Are we spending too much on HIV?

[Guest guest]

Are we spending too much on HIV?

England, Health Systems Workshop, Grenada, West Indies

roger.england@...

BMJ 2007;334:344 (17 February), doi:10.1136/bmj.39113.402361.94

Billions of pounds are being spent on the fight against AIDS in

developing countries. England believes that much of the money

could be better used elsewhere, whereas 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 ation 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; 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.

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