Despite remarkable achievements and a wave of recent optimism, the stark truth is that the end of Aids is not in sight.
Nearly 50 per cent of eligible Africans do not receive life-saving antiretroviral drugs, and achieving universal access to HIV prevention and treatment over the next decade will cost $200bn, according to UNAids estimates – requiring $24bn in 2015 alone, $8bn more than was spent globally last year.
Resources for treatment today remain woefully inadequate compared to the numbers of those in need, with the cost of fighting HIV over the next two decades in the worst-hit countries such as Swaziland and Uganda expected to be three-times higher than annual national
Developing countries remain reliant on short-term pledges from foreign donors in order to fund the lifetime entitlements of those now on antiretroviral drugs. But the economic slowdown has caused external funding to flatline. The ability of many countries to deliver suitable HIV treatment and prevention programmes is also hindered by financial and structural barriers. Achieving universal access to treatment for the 23.5m Africans living with HIV will require many more physicians and nurses than are currently available – against a backdrop of a crisis in the provision of health workers.
Poverty, stigma, gender inequality, and repressive laws continue to worsen the HIV epidemic and stop too many people from receiving vital health services.
A reinvigorated approach is required to finance the HIV response. Funding needs to become more predictable, aligned to national priorities, and nationally ‘owned’, rather than remaining the province of foreign donors. A decade of sustained growth and rising tax revenues in parts of sub-Saharan Africa is beginning to create some new opportunities in increased co-financing of the HIV response.
We know more today than we ever have about the epidemic and how to fight it. Life-saving antiretroviral drugs have lengthened and improved millions of lives. Recent evidence shows that antiretroviral treatment should also be seen as a prevention tool, as it can reduce the likelihood of sexual transmission. In addition to condom distribution, male circumcision has been added to the HIV prevention arsenal.
However, to continue to attract external funding in a crowded field of competing priorities, HIV programmes will need to provide greater evidence of sustainability, efficiency, and of value for money. Low costs alone cannot be the aim; it may cost more to ensure that HIV services reach the most at-risk, who often have limited access to health services.
Opportunities exist to reorient the HIV response to prioritise investments that have multiple benefits. Some HIV investments generate wider health benefits, for instance improvement in sexual and reproductive health, or maternal and child health. Similarly, programmes that improve livelihood opportunities or keep young girls in school may yield HIV as well as development gains.
When earmarked funds create a “silo” mentality, HIV programmes miss out on these potential synergies with other health and development sectors. Given the multiple demands on international and domestic finances, it is critical not to do so.
Spending decisions must also reflect that Aids today is not one epidemic, but many, with variations not just from country to country, but also between communities and socioeconomic groups. Catch-all programmes have resulted in inefficiencies, and have seen some highly vulnerable groups miss out. In ‘lower prevalence’ African countries, only 7 per cent of the total HIV budget is spent on services targeting the most-at-risk populations, although the bulk of new infections are among these groups.
Adjusting to these new realities will require a concerted global effort. Finance ministries in the most affected African countries will increasingly be at the front-line of the fight against HIV and they will need the economic, epidemiological and developmental evidence that reflects their national contexts to guide and adjust their priorities.
Developing and sharing that evidence is the goal of a new research programme being conducted by the London School of Hygiene and Tropical Medicine with the Centre for the Study of African Economies, University of Oxford, and Imperial College, London, among other institutions, funded by the Rush Foundation.
Read the article online at the FT 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.