Photo: © AIDS Healthcare Foundation
The first 90 is the gateway
Carine Weiss: During the MMS/aidsfocus.ch conference we discussed the feasibility of reaching the 90-90-90 targets. We have a window of three years in which to do so. How is your organisation, AIDS Healthcare Foundation (AHF), contributing?
George Ojamuge: The first ‘90’ aims to ensure that people living with HIV who do not know their status are identified.This is the first essential step before treatment can be initiated.HIV testing is therefore the gateway to the attainment of the 90-90-90 targets.
So in this regard, what is AHF’s contribution to these global targets?
AHF provides HIV-testing services which we implement both in health facilities and in communities. Within the health facilities, health workers provide HIV-testing services for patients who come to the facility with different medical conditions. All patients who are eligible have the opportunity to learn of their HIV status unless they opt out.
Alongside this, we also run a community testing program. We send out teams to provide HIV testing services in the communities, targeting key populations and underserved populations. These interventions take different forms and take place at different times of the day, depending on the population. For instance, we conduct ‘moonlight HIV testing’, targeting people who are normally difficult to reach during day time. We also conduct door-to-door testing and index client testing. Index client testing means working with individuals who are already living with HIV and encouraging them to advice their household members, partners and other close people to undertake an HIV test and get linked to treatment.
2017 AHF revised its testing strategy and has introduced a so called ‘targeted testing’ that aims to reach out to vulnerable populations. These vulnerable groups have a higher risk of HIV. We used our program data to profile different individuals in the populations to help us understand who is more at risk and offering them the opportunity to know their HIV status early.
Photo: © AIDS Healthcare Foundation
The second 90
We are undertaking proactive linkage to HIV treatment once someone is tested HIV positive. We work to continue our contact with that client to ensure that they gain access to a health facility or organisation that provides HIV treatment. We have found that this is an extremely useful strategy which is helping many people to get access to HIV treatment services in time according to the test and treat requirements. Because we know that testing without supporting the clients to gain access to treatment services does not offer much benefit.
Furthermore,we support networks of HIV clinics staffed with teams of health care providers. In these clinics we provide care and treatment, adherence support, patient monitoring and follow-up to ensure that the patients continue treatment to work towards viral suppression. The clinic teams’ responsibility is to ensure the provision of quality services to facilitate patients’ adherence to treatment. In this case, we are keen to ensure that scheduled patients keep their appointments. If they miss a clinic day, we are very keen to contact them to find out why they haven’t turned up.
There is a category of patients who may not come to the clinic for between three and six months. Normally, such people are considered as lost to-follow-up. In such scenarios we deploy linkage facilitators in the communities to find these patients, counsel them and encourage them to return to treatment. We further seek to understand what makes them fail to attend clinic days.
In addition, AHF has a strong passion for advocacy. Our advocacy efforts aim to influence policies, guidelines and to challenge punitive laws.
We reach out to all the population of higher risk
Carine Weiss: You mention that you are targeting key populations. Are you targeting all of them, or only female sex workers (FSW), or men who have sex with men (MSM)? Who exactly are you targeting?
George Ojamuge: We basically work with all the populations that we can reach out to and where the legal environment is conducive to work. For example, in countries where we can work freely with men who have sex with men and female sex workers, we target them. In countries where there are injecting drug users, we equally target them. By this we follow our value on diversity that states that whoever is in need and comes to our service points gets the service needed.
However, in some countries in Africa, punitive laws affect the delivery of services to these populations. In countries like Nigeria, there is active legislation against homosexuality and these kinds of laws have an implication on the health seeking-behaviour of this subpopulation. Wherever the legal environment is conducive, we reach out to all the populations that are at higher risk of or vulnerable to HIV.
Effective councelling is crucial
Carine Weiss: Wow, this is impressive! It’s fantastic! Based on your experiences, what works well and what are the challenges?
George Ojamuge: Let me begin by saying that evidence-based interventions are really crucial to reaching the 90-90-90 targets. So, if you have evidence-based interventions, there is no need to waste time, they simply have to be implemented.
