[procaare] Are we spending too much on HIV?

["BMJ" <procaare@healthnet.org>]

Are we spending too much on HIV?
****************

Two sides of the argument in the recent BMJ:

(1) Are we spending too much on HIV? - Roger England - BMJ. 2007; 334:344.
(2) Are we spending too much on HIV? - Paul de Lay, Robert Greener, and Jose 
Antonio Izazola - BMJ. 2007; 334:345.

= = = =

(1) Are we spending too much on HIV?
Paul de Lay, director, evaluation department, Robert Greener, economics 
adviser, Jose Antonio Izazola, senior adviser, resource and finance analysis
UNAIDS, 20 Avenue Appia, 1211 Geneva 27, Switzerland
BMJ  2007;334:345 (17 February), doi:10.1136/bmj.39113.539595.94
http://www.bmj.com/cgi/content/full/334/7589/345
*******************************

Correspondence to: P de Lay communications@unaids.org

Billions of pounds are being spent on the fight against AIDS in developing 
countries. Roger England believes that much of the money could be better 
used elsewhere, whereas Paul de Lay and colleagues argue that current 
spending is not enough

AIDS is widely acknowledged as a public health crisis and is now one of the 
make or break forces of this century, as measured by both its actual effect 
and potential threat to the survival and wellbeing of people worldwide.(1) In 
2005, the UN Human Development Report concluded that "the AIDS pandemic has 
inflicted the single greatest reversal in human development."(2) In that year, 
AIDS caused a fifth of deaths globally in people aged 15-49 years. Within 
the next five years, every seventh child in the worst affected sub-Saharan 
countries will be an orphan, largely because of AIDS. By 2010, an estimated 
9 million people will need antiretroviral treatment.(3)

Unmet need

Much has been done to raise awareness and resources. However, the Joint 
United Nations Programme on HIV and AIDS (UNAIDS) estimates that resources 
currently pledged are only half what is needed for a comprehensive response. 
In 2006, $9bn (£4.6bn; E7bn) was available for the AIDS response but the real 
need was estimated at $15bn.(4) This sum represents the costs for prevention, 
treatment, and support services; human resources; and infrastructure. The 
bulk of the funding is additional to amounts spent on other aspects of 
health development.

Resources are woefully short in almost every area of public health in low 
and middle income countries. HIV funding should provide an opportunity and 
entry point for strengthening health and social service systems if it is 
used appropriately. For example, large amounts have been spent on laboratory 
networks, universal precautions, blood bank safety, and safe injections, as 
well as focusing on the wellbeing and training of health workers, doctors, 
and nurses and not only those working in AIDS.

In 2003, the total health expenditure in high income countries was $3.3 
trillion, while in low and middle income countries total health expenditure 
was $427bn.(5) The percentage spent on HIV from all sources including donors, 
governments, international foundations, and affected people was just 1.1% of 
these health expenditures in low and middle income countries.

The resources spent on HIV must be proportionate to the overall disease 
burden, adjusted by deferred disease and mortality that will result from the 
current HIV prevalence. Recent estimates by the World Health Organization of 
the disability adjusted life years (DALY) indicate that 31% of communicable, 
maternal, perinatal, and nutritional conditions were attributable to HIV in 
2002.(6) As a sign of this increasing trend, in 2003 HIV accounted for the 
third highest amount of DALYs in low and middle income countries. By 2030 it 
will be the third highest contributor of DALYs globally.(7)

We urgently need stable, predictable, international funding for public 
health and development. Volatile funding flows from donors, often reflecting 
priorities that are not shared by national governments, make it difficult to 
implement national plans. Many countries are reluctant to include these 
uncertain future revenues in the national planning systems. In addition to 
ensuring predictable and sustainable international funding, greater efforts 
are needed to make sure that countries who are able to do so invest more of 
their own money in AIDS and health in general. Currently around one third of 
the total AIDS spending is from domestic sources.

Multisectoral response

HIV is a development problem with multisectoral causes and effects. It 
therefore requires a similar response, with many components lying outside 
the health sector. A large proportion of funding, especially for prevention, 
is actually for activities outside the health sector. Some of these 
activities tackle social issues that underlie vulnerability to HIV 
infection. HIV is highly stigmatised in many countries, often affecting 
marginalised populations such as injecting drug users, sex workers and their 
clients, men who have sex with men, migrants, and mobile populations. Both 
donors and governments are often reluctant to commit resources to help 
people whose activities may be subject to social disapproval.

Poor coordination between different stakeholders in affected countries 
impedes effective spending. The problem is compounded by weak institutions 
and regulatory policies, poor governance, and in some cases corruption. 
UNAIDS is promoting the principle of a single, country owned strategic plan 
coordinated by a single national authority, with an integrated system for 
monitoring and evaluation.

The response to AIDS needs to be seen in the context of international 
commitments to the millennium development goals, which also call for 
progress across many other development priorities. HIV threatens many of 
these goals, especially those related to poverty and health. The cost of 
inaction against AIDS is huge, far greater than for any other public health 
crisis. Current costs are so high because of the inadequacy of previous 
investments. They will be higher tomorrow if we continue to underinvest.

