Wealthy Nations Should Increase Global HIV/AIDS Spending, Editorial Says

I thought I’d return to that AIDS story from India. From the Kaiser Network:

“Now that the Group of Eight industrialized nations has pledged to commit $60 billion to combat AIDS and other diseases around the world in coming years,” Congress and “other national legislatures ought to look hard for additional funds to close a looming gap between the funds committed and the needs of desperate patients,” a New York Times editorial says. Donor nations have “greatly increased their funding for AIDS programs in recent years in belated recognition that the epidemic threatens to destroy not just its victims but also the social and economic fabric of many countries in sub-Saharan Africa,” the editorial says.

Although President Bush’s recent proposal for a $30 billion, five-year extension of the President’s Emergency Plan for AIDS Relief is a positive move, the funding request “represents only a modest increase from the spending trajectory” the U.S. already was on, according to the Times. The U.S. has been “by far the largest AIDS donor in recent years, providing almost half of the funding commitments made by donor governments,” the editorial says, adding, “But when measured against the size of the national economy, the American donations rank only fifth. There is room to do more.”

The G8 pledge and Bush’s PEPFAR proposal will not be “enough to keep up with the devastating epidemics” of HIV/AIDS, tuberculosis and malaria, the editorial says, adding that tens of “billions of dollars more will be needed to provide treatment, care and preventive services for AIDS alone over the next five years.” As Congress this year “wrestles” with the fiscal year 2008 appropriations bills, it should “provide the full $1.3 billion being sought by congressional health advocates” for the U.S. contribution to the Global Fund To Fight AIDS, Tuberculosis and Malaria, the editorial says, concluding that Congress also should “set the nation – and by its example, the world – on course toward universal access to AIDS treatment by 2010” (New York Times, 6/18).

We know that AIDS funding is ever-increasing:

AIDS Funding (KFF)

and putting that into some sort of context, from the same report:

share of global GDP/share of AIDS funding

The question is, is it making any difference? Talking to a friend (who reminded me that I wanted to revisit this), whose work is kind of related to this sort of thing, his perspective was that AIDS funding had gone a little IMF – in that it was used to impose “good governance” (caveat: he did say he thought this in his more paranoid moments). One can see pieces of this for themselves – the Bush administration’s horrid little gag rule a splendid case in point. Even above, the New York Times editorial tells us that Congress also should “set the nation – and by its example, the world – on course toward universal access to AIDS treatment by 2010.” What does that mean, on course toward universal access to treatment? Who defines what is ‘on’ or ‘off’ course.

The holders of the purse strings, ‘of’ course (bad pun. Sorry. I’m Australian, we can’t help ourselves).

If you go searching for longitudinal studies of HIV/AIDS, you’ll find a lot of first-world work, looking almost entirely at first-world concerns. Not so much incidence (or structure), or response to funding. We’re all more or less familiar with the pandemic,

AIDS prevalence, map

but only in that static sense. Personally I don’t think my friend is as far off as he thinks he is: look at the response to the Indian story:

Millions of dollars have poured in from international donors, NGOs and the government for prevention and awareness programmes.

But today, this flow of funds could dry up. New estimates reveal that the number of people living with HIV could be much smaller than believed and ironically, activists fear the first casualty would be aid.

”Funding would be affected at their level. Small NGOs would be at the receiving end,” said Kaushalya, Positive Women’s Network.

That ‘small NGOs’ comment is telling. A UNAIDS’ Report on the global AIDS epidemic 2006 included the lines:

More leadership and more money are still urgently needed, and thus these two areas of focus remain essential, but now there is widespread recognition that a third focus is also vital: making the money work more effectively.

Why is this necessary? As more money has become available, more government,international, civil society and other organizations have been responding to AIDS in many of the low- and middle-income countries most heavily burdened by the epidemic. Often, there have been no mutually agreed-upon strategies or mechanisms guiding, coordinating, monitoring and evaluating their efforts. The result has been duplication, waste and serious gaps in the national AIDS response in many countries.

Often, for example, there has been insufficient surveillance to identify the people whose behaviour places them most at risk of infection and consequent failure to reach these people with prevention, treatment, care and support services.

This is the beginning of chapter 11, Getting the Best Out of National Responses. It continues into stake-holder, guiding principles, action framework speak (not my bag).

I’m not suggesting funding be cut. I do get as annoyed as any other healthy-in-a-rich-country welfarist at the popularity of one illness over another, and Bono really does send me spare. Returning to the India story Anjali Gopalan, Executive Director of the Naz Foundation, said

”I see this as a very political disease. This kind of response has not come from communities in cancer and malaria, even if studies show that numbers are lesser. Donors can’t pull back now. It’s opened a Pandora’s box because we are also looking at opportunist infections. For the first time because of HIV there are health initiatives that have gone down to the district level.”

I mean, good, but that’s a fine demonstration of the problem – funding for AIDS has increased as though it is funding for aid. Little is known about the impact of this funding, but little enough even seems to be known about the implementation of it. With the bodies involved it is not surprising: governments and the strings that they attach to their funding, the UN, WHO and down through all of the NGOs at work in various countries.

It strikes me though that, in an age when the NHS won’t consider a treatment without some idea of its cost-effectiveness, we could do with some of that waste-not-want-not attitude in our response to the AIDS/HIV pandemic. Again, thank God, I don’t have it and I don’t need access to treatment while having no running water. Which is why I’m not suggesting funding simply be cut when a country’s numbers go down – because as I said the other day, numbers are remarkable fungible, to the point of being meaningless, things. I just think we’re spending some rather inefficient dollars on the problem.

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