Analysis: CHAMA BOWA-MUNDIA
IN AUGUST 2017, Government announced a new policy measure, notably mandatory universal routine HIV Testing, Counselling and Treatment (HTCT) as a step to ending HIV by 2030.
Under this policy, general consent to medical treatment will give public and private health facilities mandate to test one for HIV (with opt-out option) under the Provider Initiated Counselling and Testing (PITC) model.
Over the years, however, diverse programmes have been implemented and remarkable achievements made in response to the 30-year HIV/AIDS epidemic the country has grappled with. Albeit, with low uptake of HIV testing initiatives. About 1.2 million people are estimated to be living with HIV in Zambia, but only 67 percent of these know their status. Partly because of this, the country records an average of 20,000 AIDS related deaths and 60,000 new infections per annum. The epidemic has had enormous socio-economic impact evidenced by reduced labour supply due to mortality and morbidity and at the household level, psycho-social trauma and increased healthcare and funeral spending.
As far back as 2008, global calls were made for a more pragmatic approach to contain the HIV/AIDS pandemic. To this effect, the joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organisation (WHO) recommended the implementation of PITC or routine testing (where one has no symptoms but is screened mainly as a preventive measure) in all health facilities of countries with generalised HIV epidemics; countries where more than one percent of the population is HIV positive. In sub-Saharan countries like Botswana, Uganda, and Rwanda as well as developed countries like the US, routine PITC has been implemented but requires verbal or written consent; although in certain instances general consent to medical treatment gives the doctor or hospital permission to test one for HIV. In Zambia, PITC implementation began in 2008 through the Prevention of Mother to Child Transmission (PMTCT) programme. The programme successfully reduced HIV transmission rate from mother to child from 24 percent in 2009 to less than 9 percent in 2014.
Notwithstanding human rights arguments against mandatory routine PITC that focus on the legal and constitutional implications of the policy, empirical evidence indicates that PITC increases both testing rates and life expectancy of infected individuals and reduces HIV transmission rates. But routine PITC is not without its limitations. Primarily, on the supply side, the integration of routine testing into medical services poses a sustainability challenge due to already existing resource constraints in financing, staffing, infrastructure and drugs. The 2015 USAID, PEPFAR and Health Policy Project (HPP) baseline analysis of HIV financing in Zambia, revealed that funding remains a major concern for Zambia’s national HIV response. It estimates that the annual funding deficit will grow from US$132 million in 2016 to US$268 million in 2020. Therefore, the discrepancy between those in need of ARVs and those actually receiving treatment exists partly due to financing limitations and is likely to grow. Further, a study conducted at the University Teaching Hospital (UTH) in 2015 reveals that inadequate staffing results in non-adherence to HIV testing procedures due to a high treatment burden. Limitations in infrastructure and space also compromise confidentiality and hinder privacy. Coupled with this, when testing is routine, the counselling approach prior to testing focuses on providing cursory information on HIV/AIDS and patients do not receive adequate information. This raises concerns about the effectiveness of routine PITC as an HIV-prevention approach.
On the demand side, limitations also exist. Firstly, a major limitation lies in socio-demographic disparities that hinder PITC uptake. Anecdotally, more women than men utilise outpatient healthcare services, indicating that strategies other than clinic-based programmes may be required to improve men’s access to HIV preventive care and treatment. Additionally, there exists a culture of poor health services utilisation, sustained by high poverty levels and limited access to health facilities. Thirdly, health services utilisation may decline as people avoid utilisation of health facilities due to fear of being tested; empirical evidence indicates fear as one of the major reasons for low testing uptake. Lastly, according to a 2010 Randomised Control Trial (RCT) conducted in Zambia by USAID, individuals were four times more likely to use voluntary counselling and testing (VCT) as a testing option than PITC.
In view of these issues, as Zambia makes efforts towards ending the HIV epidemic by 2030, the expansion of HIV testing is crucial. However, so is the need to fully address the supply and demand limitations that affect the uptake of HIV testing? Nevertheless, increasing access to testing is a necessary step but not a panacea in stemming the pandemic. It was the combination of programmes that aggregately reduced the level of new HIV infections by 41 percent from 77,500 in 2010 to 46,000 in 2016. Ultimately, HIV/AIDS is markedly a behaviour-induced epidemic. As such, the object of prevention lies in changing individual behaviour, which cannot be brought about by increasing access to HIV testing alone. Thus, a comprehensive approach to HIV/ AIDS prevention, treatment, care, mitigation and support would be desirable.
The author is a Researcher at the Zambia Institute for Policy Analysis and Research (ZIPAR).