. Data were analysed using 2 and multiple logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI).

Results:

The prevalence of HIV infection is 60.5% among male injecting drug users.96% of the injecting drug users who participated in this study had body tattoos and reported use of contaminated sharps .In the multivariable analysis, a history of shared contaminated sharps while injecting drugs (OR, 0.15;95% CI,0.45-0.54)and tattooing (OR, 0.11;95% CI,0.052-0.23) was associated with significantly high prevalence of HIV infection.96% of the IDUs in this study had body tattoos . Findings indicated a higher prevalence in the HIV positivity status among IDUs who share injectible drugs and get tattooed inside prisons.

Lessons learned:

The prevalence of HIV-1 infection has reached an alarming level of 60.1%in Chennai city among the IDUs.41.3 % of IDUs tattooed in the community were HIV infected when compared to the HIV infection in 86.4% of IDUs with tattooing exposures in prison. Thus tattooing exposures and incarceration proved to be one of the main correlates of HIV-1 infection. Urgent and comprehensive harm reduction programmes and rehabilitation units are vital for IDUs living in prisons and in the community.

Determination of Knowledge of Mass Media Journalists Participating in 1st Congress of Mass Media Relations with AIDS, on Prevention of HIV Transmission

Author(s): S. Karim Dizani*1, N. Sadigh1, N. Shams hosseini1, F. Mohammadi1, M. Mohraz2
Affiliation(s): 1Iran University of Medical Sciences, 2Tehran University of Medical Sciences, Tehran, Iran (Islamic Republic of)
Keywords: HIV, AIDS, mass media, knowledge
Background:

AIDS Epidemic is drastically increasing. More than 1159 new cases of AIDS & HIV infection have been reported in Iran in year 2001 which is approximately 3 times more than those in year 1999 & 2000. The mass media have played a visible role in the human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS) epidemic in developing countries since its onset in the early 1980s. These efforts met with considerable success in raising awareness: In the present study we assessed the mean HIV/AIDS knowledge score among mass media staff by using a knowledge questionnaire.

Summary/Objectives:

This analytic cross-sectional study was performed on all 151 mass media staff attended in the first mass media conference on AIDS Data were collected with a questionnaire containing 31 questions. (Cronbach’s Alpha =0.69). Correlations and Independent T-test were used for data analysis. A P<0.05 was considered significant.

Results:

The mean age of cases was 36(± 12) years. There was a significant correlation between age and the sum of each case score (P= 0.043, r= 0.16). Level of education and the sum of each case score had significant correlation (P= 0.001, r= 0.27). But no significant difference was found between sum of each case score in male and females. (á = 0.11). The mean score of women was 19.34 and for men was 17.75 out of 31.

Lessons learned:

Our findings show that there is no significant correlation between age, level of education and sum of each case score. Also sex has no effect on the level of knowledge. In the other words, our findings demonstrate that the HIV/AIDS knowledge of mass media staff is little and further prospective studies is being suggested to do after holding course for the cases.

HIV Positive Status and Nutritional Assessment of Injecting Drug Users in Chennai City, Tamil Nadu State, India

Author(s): C. Pauline Dinakar*1, Roshanara2, R. Sundaralingam3
Affiliation(s): 1Dept. of P.G Studies and Research in Human Science, 2Controller of Examinations, Justice Basheer Ahmed Sayeed college, Chennai, 3International Drugs Expert, ex-Interpol, India
Keywords:

Nutritional assessment, injecting drug users(IDU), HIV infection, poverty, malnutrition.

Background:

The intertwined epidemics of HIV/AIDS and injecting drug use are among the most vexing public health problems in India. The non sexual transmission of HIV/AIDS has been overlooked in developing countries. India has an estimated number of 3.1 million HIV infected population. A high prevalence of injecting drug users has been reported in the southern states of India, such as Tamil Nadu and is adding fuel to the HIV scenario in India. This study focuses on the Injecting Drug Users (IDU) living in the urban slums and seeking help from the community based organizations in Chennai city, India. Poverty and malnutrition problem is rampant in India. Majority of the IDUs living in the urban slums were illiterate, unemployed and some homeless. Malnutrition is a common problem prevalent among the IDUs due to their poor food intake and high intake of drugs. Hot pursuit for drugs lands the IDUs in complex situations such as crime, frequent incarceration, social ostracization, homelessness and malnutrition. The nutritional status of this population has been highly neglected.

Summary/Objectives:

1 – To determine the prevalence of HIV infection in the selected IDU population in Chennai city;
2 – To assess the nutritional status of the selected IDUs;
3 – To assess the CD4 count of the selected IDUs and to determine the percentage of IDUs taking advantage of the antiretroviral treatment regimen provided by the government.