References
1. Piot P. AIDS: from crisis management to sustained strategic response. Lancet 
2006;368:526-30.[CrossRef][ISI][Medline]
2. United Nations Development Programme. Human development report 2005. 
http://hdr.undp.org/reports/global/2005/pdf/HDR05_complete.pdf
3. UNAIDS. 2006 report on the global AIDS epidemic. Geneva: UNAIDS, 2006.
4. UNAIDS. Resource needs for an expanded response to AIDS in low- and 
middle-income countries. Geneva: UNAIDS, 2005.
5. WHO National Health Accounts Unit. National health account EIP/HSF/CEP. 
Geneva: WHO, 2003.
6. WHO Department of Measurement and Health Information. Estimated total DALYs 
(000) by cause and WHO member state, 2002. 
www.who.int/healthinfo/statistics/bodgbddeathdalyestimates.xls
7. Mathers CD, Loncar D. Projections of global mortality and burden of disease 
from 2002 to 2030. PLoS Med 2006;3(11):e442.[CrossRef][Medline]

= = = =
(2)

Are we spending too much on HIV?
Roger England
Health Systems Workshop, Grenada, West Indies
BMJ  2007;334:344 (17 February), doi:10.1136/bmj.39113.402361.94
http://www.bmj.com/cgi/content/full/334/7589/344?ct
***************

roger.england@healthsystemsworkshop.org

Billions of pounds are being spent on the fight against AIDS in developing 
countries. Roger England believes that much of the money could be better 
used elsewhere, whereas Paul de Lay and colleagues argue that current 
spending is not enough

HIV is receiving relatively too much money, with much of it used 
inefficiently and sometimes counterproductively. Data from the Organisation 
for Economic Cooperation and Development show that 21% of health aid was 
allocated to HIV in 2004, up from 8% in 2000.(1) It could now exceed a 
quarter. Yet HIV constitutes only 5% of the burden of disease in low and 
middle income countries as measured by disability adjusted life years lost 
(DALYs),(2) less than that for respiratory infections, perinatal conditions, 
or ischaemic heart disease. It causes 2.8 million deaths a year 
worldwide-fewer than the number of stillbirths, and much less than half the 
number of infant deaths.(2) More deaths are attributable to diabetes than to 
HIV.(3)

Even within sub-Saharan Africa, HIV funding is out of balance. HIV is the 
biggest single killer, contributing 17.6% of the burden of disease in 2001.(4) 
But it received 40% of all health aid in 2004.56 Although incidence and 
prevalence have peaked in Africa,(7) HIV aid to Africa increased by an average 
of $240m (£123m; E185) a year from 2001 to 2004.(5) Global HIV expenditure 
increased by an average of $1.7bn a year in this period.(8) The 2006 UN 
General Assembly high level meeting on AIDS called for annual HIV 
expenditure in low and middle income countries to rise from $8.3bn in 2005 
to around $23bn by 2010.(9) If, as now, aid constitutes a third of this 
expenditure, and if non-HIV health aid continues to increase at current 
rates, HIV would then claim half of all health aid.

Are HIV interventions so cost effective that they justify this 
disproportionate spending? No, they are not. Costs per DALY averted are 
lower for immunisations, malaria, traffic injuries, childhood illnesses, and 
tuberculosis.(10,11) Much HIV money could be spent with more certain benefits 
on, for example, bed nets, immunisation against pneumonia, or family 
planning.

An exceptional disease?

Why has this happened? One factor surely has been the success of HIV lobbies 
and activists in promoting HIV as exceptional.(12) In rich countries, HIV has 
become the crusade of the famous, fashionable, and influential. In high 
prevalence countries, HIV affects the middle classes more than the poor(13) 
and is of more concern to them: middle class children do not die from 
pneumonia or malaria and middle class women do not die in childbirth.

The exceptional status accorded HIV, and its excessive relative funding, has 
produced the biggest vertical programme in history, with its own staff, 
systems, and structure. This is having deleterious effects apart from 
underfunding of other diseases. These include separating HIV from sexual and 
reproductive health and creating parallel structures that constrain the 
development of health services. National AIDS commissions, country 
coordinating mechanisms, UN agencies, etc are tripping over each other for 
funds and influence.

HIV is also affecting adversely the organisation of health services. Funding 
for prevention of mother to child transmission, for example, is producing 
separate structures rather than strengthening everyday antenatal care and 
maternal child health by making testing and prevention part of the routine 
work of nurses and midwives. Also, well funded HIV programmes attract staff 
from other health services, aggravating chronic shortages.

