Blockchain Papers

Zarni Htun, Yingxi Zhao, Hannah Gilbert, Chunling Lu

BACKGROUND: The Global Fund has been a major funding source for HIV/AIDS programs in Myanmar. In this qualitative study, we aim to understand the impact of Global Fund on national HIV/AIDS response in Myanmar during the era of Millennium Development Goals (MDGs). METHODS: We conducted individual in-depth interviews by recruiting key informants through purposive snowball sampling. The respondents were engaged in the national/subnational response to HIV/AIDS in Myanmar and worked for the United Nations agencies, non-governmental organizations (NGOs), and civil society. Interview questions were organized around the role of Global Fund in strengthening national response to HIV/AIDS in the six building blocks of the Myanmar's health system. Transcripts from the key informants were synthesized into specific themes through a deductive approach. RESULTS: We found that the Global Fund has provided substantial support to (1) finance the national HIV/AIDS response in Myanmar, and (2) strengthen leadership and governance at the central level through improving coordination and collaboration, including more stakeholders (e.g. civil society, NGOs) in decision making process, and catalyzing policy changes on scaling-up key interventions. Yet, its role remains limited in addressing new demands at the township level in terms of capacity building, staffing, and medical supply resulting from rapid scale-up of HIV interventions and decentralization of service delivery in the public sector. CONCLUSION: There was a missed opportunity for Myanmar to capitalize on the use of the Global Fund's funding to strengthen the health system. Deliberate planning is required to optimize the use of those scarce resources to provide universal coverage for HIV/AIDS.

Nisha Bhat, Peter H. Kilmarx, Freeman Dube, Albert Manenji · 6 authors

BACKGROUND: We conducted a case study of the Zimbabwe National AIDS Trust Fund ('AIDS Levy') as an approach to domestic government financing of the response to HIV and AIDS. METHODS: Data came from three sources: a literature review, including a search for grey literature, review of government documents from the Zimbabwe National AIDS Council (NAC), and key informant interviews with representatives of the Zimbabwean government, civil society and international organizations. FINDINGS: The literature search yielded 139 sources, and 20 key informants were interviewed. Established by legislation in 1999, the AIDS Levy entails a 3% income tax for individuals and 3% tax on profits of employers and trusts (which excluded the mining industry until 2015). It is managed by the parastatal NAC through a decentralized structure of AIDS Action Committees. Revenues increased from inception to 2006 through 2008, a period of economic instability and hyperinflation. Following dollarization in 2009, annual revenues continued to increase, reaching US$38.6 million in 2014. By policy, at least 50% of funds are used for purchase of antiretroviral medications. Other spending includes administration and capital costs, HIV prevention, and monitoring and evaluation. Several financial controls and auditing systems are in place. Key informants perceived the AIDS Levy as a 'homegrown' solution that provided country ownership and reduced dependence on donor funding, but called for further increased transparency, accountability, and reduced administrative costs, as well as recommended changes to increase revenue. CONCLUSIONS: The Zimbabwe AIDS Levy has generated substantial resources, recently over US$35 million per year, and signals an important commitment by Zimbabweans, which may have helped attract other donor resources. Many key informants considered the Zimbabwe AIDS Levy to be a best practice for other countries to follow.

Angela Akol, Ingunn Marie Stadskleiv Engebretsen, Vilde Skylstad, Joyce Nalugya · 6 authors

BACKGROUND: Robust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15-30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective. METHODS: Seven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes. RESULTS: Eleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning. CONCLUSION: Managers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent.

