How to reach zero? HIV/AIDS treatment in a low prevalence country
Kimmo Karsikas ,
22 May 2012
The Joint United Nation’s Programme on HIV/AIDS (UNAIDS) has set goals for its 2011 – 2015 strategy: to achieve zero new infections; zero AIDS-related deaths; and zero discrimination. How could a country like Finland reach these goals? Or, more pertinently, what are the obstacles on the way to reaching them?
Finland is a country of 5.3 million people, with less than 3,000 people living with HIV. According to the National Institute for Health and Welfare in Finland and UNAIDS the adult prevalence rate is 0.1%.
Finland offers its residents universal health care. Even though health promotion, including prevention of diseases, has been the main focus of Finnish health care policies for decades, HIV/AIDS is not considered a major public health concern.
With the high level and coverage of health care in Finland, the low prevalence of HIV and the history of health promotion in the country, one might expect that reaching the UNAIDS goals would be comparatively easy. Instead, partly because of the low prevalence, there are some major obstacles in the way.
Reaching zero new infections
In 2011, 176 new HIV-infections were diagnosed in Finland according to the statistics of the National Institute for Health and Welfare. Since 1999 the annual new HIV-infections have been between 126 and 193. In 2011, 36 cases were through homosexual contact, 45 heterosexual contact and 9 through intra venous drug use.
Even though new infections among men who have sex with men (MSM) is currently not the leading factor, during the epidemic, it has become evident that it is the main vulnerable group on which prevention methods should be focused. According to a 2010 study done by the National Health Institute for Health and Welfare and the Finnish AIDS Council the prevalence rate among MSM is 1.4 % compared to the general population’s 0.1 %.
Finnish AIDS Council is the only organisation at the moment undertaking MSM targeted prevention work in Finland. In 2012 the Finland’s Slot Machine Association (RAY, a major funder for organisations) gave the Council EUR 959 000 for general use on increasing awareness of HIV and prevention work. According to the official decision, some of that money must be used towards prevention among MSM but the amount was not specified.
It is clear that the current level of funding does not reflect the prevalence rate among MSM. Even though specific groups need to be targeted with prevention campaigns in order to maintain high levels of safer sex practices, it is not happening at the moment.
The funding for different organisations undertaking HIV/AIDS work in Finland is very centralised and there is an obvious dependence on one of the major funders. RAY's main purpose is to raise funds through gaming operations to promote Finnish health and welfare. Funding is annually distributed to various health and social welfare organisations based on applications. Nearly 900 organisations receive funding each year, among them Hiv-Finland, which is the only patient organisation in Finland; and the Finnish AIDS Council, the main focus of which is prevention and information.
In 2011 Hiv-Finland received approximately 86 % of its funding from RAY. Even though the funding decisions include a three year plan, there is still an element of uncertainty as the applications need to be submitted and approved annually. This and the fact that the money mainly funds the basic running costs means that planning and execution of prevention and information campaigns is a lengthy process and they often do not materialise due to lack of funding.
Because of this rather restrictive system it should be up to the Finnish government to ensure that HIV services, including information, education and prevention within and outside the national healthcare system are safeguarded at all times, even during economic downturn. The priority for Finland should be to focus on funding and making sure that services are cost-effective and sustainable.
Reaching zero AIDS-related deaths
Since the introduction of highly efficient antiretrovirals that are available free of charge for the HIV-positive residents in Finland, the number of AIDS-related deaths since 1996 has gone down dramatically. Nevertheless, there are still measures that could lower the number even more, most notably to identify people that are HIV-positive without them knowing their status.
Almost a quarter of new HIV-infections are so called late presenters (diagnosed either at a stage when the CD4 count is less than 200 or there are AIDS-related infections). According to a study (Kivela et al, HIV Medicine, Epub 2009) done in the Hospital District of Helsinki and Uusimaa1997-2005), if HIV was diagnosed at early stages, there was a death rate of 1.6 % during the first year versus a death rate of 17 % if the diagnose took place at a later stage.
Identifying late presenters at an earlier stage would be vital not only to ensure that individuals could get treatment but also ensuring that there would be a reduced risk of transmission and of AIDS-related death.
The public health care system is obliged to offer anonymous testing when requested without a referral from a doctor anywhere in Finland. Unfortunately this system is not fully operational. According to a phone survey by the Finnish AIDS Council in November 2011, the majority of health care centres (55 %) could not provide anonymous HIV-testing nor could they refer the callers to a place where this could be done. Greater enforcement of rules and regulations should be in place and more anonymous testing sites as well as services for specific groups. For example, MSM targeted sexual health services should be in place.
HIV testing has to be promoted to increase the number of people who are aware of their status and to ensure early access to antiretroviral treatment.
Reaching zero discrimination
A survey undertaken by the World Aids Day working group last year identified some alarming issues when it comes to the knowledge Finnish people have of HIV/AIDS and of their attitudes towards people living with HIV/AIDS. One third of respondents thought that HIV-positive people should disclose their status at a day care facility or when playing football. Twenty percent thought that HIV-positive people should disclose their status at the work place or at school. In addition over 60 % of respondents thought that the most common way of transmission was through intra venous drug use.
"It does not concern me" is a phrase often heard in Finland. As HIV has hitherto mainly affected vulnerable groups, it is often not considered to be general public’s concern. Even though we have clear evidence that the main form of transmission is through heterosexual contact, this piece of information has never reached the whole population. Most regard HIV as still being a problem for specific groups.
During the epidemic only a handful of prominent individuals have publicly disclosed their HIV-status. Not everyone might wish to announce their HIV stats – however, it is still clear that the lack of positive role models has affected public attitudes. In a low-prevalence country stigma and discrimination are still a major problem. We cannot always expect for people living with HIV/AIDS to fight for their own cause as they are often burdened with other issues. For a low-prevalence country like Finland it is important to attract public figures to speak out for HIV-positive people, but as long as it is identified as a problem only for specific groups, it will not happen.
Regardless of the obstacles we are still facing, I do believe Finland has the potential to lead the way and with appropriate policies to actually reach these partly idealistic goals. All it takes is the efficient co-operation between the government, civil society and other actors in the field together with a new understanding of priorities.
Download full article (PDF 90 KB)