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Actual Needs and Donor Priorities in HIV/AIDS—The Frustrating Gap

Reading Samuel Loewenberg’s article, “Ethiopia Struggles to Make Its Voice Heard,” in the Lancet and a recent comment on it from Abel Hailu Irena, I thought, finally, someone is speaking out about something too many of us remain silent on—the vast gap in some countries between actual needs and donors’ perceived priorities, particularly when it comes to HIV/AIDS funding.

I started supporting HIV/AIDS programs in Ethiopia during the early years of the President’s Emergency Plan on AIDS Relief (PEPFAR) efforts. Over the years, I have observed millions of dollars being spent on these programs even as the country struggles to improve the most basic maternal and child health services and adequately treat tuberculosis and malaria. For anyone working in the health sector in Ethiopia, it is obvious that the health system is struggling, and the dismal health statistics are hard to ignore. Having lived through the HIV epidemics in South Africa and Namibia, where the situation truly is an emergency and national prevalence rates are nearly ten times that of Ethiopia, I wonder why donors invest  so much for HIV/AIDS work in Ethiopia, when clearly there are much more pressing priorities.

IntraHealth International is one of many international nongovernmental organizations supporting the government of Ethiopia on the HIV/AIDS response. We all face the same dilemmas: high staff turnover at every level of the health system which feeds a never-ending, and costly, cycle of training, and a weak logistics system making it difficult to keep facilities stocked with basic supplies even when well-trained personnel are in place. Health facilities struggle with a lack of or intermittent access to safe water and electricity, which can make the most basic health procedures impossible to perform. We continue to implement our HIV programs, even as we witness too many deaths from other diseases.

I support the Community Prevention of Mother-to-Child HIV (PMTCT) Project that aims to improve maternal and child health and prevent this form of HIV transmission by making the necessary services more accessible in local communities. The emphasis is on communities, particularly those in semi-rural and rural areas—even though we know that in Ethiopia the HIV epidemic is not a generalized one but rather concentrated within high-risk groups and in urban centers. During the first eight months of the program implementation we tested more than 13,000 pregnant women for HIV and found only 50 women tested positive. In other words, only 0.038% of these women were living with HIV! In one respect, that is great news, but it also indicated that in some of the communities and health centers where we were investing the bulk of our HIV resources, the HIV prevalence was too low to justify continuing the program as it was conceived. We knew, too, that in these very same communities, women and children continue to die during childbirth and from other preventable and treatable diseases. Donors in Ethiopia and elsewhere are recognizing these realities and beginning to shift policies and priorities. In IntraHealth’s programs, for example, we are adjusting to focus in those areas with higher HIV prevalence and reinforcing the maternal health components of our work.

As the global health community continues its dialogue around the importance of building in-country capacity of host country governments in data-driven decision-making, I encourage donors, technical assistance agencies and others to do the same.