Iryna Zablotska

In 2010, the fourth decade of the HIV pandemic arrived during a time of unprecedented success in HIV prevention. Globally, UNAIDS estimated that new HIV infections fell by 33% between 2001 and 2011; new infections among adults and adolescents fell by 50% or more in 26 countries (more than half of these countries were in sub-Saharan Africa), and new infections among children worldwide dropped by 52% [1,2]. The declines in new HIV infections are particularly evident in countries with sustained and more strategic investments, which take into account the specifics of local epidemics, increased political leadership and community engagement in response to the HIV epidemic, and scale up of HIV prevention and treatment programmes [2]. The rapidly growing delivery of antiretrovirals to women and infant feeding–based prevention programmes has resulted in a sharp decline in new HIV diagnoses among children. The encouraging declines in HIV infections can also be attributed to the improved effectiveness of combination antiretroviral treatment (cART), an expanded range of improved medications, the declining prices that make cART more accessible to people in low-income countries, growing coverage with HIV testing, and improved access to prevention and treatment services (particularly for women and young people in low-income countries). Global investment in the AIDS response jumped from US$3.8 billion in 2002 to US$18.9 billion in 2012. The new decade also saw a revolution in HIV prevention with ground-breaking scientific advances in HIV biomedical prevention, and specifically, proof that microbicides containing an antiretroviral agent can reduce sexual transmission of HIV to women by 39% [3], that earlier start of treatment by HIV-positive people (treatment as prevention or TasP) can reduce the risk of onward transmission by as much as 96% [4], and that consistent, correct use of a daily antiretroviral tablet by men who have sex with men (MSM) can achieve substantial reductions in HIV infections (pre-exposure prophylaxis or PrEP) [5]. In response to the excitement and optimism surrounding the preventative effects of antiretroviral medications, the UN member states considered and unanimously approved the new Political Declaration on HIV/AIDS at a special session of the General Assembly in New York in 2011 [6]. At the core of the 2011 UN Political Declaration are ambitious new HIV prevention targets calling on governments to commit to reducing sexual transmission of HIV by 50%, reducing HIV transmission though injecting drug use by 50% and eliminating mother-to-child transmission of HIV by 2015. These targets are aimed at reinvigorating the commitment towards achieving the Millennium Development Goal #6 to combat HIV/AIDS [7]. In the past two years, research on HIV biomedical prevention has focused on adapting the new prevention strategies to the context of local HIV epidemics [8]. There have been equal measures of optimism and pessimism expressed about the ability of new prevention strategies to halt the HIV pandemic. Based on the evidence that starting treatment earlier can increase health benefits and extend life for people with HIV [9,10], many clinicians are already recommending early treatment for both medical and TasP purposes. Regarding PrEP, the widespread reaction is caution in recommending this strategy. Such reluctance is based on concerns about the common adherence issues in the studies of PrEP [11], the obvious relationship between level of adherence to daily medication schedule and its preventative effect [12] and side effects and drug-resistant HIV [13], among others. Despite little evidence that PrEP use can affect behaviour, many concerns have been voiced about the future of safe sex practices, particularly condom use among MSM, if new biomedical prevention strategies are introduced. More research is needed to investigate this issue using appropriate study designs. In its current form, daily PrEP may benefit only a small number of people with very high and ongoing risk for HIV infection, and other PrEP regimens must be explored. The overarching concern about new