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Are we spending too much on HIV?
  Head to head: pro and con commentaries below
BMJ 2007;334:344 (17 February)
Roger England
Health Systems Workshop, Grenada, West Indies
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; {euro}185) 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.1011 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 poor13 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
Competing interests: None declared.
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
Correspondence to: P de Lay
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; {euro}7bn) 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.
Competing interests: None declared.
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