Results:

The prevalence of HIV infection was 60.5% (109 out of 180 IDUs) among male injecting drug users.85% of the IDUs were school drop-outs and remaining 15% were illiterate. 75% of the IDUs were unemployed and led a sedentary lifestyle. The nutritional assessment revealed a body mass index (BMI)of 18.06 +2.3Kg/m2 for the HIV positive IDUs and 18.50+ 1.88 Kg/m2 for HIV negative IDUs which is below the normal Indian BMI values (23 Kg/m2 ) . The BMI values were found to be lower than the HIV-infected non-injecting drug users (non IDUs) which was 19.4+ 3.3 Kg/m 2. ‘Blood speaks volumes’- There was significant difference between the HIV positive IDUs and the HIV negative IDUs with relation to their CD4 , Blood glucose levels, hematocrit, Albumin globulin ratio, total protein and serum HDL levels. The Blood glucose level was normal for both HIV positive and HIV negative IDUs. The Albumin globulin ratio was 1.31±0.0338 for the HIV negative IDU when compare to 0.97± 0.0244 in HIV infected IDUs. Albumin and Globulin measure the amount and type of protein in your blood and is an index of overall health and nutrition. The HIV positive IDUs had a significantly lower HDL (35.69±1.141 mg%)when compared to the HIV negative IDU (43.15±1.9386 mg%)indicating a sedentary lifestyle. The HIV positive IDUs had a significantly lower Hematocrit level ( 39.93±0.6537% ) when compared to the uninfected IDUs (45± 0.6555%) which is an indicator of anaemia in the HIV positive IDUs .CD4 counts were low for the HIV infected IDUs (477±34.1146 cells perc.mm) when compared to 958.22±46.467 cells per c.mm of the HIV negative IDUs in this study. Strikingly only 3% of the HIV positive IDU were on antiretroviral treatment (ART).

Lessons learned:

Urgent need for comprehensive medical nutrition therapy, awareness programmes on HIV/AIDS and Nutrition are quintessential for IDUs living in the community and in the prisons of Chennai city, India.

Why Taking into Account Social Determinants is Essential to Reach a Successful Global Health Policy? An Example from the HIV-Care Sector in Burundi

Author(s):

J. Cailhol*1, T. Nahimana2, L. Munyana2, H. Ntakarutimana2, F. Musanabana3, D. Diack4, M. Dubreuil4, C. Arvieux5, O. Bouchaud1, T. Niyongabo2

Affiliation(s): 1Infectious and Tropical Diseases, Avicenne Hospital, Assistance Publique Hôpitaux de Paris, Bobigny, France, 2HIV-care centre, University Hospital of Bujumbura, 3HIV-care centre, Prince Régent Hospital, Bujumbura, Burundi, 4Project Department, ESTHER, Paris, 5Infectious and Tropical Diseases, University Hospital of Rennes, Rennes, France
Keywords: Social determinants; HIV-care; global health policy; international funding
Background:

Health policy usually targets epidemiologically defined population in a specific intervention programme. However, the sectorisation of health problems and the development of health policies, missing ‘surrounding’ socio-economic determinants, may result in inequitable long term results.

Summary/Objectives:

In Burundi, the HIV sector is mainly financed by international funding (IF), including the Global Fund (GF). By this way, HIV-infected people can have access to care, antiretrovirals and opportunistic infections medications free of charge. IF can also contribute to major the HIV-healthcare professionals (HCP) salary. Indeed, because of extremely low incomes, public sector HCP move frequently through the country or migrate towards foreign countries, attracted by higher salaries and better working environment. In Burundi, there are now less than 250 physicians left. Through three examples, we will attempt to demonstrate that health policies should consider social determinants.

Results:

Example 1: Burundi is one of the poorest countries in the world (more than 70% of the inhabitants earn less than 1 dollar per day): as a result, few people can afford a medical insurance. Apart from HIV-infection, in case of any disease, patients either pay by themselves, almost always helped by their community or remain without any medication. In governmental hospitals, physicians are aware that some common medications such as amoxicillin or cotrimoxazole are available through the GF and use these GF-drugs without regard to HIV status. This behaviour cannot be condemned as physicians cannot leave a patient without medication only because he is not HIV-infected. However, these medications are becoming out-of-stock quickly, and it is impossible to produce accurate estimations of the need in opportunistic infections medications. After all, who will be blamed by the GF for this misuse of a specifically HIV-dedicated funding?
Example 2: HIV-patients must be highly adherent to their medication to be successfully treated. Many patients, who are fully aware of the importance of the treatment for their own health, are forced to interrupt their treatment because they cannot afford daily food. A quick overview of temporary lost of follow-up patients revealed that most of them did not have any money for the monthly transportation costs to their care-centre. On the same way, sustained adherence to HIV prevention cannot be expected if poverty does not allow inhabitants a prospective sight. Indeed, why would they care for their tomorrow’s health if today they don’t have enough food for themselves or their family?
Example 3: Due to better funding in the HIV-sector, deleterious consequences can be expected for the general population and for HIV-patients as well. First, many physicians, even though scarce, are concentrated in the HIV sector, dropping other priority sectors (paediatrics, diabetes mellitus…). Among HIV-sector, well-trained physicians leave the public care sector to join up with international agencies (particularly the WHO and UNAIDS) and also NGOs. Sometimes, pair-educators earn better salaries than nurses or even physicians, leading to a demotivation and conflicts between HCP.

Lessons learned:

Lessons learned in the expanding access to HIV-care in Burundi, i.e. IF repartition and organisation of prevention and HIV-care may be applied to other sectors, leading to a global health policy. Health determinants are linked together and merged into social determinants. Ideally health policies should consider the whole population and its social determinants, instead of focusing on one particular group of diseased people. In concrete terms, for instance, using part of IF dedicated for example to TB, HIV and malaria (GF) to provide HCP viable salaries and medications for other sectors would probably result in a significant improvement of global health.