prevention strategies, particularly PrEP, is that the cost and burden of providing them are currently unacceptable for most, even high-income, countries. As a result, there have been calls for more evidence and a very slow progress in implementing these two new exciting HIV prevention developments. Regarding PrEP, only two countries to date have prescription guidelines for people at high risk of HIV infection [14,15]. We now have the knowledge and new tools to revolutionize HIV prevention, and we have the bold new Political Declaration with ambitious targets. It must be acknowledged that the task of bringing HIV infections down to zero seems daunting from where we stand now in late 2013. Despite the global success in lowering the HIV infection rates by 33% [1], sub-Saharan Africa has seen only a 25% decline [16]. Some regions have seen increases (8% in Eastern Europe and central Asia [17], 19% in East Asia [18] and 37% in the Middle East and North Africa [19]). This lack of progress has been associated with insufficient resources, inadequate coverage of women with antiretroviral treatment and HIV testing programmes not reaching the population groups at high risk for HIV infection. While sexual behaviour has changed to become safer in some countries and populations, sexual risk taking has increased in other settings. This is the case in most high-income countries in North America, western and central Europe and Australasia, where MSM are central to local HIV epidemics. In these countries, both high-risk sexual practices among MSM and HIV infections have been on the rise [20,21]. Condom use has increased in some countries, but declined in others. Proven effective interventions (e.g., prevention of mother-to-child transmission (PMTCT) and needle- and syringe-exchange programmes) have not achieved sufficiently high coverage in many countries [1]. Although trends in risky sexual practices have been linked to the trends in HIV incidence [22] and population-level behaviour change to the reduction in HIV prevalence, there are still challenges in linking behaviour-change programmes to specific HIV outcomes on the population level [2]. While new expectations have been raised about the role of antiretrovirals for HIV prevention, mixed progress was observed in access to cART, and only 61% of people eligible for treatment under the 2010 WHO guidelines received it (this is as little as 34% under the 2013 WHO guidelines). The Political Declaration has for the first time named and acknowledged the importance of such population groups as MSM, people who inject drugs and sex workers for HIV prevention, but in many settings, stigma and access to treatment and prevention services for these groups are still important challenges. Many low- and middle-income countries have stepped up their local investments in HIV prevention [2], but, regrettably, the lack of resources has remained a major issue: only US$18.9 billion was available from all sources for the AIDS response in 2012, and this was estimated to be 16–26% short of annual need [1]. It is at this time of some successes in HIV prevention and challenges in how to optimize the available resources and tools that the aspirational Political Declaration of commitment to fight the pandemic is necessary. This year's International AIDS Day marks the midpoint towards the deadline set by the Political Declaration in 2011. It is an opportunity for governments and each of us to revisit and reinvigorate the universal commitment to bring HIV infections to zero. Like never before, we have good cause to expect the next generation to be AIDS-free and new HIV infections to move towards zero. In the face of the 75 million people who have suffered from HIV/AIDS and the many more affected, the international community should keep the promise and bring this HIV pandemic to an end. None were declared. The Kirby Institute receives project funding from the Australian Government Department of Health and Ageing. The views expressed in this publication do not necessarily represent the position of the Australian Government. IZ has prepared the manuscript and approved its final version.

