Improvements in AIDS Care
Talk to anyone who works on AIDS, and they’ll tell you it’s not just an epidemic, it’s a barometer. “It exposes the weak spots,” says Rachel Snow, who’s spent the last decade of her life working to combat the disease. “Because it’s tied up with the sexual transmission of infection, it tells you a lot about social power. It illustrates global disparities, which reflect basic educational systems. And it really shows you how bad the health care system is.”
It’s factors like these, Snow adds, that determine who gets tested for AIDS—the crucial first step to treating the disease and preventing its spread.
AIDS has already killed 20 million people around the world, and another 39 million are currently infected with HIV, or human immunodeficiency virus, which leads to AIDS. As Snow points out, that makes this a 60-million-person epidemic. “It really is, without question, the epidemic of our lifetime,” she says.
In South Africa, which has the third-highest rate of AIDS in the world (only neighboring Botswana and Swaziland are worse), 11 percent of the total population and 24 percent of the country’s adult population, ages 15–49, have HIV. As is true elsewhere in sub-saharan Africa, HIV testing in South Africa is at best scattershot, which means people who are sick aren’t getting treated, and people who are healthy are in grave danger.
The main reason for this is infrastructure, says Snow, an associate professor of health behavior and health education and associate director of the University of Michigan’s International Institute. Most health clinics in South Africa lack space for private consultations. Add to that a “very weak, tattered health infrastructure—a legacy of apartheid— and you have a very undersourced medical infrastructure for primary health care for the black population,” she says.
To help address the problem, Snow has been working for the past four years with the South African Department of Health and the Development Bank of Southern Africa to strengthen health care systems in three provinces where the incidence of AIDS is especially high and the health infrastructure especially weak: Mpumalanga, Kwazulu-Natal, and Eastern Cape. Baseline surveys had found that a lack of privacy was a major stumbling block for both HIV testing and AIDS–related care, so Snow and her colleagues have created private and semi-private consultation rooms, as well as break-out rooms for counselors, in over 200 primary-care facilities. As strategic planner for the project, Snow is overseeing evaluations to determine the extent of the impact this investment has made on health care providers and their clients.
Snow is also trying to find out who gets tested in sub-saharan Africa and why. In Mpumalanga province, for instance, preliminary data suggest that more women than men are getting tested, and of the men who do get tested, a higher percentage are old and sick, whereas most women who get tested are young and healthy. Snow and her colleagues are reviewing all public testing facilities in Mpumalanga to get a definitive picture of these patterns.
Snow wants to know how people get referred to clinics for testing and why they come in. Does pregnancy alone account for the extra testing of young women? Are those in greatest need getting tested?
Testing is key, she says, because it’s the entry into care. Long before HIV patients need full-blown antiretrovirals and drug therapies, they need help finding basic health care and social services, advice about finances and child care, and information on how to manage HIV.
In Kenya, Snow has found that geography, education, and wealth help determine which women get tested, while income seems to be the dominant factor for men. She is conducting similar research in Burkina Faso. “Testing is an infrastructure that takes you partway to treatment,” she says. With treatment comes prevention—and maybe, some day, an end to an epidemic that has destroyed so many lives.
Photo by Peter Smith
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