Because HIV interventions are not integrated into health services, this 
excessive spending is not effective. Nevirapine or other prophylaxis is 
given for only 9% of pregnancies in women with HIV, and only 1.5 million 
people are receiving antiretroviral drugs.(8)

What is all this money being spent on? Much of it goes on "multisectoral" 
activities and "mainstreaming" HIV into just about every social activity. 
These have become the emperor's new clothes of public health. The World 
Bank's evaluation notes: "projects are complex with many participants 
engaged in activities for which they have little capacity, technical 
expertise, or comparative advantage."(14) Much money is wasted in areas that 
reflect the interests of those on the AIDS industry payroll more than 
evidence. It could be more effective if used to strengthen public health, 
which already provides preventive interventions in other sectors, 
cooperating with local authorities and ministries. Moreover, claiming HIV as 
exceptional may have increased stigmatisation.(15)

Health systems not diseases

More health aid should be used to strengthen health systems that can 
integrate funding at country level and allocate it to evidence based 
priorities through effective delivery organisations, whether state or 
private. Sector wide approaches try to do this by pooling aid and government 
funding and spending it to an agreed plan.(16) They should be more independent 
of government and more representative-able to drive a big shift to market 
mechanisms that create real incentives to deliver and use the mass media to 
empower poor consumers to influence demand and improve self medication.

A global basket fund is needed to transfer sustainable and predictable 
funding to countries, avoiding the hugely unpredictable aid flows from 
fickle donors that make planning impossible.(17) The Global Fund to Fight 
AIDS, Tuberculosis, and Malaria could abandon disease dedicated support to 
become this fund. Its participation in sector wide approaches would give a 
big boost to rational resource allocation. Improving health systems should 
form the platform for action and research now, transcending HIV and other 
disease-specific programmes.(18)

References
1.Kates J, Morrison JS, Lief E. Global health funding: a glass half full? 
Lancet 2006;368:187-8.[CrossRef][ISI][Medline]
2. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ. Global and regional 
burden of disease and risk factors, 2001: systematic analysis of population 
health data. Lancet 2006;367:1747-57.[CrossRef][ISI][Medline]
3. Danaei G, Lawes CM, Vander Hoorn S, Murray CJ, Ezzati M. Global and regional 
mortality from ischaemic heart disease and stroke attributable to 
higher-than-optimum blood glucose concentrations: comparative risk 
assessment. Lancet 2006;368:1651-9.[CrossRef][Medline]
4. WHO. Estimates of global burden of disease 2001. 
www.who.int/healthinfo/statistics/gbdwhoregiondaly00302001.xlswww.who.int/healthinfo/statistics/gbdwhoregiondaly00302001.xls
5. Organisation for Economic Cooperation and Development. HIV/AIDS Aid 
activities online database. Available from 
http://stats.oecd.org/wbos/ViewPivot.aspx?DatasetCode=CRS±HIVAIDS
6. OECD. Development aid at a glance: statistics by region, 2. 
Africa.www.oecd.org/dataoecd/40/27/7504863.PDF.www.oecd.org/dataoecd/40/27/7504863.PDF
7. Shelton JD, Halperin DT, Wilson D. Has global HIV incidence peaked? Lancet 
2006;367:1120-2.[CrossRef][ISI][Medline]
8. UNAIDS. Report on the global AIDS epidemic 2006. Geneva: UNAIDS, 2006. 
www.unaids.org/en/HIV_data/2006GlobalReport/default.asp
9. United Nations. Resolution adopted by the General Assembly, 60/262 Political 
Declaration on HIV/AIDS. 15 Jun, 2006. 
http://data.unaids.org/pub/Report/2006/20060615_HLM_PoliticalDeclaration_ARES60262_en.pdf
10. Jamison DT, Breman JG, Measham AR, eds. Disease control priorities in 
developing countries. 2nd ed. New York: Oxford University Press, 2006.
11. Laxminarayan R, Mills AJ, Bremen JG, Measham AR, Alleyne G, Claeson M, et 
al. Advancement of global health: key messages from the disease control 
priorities project. Lancet 2006;367:1193-208.[CrossRef][ISI][Medline]
12. Piot P. Why AIDS is exceptional. 
http://data.unaids.org/Media/Speeches02/SP_Piot_LSE_08Feb05_en.pdf
13. Mishra V, Rutstein S, Greener R. Are poor more affected by HIV/AIDS in 
sub-Saharan Africa? [Abstract 29]. HIV/AIDS Implementers Meeting of the 
President's Emergency Plan for AIDS Relief, Durban, South Africa, 2006. 
www.blsmeetings.net/implementhiv2006/orals26-50.htm#49
14. World Bank Operations Evaluation Department. Committing to results: 
improving the effectiveness of HIV/AIDS assistance. World Bank, 2005. 
www.worldbank.org/oed/aids/?intcmp=5221495
15. Jewkes R. Beyond stigma: social responses to HIV in South Africa. Lancet 
2006;368:430-1.[CrossRef][ISI][Medline]
16. HLSP Institute. Effective development assistance: a guide to sector wide 
approaches (CD-ROM). London: HLSP Institute, 2006. CD-ROM available from: 
http://www.hlspinstitute.org/projects/?mode=type&id=115030
17. High Level Forum on the Health Millennium Development Goals. Fiscal space 
and sustainability from the perspective of the health sector, Paris 14-15 
Nov, 2005. www.hlfhealthmdgs.org/Documents/FiscalSpacePerspective.pdf
18. Health Systems Workshop. 
www.healthsystemsworkshop.orgwww.healthsystemsworkshop.org