Dermot Maher, Tido von Schoen-Angerer, Jennifer Cohn

The HIV epidemic is a leading global health challenge. While controversy has surrounded the best HIV prevention strategy, remarkable consensus has supported the campaign for universal access to antiretroviral therapy (ART) for people with HIV infection. As a necessary humane response to the epidemic, the moral imperative to provide ART to people with HIV infection has struck a chord of global solidarity. Much of the funding mobilised for the global response to HIV has supported successful expansion in ART access. Funding is now at a critical juncture as the global financial crisis bites and funders hesitate. Providing universal ART access is a steep hill only half climbed – faltering at this point risks rapid loss of recent gains, and the need to begin again an even steeper climb in future just to regain our current incomplete and perilous position. Against the background of overall efforts to roll back the HIV epidemic, we consider the implications of faltering finances for universal ART access and argue for additional funding, used efficiently. Progress towards universal ART access has individual and also potential community benefits. Although we focus mainly on sub-Saharan Africa as the region most badly affected by HIV and with the least resources to respond, other regions face similar issues. The seemingly inexorable rise in global HIV incidence during the first 30 years of the epidemic peaked towards the end of the 1990s. However, global HIV prevalence and deaths still remain at crisis levels, with 33.4 million people living with HIV and 2 million deaths in 2008 (1). The region most severely affected is sub-Saharan Africa, with 67% of HIV infections and 72% of HIV-related deaths worldwide in 2008 (1). Changing the course of an epidemic of a primarily sexually transmitted infection by changing sexual behaviour is difficult –‘king sex is an unruly monarch’. Demonstrating effectiveness and impact of behaviour change interventions has been difficult and there is little agreement on which specific interventions most effectively change behaviour. Male circumcision is one of few interventions shown in randomised trials to be effective in decreasing HIV transmission risk (2–4), but programmatic delivery is limited and long-term results are awaited. Thirty years’ advances in HIV virology and immunology have been a tremendous scientific success, but have not yet resulted in widely available HIV prevention technologies. The high variability of HIV envelope glycoproteins has frustrated attempts to develop an effective vaccine. After nearly 2 decades of research which failed to find an effective vaginal microbicide (5), the recent finding that tenofovir gel decreases risk of HIV acquisition by 39% is promising (6). Scientific advances have, however, resulted in widely applied HIV diagnosis and treatment technologies. Diagnostic HIV tests are widely available, rapid, easy-to-use, accurate and relatively cheap. Antiretroviral (ARV) drugs can effectively contain HIV even if a cure is not yet possible. Prolongation of life by ART – a tribute to science and technology – has transformed the previously bleak outlook for people with HIV infection. The impact of improved ART access on HIV-related mortality at the population level has been shown in countries with high income, e.g. UK (7) and low income, e.g. Malawi (8). The 10-fold expansion in access to ART in low- and middle-income countries over the 5 years up to 2007 is a tremendous achievement (9). However, the uphill task is not even half completed. The five million adults and children with HIV infection in low- and middle-income countries receiving ART by the end of 2009 represented only 36% of those in need (based on 2010 WHO guidelines) (9). This progress demonstrates proof of principle – that with political and financial commitment universal access to ART is possible – but an unfinished agenda remains. Faltering political and financial commitment threatens to stall progress towards universal ART access. Starting in 2008 the shock waves of the global financial crisis emanated quickly from the USA around the world. The myriad effects of the crisis include threats in developing countries to health services, including ART provision (much of which is funded by donors). The health infrastructure which has been painstakingly built up for ART provision can be easily dismantled in a funding downturn. Developed nations have responded to the ‘credit crunch’ and the collapse of banking systems by allocating vast national resources to bail out financial institutions and industries while their economies contract. Under domestic pressure to curb spending, donor governments are cutting back on development assistance, which may account for a significant proportion of health service expenditure in developing countries. Developing country governments under fiscal constraint may also squeeze health sector expenditure. The global economic downturn therefore compounds the problems of diseases of poverty (e.g. HIV, tuberculosis and malaria) by a double whammy – as socioeconomic conditions which favour the spread of these diseases deteriorate, funds for the health sector response are restricted (10). After substantial yearly increases since 2002 in support for ART access, the USA and other donors have stalled in their funding commitments, with disbursements decreased for 2009 (11). Already by 2009 UNAIDS reported an adverse effect of the economic crisis on ART programmes (12). The Global Fund replenishment pledges for 2011–2013 reached $11.7 billion, far short of the $20 billion needed to expand programmes and even short of the $13 billion needed to keep existing programmes running (13). Although the latest WHO guidelines recommend a CD4 cell count of 350 cells/μl as a starting threshold for ART (14), many centres in Africa continue to use a threshold of 200 CD4 cells/μl because of insufficient ARV supply (15). Medecins sans Frontieres have reported ART rationing to the sickest patients in developing countries, directly contradicting the evidence of benefits of earlier treatment and WHO guidelines (16). Consequences of failure to maintain even the