For anyone concerned about a pullback in funding for global AIDS programs, this commentary in The Lancet Infectious Diseases is a must read. It addresses the apparent wavering commitment of donor countries amid the economic downturn and touches on the unfolding debate about the merits of disease-specific initiatives, such as PEPFAR, versus efforts to efforts to strengthen health systems. Here’s what the editorial has to say on that point:
“Although programmes that focus on single diseases are under increasing criticism as being too narrow in focus to bring about sustainable changes to health, efforts funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, and the US President’s Emergency Plan for AIDS Relief have not only enabled countries to start tackling their HIV/AIDS problems over the past 9 years, but also helped to strengthen health systems generally. These initiatives also have the potential to help tackle the problems of malnutrition and gender and social inequality.”
Here’s the whole piece:
The World AIDS Conference in Durban, South Africa, in 2000 was a watershed moment in the global response to the HIV/AIDS crisis. At the time, the virus raged largely unchecked in sub-Saharan Africa and was spreading with alarming speed throughout Asia. The holding of the conference in South Africa put political and health policy makers at the door of the most affected areas—signalling that a united effort from all nations was needed to tackle the pandemic. 9 years on, the fifth International AIDS Society Conference on Pathogenesis, Treatment and Prevention, the society’s scientific conference, was held in Cape Town (July 19—22). The return of the an international AIDS meeting to South Africa, which still has one of the highest burdens of disease, gives pause to reflect on developments in the past 9 years.
The scientific highlights of the conference, outlined further in the Newsdesk by Nathan Ford, included improvements to treatment regimens, the benefits of starting therapy earlier, possibilities of using antiretroviral therapy in disease prevention, and insights from operational research.
The Cape Town meeting drew attention to the effects of AIDS prevention programmes on tuberculosis, malaria, sexually transmitted infections, and other health problems. Although programmes that focus on single diseases are under increasing criticism as being too narrow in focus to bring about sustainable changes to health, efforts funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, and the US President’s Emergency Plan for AIDS Relief have not only enabled countries to start tackling their HIV/AIDS problems over the past 9 years, but also helped to strengthen health systems generally. These initiatives also have the potential to help tackle the problems of malnutrition and gender and social inequality.
Despite all the progress and the messages of success and hope, the past 9 years are also marked by missed opportunities, unfulfilled promises, and worries for the future. By the end of 2005, 1·3 million people were receiving antiretrovirals, a far cry from the 3 million aim of WHO’s 3 by 5 programme. And as 2010, the deadline for Universal Access, approaches, this effort looks set to fall short with an estimated 3 million receiving treatment but 7 million still wanting. As these optimistic targets are missed, health organisations and political leaders risk damaging the trust of the people to whom the promises have been made. Activists in Cape Town were keen to highlight the inequality of drug access, with people in poorer countries struggling even to obtain treatment with drugs viewed as outdated elsewhere, and any talk of earlier treatment is something of a moot point for 70% of people with HIV/AIDS in sub-Saharan Africa.
The achievements so far have been dependent on unprecedented growth in donations for health. Spending on HIV/AIDS programmes has increased nearly 40 times in the past decade, with US$10 billion being spent worldwide in 2007. Annual requests submitted to the Global Fund leapt from between $500 million and $1 billion up to 2007 to $2·75 billion in 2008, and even larger requests are expected in 2009 for 2010. But in the face of the global economic downturn, the donations to the Global Fund might be left wanting to the tune of $3 billion. To continue to expand prevention and treatment for HIV/AIDS, as we must, the global community will need to find innovative solutions that do more with less, are more efficient, build on past advances and experience, and marshall the grass-roots resources of the communities most affected.
As we look ahead through a period of financial uncertainty, we must not despair. More people are receiving better treatment than ever before, and HIV/AIDS programmes have had far reaching effects well beyond the borders of the disease they were designed to tackle. Although many people understand that the targets set are usually goals to inspire politicians and health-care workers rather than realistic aims, not everyone is so disingenuous. As we consider new approaches to adapt to reduced funding, we must remember that the targets we set give expectations to a vast number of people for whom 3 by 5 meant 3 million people on treatment by 2005, and for whom Universal Access meant 100% by 2010. To adapt to the changing climate and devise new approaches that eventually meet unmet targets of the past and any future goals that are set, we will need to engage the many people who live in desperate need because of past failures. With each unmet target, we risk damaging the trust of the people we set out to help, we must remember this and protect that trust—in the coming years we will need it.