Therapy in the living room
Mats'eliso Setoko
HIV/AIDS in the new millennium
Thomas Gass
Former SolidarMed employee, ethnologist and health expert Thomas Gass has shaped the SolidarMed Antiretroviral Treatment Programme (SMART) from the very beginning. A conversation about the challenges of HIV control in Africa and new partnership models in the age of decolonisation.
Thomas Gass, SolidarMed's core business was traditionally limited to recruiting and sending Swiss doctors to Africa. In 2024, SolidarMed broke new ground with HIV therapy programmes in affected African countries. How did this come about?
«From 2000 onwards, in addition to its traditional partnership with mission hospitals, the NGO established country offices with local staff. This made it possible to attract larger projects and handle them efficiently. Thanks to generic drugs from India, the prices of effective antiretroviral therapies (ART) fell to an affordable level. There was a lot of money and few local structures. And SolidarMed was able to capitalise on this with a new focus and tried-and-tested partnerships.»
The core of the new therapy programme was the establishment of HIV/AIDS clinics in African hospitals. What were the challenges?
«Continuous monitoring of a chronic disease was a novelty in the African healthcare systems. There was neither an appointment book nor a digital patient file. We had to redefine all processes. It was all very labour-intensive and required a lot of discipline and a change in mindset on the part of the patients themselves.»
Effective antiretroviral therapy fundamentally changed the nature of the disease. It was no longer a question of dying of AIDS, but of how to live with HIV.
Thomas Gass, ethnologist and health expert
Allow me to make a critical comment: with the vital HIV/AIDS therapies in Africa, Swiss doctors seemed to have rid themselves of their nagging self-doubt. The pressure to Africanise the healthcare system suddenly vanished, and Western expertise experienced a renaissance.
«This interpretation is certainly correct for the initial phase. The knowledge that Swiss infectious disease specialists had was indispensable and irreplaceable. However, with the ongoing integration of SMART into national HIV/AIDS programmes, the influence of local doctors and nurses became increasingly important.»
HIV Test
Do you have a specific example of this?
«An important feature of the SMART programme was its decentralised structure. We wanted to get out of the hospital and into the countryside. We acted in a complementary manner to the state health service, taking on functions that the state was not yet able to cover.»
What role did the patients play?
«HIV/AIDS, with its millions of victims in Africa, was a pandemic of unimaginable proportions. Effective antiretroviral therapy fundamentally changed the nature of the disease. It was no longer a question of dying of AIDS, but of how to live with HIV. Numerous HIV self-help groups were established in the villages, and the disease status had a formative effect on people's own identities.»
How were these self-help groups organised?
«They were usually led by a so-called expert patient. They organised group meetings and sensitised group members to issues such as better nutrition and agriculture. In return, they were rewarded with a bicycle and a T-shirt by the programme in Zimbabwe.»
Expert patient rewarded with a bicycle by the programme in Zimbabwe
That sounds very much like HIV activist romanticism...
«It definitely shouldn't. Despite the visible successes, the challenges were enormous. Before the self-help groups were established, around a third of all patients discontinued their antiretroviral therapy. The Apostolic Church, which demonised AIDS drugs, played a significant and inglorious role in this.»
The focus is no longer exclusively on HIV/AIDS, but on the fact that patients often suffer from a combination of infectious and chronic diseases
Thomas Gass, ethnologist and health expert
On the one hand, there were the self-help groups. On the other, there was the sheer number of international NGOs that invaded African countries in an uncoordinated manner and with a lot of money in their pockets. To what extent did this situation diminish the success of the SMART programme?
«The HI virus was given top priority, while other diseases were neglected. Overfunded foundations and initiatives from the US showered African villagers with laboratory equipment, gifts and money to win them over to their programmes. This created false expectations, sowed discontent, created dependencies and fuelled inefficiency.»
Where do we stand today?
«The focus is no longer exclusively on HIV/AIDS, but on the fact that patients often suffer from a combination of infectious and chronic diseases: tuberculosis, high blood pressure, diabetes and cancer are among them. The SMART programme has been successfully integrated into health systems by African governments. Nevertheless, international cooperation is at a crossroads. The call for greater decolonisation can no longer be ignored. New forms of partnership are needed that are no longer based on the economic imbalance between North and South but are built more strongly on shared values and trust.»
People who have shaped SolidarMed
Since its founding in 1926, people with commitment and courage have shaped the history of SolidarMed. In this portrait series, we highlight individuals whose dedication has had a lasting impact on the development of SolidarMed and on healthcare in Africa.
This portrait is an extract from a series of historical eyewitness accounts, which were compiled on behalf of SolidarMed by Marcel Dreier and Lukas Meier. The historians’ complete work is available as a book.