existing ARV drug supply include: more HIV-related diseases and deaths that could have been prevented; without treatment people becoming more infectious, with increased risk of transmission; and increased drug resistance generated by treatment interruption, necessitating more expensive second-line therapies to prevent HIV progression. Financially squeezed ART programmes may further compromise the quality of ART provision in Africa, where mortality is high in the first year of ART because of health systems delays in ART initiation and the quality of care (17). The funds invested in achieving the current level of ART access are a platform for further progress. Additional investment in progress towards universal ART access benefits people with HIV infection, and also potentially the community through improved HIV prevention and improved health systems. Early ART initiation improves patient outcomes and also reduces HIV infectiousness (18) and transmission (19,20), with the potential for ‘treatment as prevention’ (21). Early ART with cessation of viral replication and subsequent immune restoration has benefits for the individual (less risk of HIV-related disease) and also potentially for public health (improved HIV prevention) and for society (increased productivity and decreased costs of HIV-related care) (22). The strategy of universal voluntary testing with immediate ART, which in a mathematical model could eliminate HIV transmission (23), needs evaluation in practice (24). Achieving universal ART access is easier if HIV incidence decreases. This is urgent as the rate of new HIV infections is greater than the rate that people with HIV start ART. Additional investments in implementing combined prevention interventions will decrease HIV incidence, thus facilitating ART provision. Progress towards universal and early ART access could become a virtuous cycle, as the more (and the earlier) that people start ART, the greater is the potential impact in decreasing transmission, with fewer incident cases and fewer people needing ART. Progress in ART provision requires investment in strengthened health systems as well as in the health system elements most directly involved in ART provision. The reasons why HIV has had a much greater impact in Africa than other regions include deficiencies in the region’s health systems. Such deficiencies lead to failure to recognise emerging health problems, diagnose cases, provide quality care, manage surveillance, promote a safe healthcare environment and gain public confidence. Lack of preparedness increases vulnerability to future emerging health problems, unless health systems are strengthened using adequate resources. Investing in ART provision while strengthening health systems is a win-win situation for people with HIV infection and the community. Additional funding generated for improved ART access must be used more efficiently (25). In developing countries, a built-in cost-efficiency is that ARV drug costs fall as coverage increases. Proposals for maximising cost-efficiencies include a cross-cutting agenda for global health to meet the challenges of the financial crisis (26). Disease-specific health initiatives and funding programmes should agree on a cross-cutting agenda to reform the global health architecture and maximise cost-efficiencies, instead of advocating and competing for their own stake in the limited and diminishing pool of donor funds. At country level, greater integration of HIV and other programme activities, e.g. tuberculosis, could improve efficiency and strengthen health systems (27). Scaling-up home-based ART (28) and clinically driven rather than routine laboratory monitoring of ART side-effects (29) can improve ART programme efficiency. ‘How to do more with less’ is a research priority for extending ART access in low-resource settings (30). Finding efficiencies in healthcare delivery is important but does not replace sufficient, predictable financing by donors and domestic funding from low- and middle-income countries. Measures to ensure the lowest possible ARV drug prices facilitate cost-efficiencies. Changes in wealthy nations’ trade policies are urgently needed to avoid creating new barriers for generic drugs. Generic competition has been critical to lowering drug costs and will be critical to also lower the prices of newer drugs needed for long-term survival (31). The free trade agreement with India pursued by the European Union, for example, will further increase monopoly protection, although India has already changed its patent law in compliance with World Trade Organization agreements (32). Donor countries’ support for policies to contain ARV drug costs should complement their commitment to fund ART provision. Achieving universal access to ART is an uphill task but feasible if funding is increased and used efficiently. The choice is stark – to build on progress or to embrace defeat and consign the global movement for universal access to the fate of Sisyphus (33). Note: The views expressed by Dermot Maher are not necessarily those of the Medical Research Council (UK). We thank Brian Williams for his encouragement –“The struggle itself towards the heights is enough to fill a man’s heart” (Camus). DM is a clinical epidemiologist and researcher with extensive experience of the global HIV epidemic as a clinician, public health expert and field researcher. TvS-A has extensive experience of the global HIV epidemic and is a leading advocate on behalf of Medecins sans Frontieres for universal access to HIV prevention and treatment. JC has extensive experience of HIV/AIDS policy and advises the Médecins sans Frontières Campaign for Access to Essential Medicines. DM had the idea for the article which he developed in discussion with TvS-A and JC. DM took the lead in drafting the article and all authors contributed to the development of successive iterations. The sources of information for the article were relevant papers from the peer-reviewed literature. DM is guarantor for the article. TvS-A is employed by, and JC is a policy adviser to, the Médecins sans Frontières Campaign for Access to Essential Medicines, which advocates for universal access to HIV prevention and treatment.