We need to use a combined approach to ensure that behavioural interventions are implemented alongside medical interventions and structural interventions. Behavioural interventions should aim to support individuals to change their behaviour. For example, if we talk about patients needing to adhere to treatment, there should be a specific communication effort that encourages them to take their medication on a daily basis.
We also need effective counselling or psychosocial support because it constitutes a strong basis for successful referral, linkage and adherence among people living with HIV. Ineffective counselling impacts the decision to make an HIV test as well as the referral and linkage to treatment.
For bio-medical interventions, it is crucial to provide a full range of complementary services that are tailored to the needs of specific populations in order to achieve good treatment outcomes. In terms of structural interventions, we need to address issues that will facilitate attainment of enabling environments, policies, reduce discrimination and stigma. If people in treatment are stigmatised they won’t adhere to their medication, nor seek health services. It is worth noting that socio-economic needs should be addressed, because they have a direct impact on health of the patients.
Inadequate funding is definitely a challenge. The majority of developing countries largely depend on donor funding to finance their HIV programmes. They also have limited allocations from their national budgets to fund their own HIV activities.
In addition, in Africa for example, weak healthcare systems and constraints in human resources have a direct effect on attainment of the targets. We don’t have enough health workers to deliver the services, because 90:90:90 implies an increase in patients to be served coupled again with inadequate infrastructure and diagnostic capacity. So, we must deal with multiple challenges in order to reach the targets.
Steps to achieve the 90-90-90 targets
Carine Weiss: Yes, I share your view. We also discussed during the conference how stigma, discrimination and funding are huge problems. Not only in your country, but also in Switzerland we are facing challenges concerning discrimination and stigma, and people who are affected by HIV do not dare to disclose their status. As a summary, from your point of view, what needs to be done to achieve the 90-90-90 targets?
George Ojamuge: Firstly, we need people to know about their HIV status. If you look at the global estimates by UNAIDS and WHO, we are still not doing well with identification of HIV positives and yet the target is intended to be reached by 2020; less than 3 years to go. There is still a big proportion of people living with HIV who have not yet been diagnosed and this is further worsened by the stream of new HIV infections.
Secondly, we must ensure that each government, especially in sub-Saharan Africa, works towards sustainability by allocating a substantial amount of money from their national budgets to complement what we are receiving from the donor community. We are well aware that, if we look at the global dynamics now, some programmes are under threat. For example, the Global Fund hasn’t been able to achieve its funding target. Big economies like China are making only small contributions. So, without adequate funding to sustain the provision of services,we will not reach the targets.
Thirdly, we need to strengthen systems for delivery of health services as well as to guarantee quality services.
Lastly, we need to tackle the issue of drug pricing. Prices are still high! For example, in Africa we need a sustainable supply of high quality, affordable generic drugs since access to drugs is critical for the attainment of the 90-90-90 targets.
Carine Weiss: Yes, I agree, we also touched on the topic of the availability of drugs. It is especially the case that, if you test more people, you need to have the drugs available so that they can immediately enter into treatment.
George Ojamuge: Correct. So, it is a very challenging situation if we want to sustain the gains realised so far and at the same time drug prices are not coming down. It is an advocacy area for everyone especially targeting the pharmaceutical companies.
Photo: © AIDS Healthcare Foundation
Carine Weiss: Would you like to give any final messages before we end the interview?
George Ojamuge: My final message is that we must get everyone to play their part. To me, this is very critical. It must come from the perspective of the individual, the institutions, the communities and the governments. We have already achieved so much recently but, if you look across the globe at the overall number of people who are being on treatment, we still need to build upon these successes.
So, we should keep our promises: keep our promise on HIV funding in order to sustain the current gains. ‘Keep the promise’ has been AHF’s advocacy message for a long time now. We can only control the global spread of AIDS if we get everyone to play their part!
Finally, 2017 is a special year in AHF as we mark 30 years of dedicated service in the HIV and AIDS response. It is key to note that everyone’s contribution is still needed until the battle is won!
Carine Weiss: Thank you so much!
