Troby
PREVENTION
THE MEDICAL PERSPECTIVE
In this perspective you might notice that I have a bit of a critical view, but let me first say that I am very grateful for the medical developments that has derived from the medical industry. Unfortunately there are still things we need to question concerning the powers that the medical perspective has in relation to other perspectives.
HIV infection is a disease mostly effecting young people in their most productive ages, making it differ from most (if not all?) other diseases in the world. As underlined above, diseases are most often associated with medical treatment, medicines, vaccines and a variety of cures. This perspective highlights the role of medical research and pharmaceutical companies.
In lower- and middle-income countries, in 2009, about 5 million people were receiving antiretroviral therapy of the estimated 13 million people (based on the 2010 WHO guidelines) who were in need of it. Treatment access has expanded extensively over the last few years, according to UNAIDS, increasing by 63 percent between 2009 and 2011. Treatment reached 8 million people in 2011, and the number of people who were eligible but without access has risen from about 13 millions in 2009 to about 14.8 millions in 2011. So even if the access to medicines increases, the number of people in need for medicines increases too. Globally in 2015, an estimation is that 25.9 million people, of the +35 million people living with HIV or AIDS, are in need of access to antiretroviral therapy.
Do you find this confusing? Exercises with numbers, percentages and statistics are not easy. They can be used to show what ever you like. This is one of the main reasons why I wanted to make this breakdown of AIDS by presenting All the 13 Perspectives of AIDS.
The essence here is, whatever efforts used on medicines, we also have to work on stopping people being infected by HIV.
In some cultures there is a strong belief in medicine and science and in others a similar mistrust in favour of more traditional alternatives. This is one of the reasons why people living with HIV in some countries do not take the medicines, despite the facts that they know about their HIV status and have access to ART.
Perceptions of disease severity, susceptibility and the benefits or disadvantages of staying on treatment are supposed to be keys in determining clinical attendance. Believing that God or alternative medicine can cure AIDS can also influence treatment patterns. Similarly, misconceptions about ART can alter patients’ motivation to stick with them. (Roura M et al, 2009).
Of course, the side effects of the medicines and the fact that some of them requires a specific diet to function properly, contribute to how willing or able people are to take ART, if it is available. When people are facing the choice of buying anti-retroviral medicines or the type of food (diet) that allows the best possible effect of the anti-retroviral medicines, they do not want to be tortured by the decision anxiety. HIV infection is at large a disease that most evidently displays inequality in a financial perspective, it put great demands on the medical sphere, which is also a large financial sphere. Through political decisions, research can be supervised and systems developed to provide the best possible response to all elements of a society (see also the political perspective). What I mean is, if the medical sphere is able to develop drugs both easy to take and cheap in the sense that even nomads in the Sub-Saharan area can afford those, and have a possibility to obtain the drugs, and not being plagued by stigma and prejudice, then, we have come a long way. Unfortunately, there are much more to be done to get there. Further, the entire medical science is facing the problems with resistant HIV and multi-drug resistant tuberculosis, a problem that is not yet clearly highlighted in the public opinion around the world.
The medical perspective also influences what happens on the overall HIV
prevention side. Who is entitled to medical treatment and what does it mean? Who has the right to decide who is going to have the medicines? Unfortunately, as medical development advances, some people (in the more developed parts of the world having access to ART) start to reason in order to reach consonance, to continue their risk behaviours as a part of their lifestyle: “There are medications now, so I do not have to be that careful anymore...”
Testing is also something that belongs to the medical perspective. Although, technically speaking, the testing has brought increased possibilities for people to easily get tested, there are still many people around the world who do not have access to it and therefore do not know anything about their HIV status. However, places offering testing usually follow the UN recommendations to develop so-called VCT – Voluntary Counselling and Testing facilities.
One part of my work in Somaliland was together with Mrs Anab Farah Ahmed, a senior qualified Midwife running a clinic in Hargeisa (the capital of Somaliland). In September 2006 we opened Somalia’s first anonymous and voluntary counselling office dealing with HIV, TB, STI and FGM. Since 2006 the number of clients benefiting from the services has risen from just a hand full to 200 in 2007, 834 in 2008 and over a thousand a year since 2009, both women and men. The information available is now well known to the people in Hargeisa, and it has been recognised by the authorities and other local and international organisations, but the clinic has only been offered financial support for the counselling if it starts taking tests of the clients. (All other sites in Hargeisa were working on tests only.) Once again, the medical perspective has directed the focus on testing and less on counselling. For example, how much better is a test that takes 30 minutes to get the result from? Are the HIV prevention measures improved with the 30 minutes test in comparison to the test taking two to seven days to get the results from? What is the increased contribution to prevention? Of course I can see the value in people knowing their HIV status, and the efficiency in “producing test results in large scale”, but I can also see a risk of not recognising counselling as a way to make people reflect on their (sexual) behaviour. In my view, testing is the bicycle chain and counselling is the steering handle of the same bicycle. They are both connected to one another. One determines the speed (testing) and the other the direction (counselling), but I have had difficulty in seeing the acceptance or priorities of counselling in the VCT work in Somalia, Somaliland, Ethiopia, Belarus, Ukraine, Sweden, Indonesia, Cuba, UK, Romania and Kenya. I believe we have always got to remember that the medical perspective is focused on PATIENTS, and there is a need to recognise the prevention efforts to a much larger extent, to put more efforts on what makes people stay healthy, and what makes them have less risk behaviours in sexually related activities. Maybe we who work in the fields of HIV and AIDS are being “tired”, and lack motivation to keep up the good work?
Testing makes it possible to obtain data, statistics and prevalence estimates. The counselling does not provide such direct results; therefore it is an area, which tends to be abused as part of a comprehensive strategy to capture people with risk behaviour. I believe the counselling must be given a much higher status and that the development of discourse forms and methods of self-estimation of risk situations and personal action plans must be developed.