In the 30 years since AIDS was first identified, science, epidemiology and advocacy have made huge strides. The virus, modes of transmission and spread are well understood and unprecedented resources have been mobilised to fight the disease. However, in 2012, the global response is faltering. It is time to make informed choices on available strategies. In June 2012, we took some important steps towards doing this, as we report.
A review of the history of the epidemic helps understand the challenges. Activities during the first decade centered on understanding the disease and its aetiology; the main interventions were around HIV prevention, both medical and behavioural. Some, where science and public health combined forces, were rolled out rapidly and were extremely successful.
The second decade saw considerable advances in drug treatment, in particular triple anti-retroviral therapy. The result was a medicalization of the disease, particularly in the developed world. The third decade saw massive scale-up of funding for HIV and AIDS combined with a significant decrease in the cost of treatment. The amount of AIDS funding rose from $3 million in 1996, the year UNAIDS was established, to $15.6 billion in 2008. Drug prices dropped from thousands of dollars per treatment course to less than $100 today.
However, apart from a slight increase in 2009, the level of international donor funding fell in 2010 and this trend is likely to continue as the donor community faces the repercussions of a deep fiscal crisis.
The challenges of the fourth decade are new and considerable. They centre on reframing the response in the light of new science, declining resources and changing priorities. Science has delivered innovative and effective biomedical interventions to reduce transmission: medical male circumcision, preventing mother to child transmission, early treatment and, potentially, microbicides and vaccines. These are scientifically-driven responses that can help reduce HIV transmission significantly. But, if there is one thing we have learnt since 1981, it is HIV/AIDS is a messy and complicated disease driven by culturally-specific behaviours with often unpredictable population-level effects.
Treatment is keeping millions alive, but funding from international donors is bound to be static at best and unlikely to sustain the increasing level of people on treatment in the long run. Moreover, the economic climate in donor countries is changing dramatically, as are their health priorities, and it is unlikely that aid budgets will remain untouched as domestic spending, especially on politically-sensitive items such as pension and healthcare benefits, is cut. The burden for funding HIV interventions is therefore likely to transition away from donor countries to affected countries. Decision makers will require sound economic analysis to make the best use of resources.
On 6 and 7 June the RUSH Foundation, a new foundation focused on funding disruptive ideas in the fight against HIV in sub-Saharan Africa, organised a consultative meeting in London to discuss ‘A new economic framework for better HIV decision making in sub-Saharan Africa’ The meeting, which followed the Rush Foundation’s first research and collaboration endeavour, RethinkHIV, was attended by over 30 leading economists, epidemiologists and representatives of civil society. Its main premise was that more efficient allocation of resources is needed, especially in the context of declining international funding. Linked to this is the requirement for stronger mechanisms for effective country ownership. The workshop aimed to develop a collaborative economic research agenda, resulting in a policy framework capable of assisting those charged with allocating resources to HIV investments, especially African ministries of finance.
HIV poses a multi-sector challenge, with both health, humanitarian and economic consequences. In the absence of a vaccine, many countries will be faced with daunting recurrent costs of treatment which will continue well after an ‘AIDS Transition’, a term coined by leading development economist Mead Over to describe the point at which the number of HIV infected people finally begins to decrease due to the number of new infections falling below the number of deaths.
Development assistance is likely to fall but domestic resource mobilisation, perhaps for the first time in decades, may become more buoyant in many African countries, in light of sustained GDP growth and recent resource finds. The choice is stark – treatment means people will live and, therefore, treatment gains more political and moral traction. However, if prevention is neglected, the future cost of treatment entitlements, especially in high-prevalence countries, will become unsustainable, threatening the sovereignty of those countries. The meeting heard that the average cost of treatment per patient per year currently ranges from a low of $136 in Malawi to $682 in South Africa. This is well above the current per capita health expenditure in most sub-Saharan countries and will pose serious developmental and political challenges.
It was clear that economic analysis should feed into national and international decision making processes in order to make resource allocation more effective. Yet, participants heard that, more often than not, the problem is not the lack of economic tools, but their lack of use by national and international donors. Ultimately, we need a better understanding of the obstacles and inducements to smarter prioritisation. Political processes, both national and international, must lead to more efficient resource allocation if they are to generate sustainable and effective responses to the pandemic. Health, diplomacy and economics all need to engage in a new dialogue to work out much-needed ways forward.
Read the article online at Health Diplomacy here.
RethinkHIV is a consortium of senior researchers from London School of Hygiene & Tropical Medicine, Imperial College London, Harvard School of Public Health, Centre for the Study of African Economies and Blavatnik School of Government at Oxford University.
The consortium will evaluate new evidence related to the costs, benefits, effects, fiscal implications, and developmental impacts of HIV interventions in sub-Saharan Africa, in order to maximise contributions to the fight against HIV there.
The aim of RethinkHIV is to find ways of creating, optimising, and sustaining fiscal space for domestic HIV investment, as well as exploring long-term, sustainable national and international financing mechanisms. RethinkHIV is funded by RUSH Foundation.