HIV/AIDS

Background

Throughout the 1990s only a small number of nonprofits provided any sort of HIV-AIDS prevention, counseling, or treatment of opportunistic infections in developing countries. Beginning in 2000 treatment with antiretrovirals became available in a number of developing countries simultaneously, both through NGOs and through private hospitals and individual private practitioners. Monotherapy was common, PMTCT was rare if available at all. That same year the World Bank MAP program, the Gates Foundation and the Merck Foundation began large-scale funding for HIV prevention and AIDS care.

In 2003 PEPFAR, the Global Fund for AIDS TB and Malaria, and WHO’s 3 x 5 initiative were all launched: the age of large-scale donor funding for HIV AIDS had begun.

NGOs / FBOs

The three large funders of HIV-AIDS care in developing countries, PEPFAR, GFATM, and the World Bank, all support a mix of government and NGO/FBO organizations, mostly government. From 2003 until 2008 between one third and two thirds of funding from PEPFAR has gone to NGOs, much of this to international NGOs who in turn subcontract implementation to local NGOs.

Out-of-pocket

Out-of-pocket payments were the main source of HIV-AIDS care and treatment financing until 2002. Since that time donors, and government in rich countries, have taken the lead in the assuring access to HIV services including ART in most countries.

As the chart shows, from 2002 on out-of-pocket payments represented less than 30% of all spending on HIV-AIDS in the majority of developing countries. This remains true today with the notable exceptions of India, Bangladesh, and Latin America where governments have consistently assured access to care and treatment.

Out-of-pocket payments  were the main source of HIV-AIDS care and treatment financing until 2002

Corporate social responsibility

Much is made of corporate social responsibility and the importance of its role in the prevention and treatment of HIV AIDS. While the corporate sector, and in particular the European and American corporate sectors, have been active in HIV counseling and prevention their impact on care and treatment, particularly antiretroviral therapy, remains negligible in the context of large-scale, donor funded, HIV-AIDS care.

Corporate social responsibility has primarily focused on information education and communication programs and these appear to be both effective and well targeted.

For-profit treatment

Very little for-profit treatment for HIV-AIDS remains in Sub-Saharan Africa or other high prevalence developing countries. In South Africa, Namibia, and Botswana the private sector is contracted to the government, to private insurance companies, and to PEPFAR for the provision and management of a range of HIV-AIDS services including ART. In these three countries private for-profit provision represents 28%, 25%, and 15% respectively of all patients on ART. The use of private practitioners as a way of expanding HIV/AIDS treatment is rare beyond these countries.

The table to the right shows WHO/UNAIDS estimates of privately provided ART in all developing countries. Taking away South Africa, Botswana, and Malawi in which government programs fund privately provided care, the data suggests that approximately 3% of all ART in developing countries is delivered by private providers - paid for through private insurance or out-of-pocket payments.

Large scale donor funding of government and NGO-provided ART has ‘crowded out’ the private sector in Africa, Latin America, and most of Asia. Because of the high cost of treatment, private for-profit provision of ART is impractical when well-stocked free care is available through other sources.

PRIVATE ART BY COUNTRY
Country 2006 2007
Botswana 8,500 9,514
China 1 500 500
Columbia 1,000 0
India 35,000 35,000
Kenya 5,000 5,000
Malawi 2,624 3,937
Nigeria 5,000 30,000
Rwanda 500 500
S.Africa 110,000 100,000
Thailand 10,000 10,000
Zambia 2,000 2,000
Zimbabwe 6,000 10,000
TOTAL 186,424 206,751

1 World Bank project
Total on ART, all sources of care, in 2007: 3,200,000
source: Towards Universal Access. Scaling up progress report. WHO,UNAIDS,Unicef 2008

Strengths

  • hours of operation
  • anonymity
  • choice of provider
  • knowledge of community
  • close-to-patient management
  • accessibility
  • existing infrastructure

Weaknesses

  • variable quality
  • lack of lab support
  • poor reporting
  • high cost drugs make oversight critical
  • no way to assure provider training
  • lack of integration with national systems

Current Activities

India. In 2005 the Clinton Foundation announced a plan to train 100,000 private doctors in India in the provision of antiretroviral therapy. In 2007 the Clinton Foundation re-announced the same plan. An estimated 77,000 people receive ART in India currently, less than 10% of those in need and almost all of them paying out of pocket to private for-profit providers. If ever a country needed to engage the private sector in order to assure access and quality of care for HIV-AIDS India is that country.

Although trainings began in 2007 according to postings by the Indian doctors on on a variety of webpages, no formal mention has been made since the early 2007 foundation announcement in the Clinton Foundation has refused to comment on this project for nearly 12 months. The current status is uncertain.

Kenya. The Gold Star network of private doctors, started and supported by FHI, currently consists of approximately 65 doctors in Nairobi, Nakuru, and Mombasa who provide treatment to 1500 patients covered by private or corporate insurance, or paying out-of-pocket. Although a limited success, the network has not grown significantly in the past three years.

South Africa. Between 60,000 and 100,000 patients in South Africa receive a RT through disease management programs (DMP) financed by private insurance, corporate insurance, or government subsidy. DMPs, and the US based, for-profit, Broadreach Corp., manage the care of patients via individual private doctors.

Current Programs and Resources - HIV / AIDS