When Martin Alonso Hernandez, an AIDS activist in Bogota, Colombia's capital, learned that his partner of six years was HIV positive, he waited another five years before getting himself tested for the virus.
"I was out of the social security system," he explained. "It was very expensive to test otherwise."
Hernandez's partner did have health insurance through his job, but was fired when his status was discovered. He lost his health benefits and fell into a deep depression, Hernandez told IRIN/PlusNews, eventually dying in 1999.
By the time Hernandez accessed Colombia's state-regulated health insurance system and tested for HIV in 2001, he had a number of AIDS-related symptoms and weighed just 32kg. "I was quite sure of the result," he said. "I just wanted the piece of paper so I could access treatment."
Colombia introduced its national health insurance system in 1997, with the goal of achieving universal coverage by 2000. But about 14 percent of the population remain uninsured and according to a 2008 grant proposal submitted by the Colombian government to the Global Fund to Fight AIDS, Tuberculosis and Malaria, a disproportionate number come from among the "vulnerable, excluded and impoverished".
In theory, those not covered by the health insurance system - mostly the very poor and those who lack identification documents - should be able to access health services directly from the state. But Dr Ricardo Luque, an advisor to the Public Health Directorate on sexual and reproductive health issues, noted that Colombia's decentralised system of government means that each of the country's 32 regional departments determines its own spending priorities. "There's competition for resources and they're spent based on demand," he said.
The Global Fund proposal confirms that some departments have not prioritised the health needs of their most impoverished populations who are most likely to be uninsured.
The health insurance system functions by requiring those who are employed to pay into a state-administered fund which is used to pay private health companies to deliver services. An additional, smaller salary deduction helps pay for a social security fund that subsidises health services for the unemployed.
The private health companies are mandated to provide essential services, including all those related to HIV and AIDS treatment, care and prevention. But according to Ricardo Garcia, UNAIDS country coordinator, people living with HIV, especially those covered by the subsidised health system, have often been refused such services and had to resort to the courts to force the health companies to meet their obligations.
Garcia added that while access to ARV treatment had improved in recent years, with 80 percent of people in need of the drugs now getting them according to government figures, the quality and consistency of provision was still patchy. "We've had complaints of people receiving the ARVs for three or four months and then, because of a shortage of drugs resulting from bad supply management, they have to interrupt treatment."
UNAIDS estimates that 170,000 people are living with HIV in Colombia, of which 18,000 are currently accessing treatment according to Luque of the Public Health Directorate. He explained that the figure of 80 percent coverage for ARVs was based on reported cases rather than prevalence estimates - the basis for most countries' treatment coverage figures. "Only 25,000 people have tested positive and found to be in need of treatment," Luque said. "Access to treatment is one thing; the gap in diagnosis is another."
Vulnerable groups miss out on prevention
Critics of Colombia's health system argue that there is little incentive for the private health companies to promote HIV testing and that regional health authorities have also under spent on either promoting testing or training health personnel to provide it.
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HIV prevalence among Colombia's general population has stayed below 1 percent, but the limited data available suggests that concentrated epidemics are occurring among certain high-risk groups such as men who have sex with men (MSM) and sex workers. People displaced by the country's armed conflict are also thought to be at greater risk of HIV infection.
Currently, Colombia has no national strategy or budget for HIV prevention programmes targeted at these vulnerable groups. Prevention and awareness-raising is left to the private health companies, the local departments and non-governmental organisations.
"The private health companies receive money from the government to do HIV prevention, but they're not using it to actually do interventions," said Garcia of UNAIDS.
"Some of the health companies are fulfilling their mandate to do prevention, others not," conceded Luque. "We do need more resources for a national strategy of prevention, that's why we're applying to the Global Fund."
If the grant proposal is approved, it will be used to target vulnerable groups such as MSM, sex workers, young displaced people, and prisoners. In the meantime, there are no programmes to even distribute free condoms to these groups. Local departments have limited budgets for HIV prevention, some of which they can choose to spend on condoms while the private health companies receive only enough condoms from the health ministry to give to people already living with HIV and those with other sexually transmitted infections.
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"It's insufficient, but it's a lack of resources," said Luque. "Most condoms have to be paid for out of people's pockets."
Unfortunately, it is the most high risk groups for HIV who are often least likely to be able to afford condoms. Eduardo Pastrana of the local NGO, Amigos Positivos which runs HIV/AIDS awareness programmes aimed at displaced people living on Colombia's northern coast, said most of the people he works with have very low incomes: "They would rather buy food than condoms."
This article was produced by IRIN News while it was part of the United Nations Office for the Coordination of Humanitarian Affairs. Please send queries on copyright or liability to the UN. For more information: https://shop.un.org/rights-permissions