The writing is on the wall for UNAIDS

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BMJ 2008;336:1072 (10 May), doi:10.1136/bmj.39569.497708.94

Views & Reviews The writing is on the wall for UNAIDS

* England*, *chairman, Health Systems Workshop, Grenada*

roger.england@...

The creation of UNAIDS, the joint United Nations programme on HIV and AIDS, was

justified by the proposition that HIV is exceptional. The foundations of

exceptionalism were laid when the " rights " arguments of gay men succeeded in

making HIV a special case that demanded confidentiality and informed consent and

discouraged routine testing and tracing of contacts, contrary to proved

experience in public health.1

<http://www.bmj.com/cgi/content/full/336/7652/1072#REF1>But

exceptionalism grew—to encompass HIV as a disease of poverty, a developmental

catastrophe, and an emergency demanding special measures, requiring

multisectoral interventions beyond the

leadership of the World Health Organization.

The exceptionality argument was used to raise international political

commitment and large sums of money for the fight against HIV from, among others,

the World Bank, through its multi-country AIDS programme, the Global Fund to

Fight AIDS, Tuberculosis and Malaria, and the US Presidents' Emergency Plan for

AIDS Relief. With its own UN agency, HIV has been treated like an economic

sector rather than a disease.

The proposition of exceptionality is now under stress. The poverty argument has

been exposed as baseless. The country surveys carried out by Measure DHS

(Demographic and Health Surveys) of, for example, Ethiopia, Kenya, and Tanzania

show that prevalence is highest among the middle classes and more educated

people.2

<http://www.bmj.com/cgi/content/full/336/7652/1072#REF2> Although

HIV can tip households into poverty and constrain national development, so can

all serious diseases and disasters. HIV is a major disease in southern Africa,

but it is not a global catastrophe, and language from a top UNAIDS official that

describes it as " one of the make-or-break forces of this century " and a

" potential threat to the survival and well-being of people worldwide " is

sensationalist.3

<http://www.bmj.com/cgi/content/full/336/7652/1072#REF3>Worldwide the

number of deaths from HIV each year is about the same as that among children

aged under 5 years in India.

Similarly, multisectoral programmes were misguided and have got nowhere slowly

and expensively. Some small projects of non-governmental organisations (NGOs)

have successfully integrated sectoral efforts, but government ministries such as

agriculture and education have not succeeded in the HIV roles imposed on them.

Vast sums have been wasted through national commissions and in funding esoteric

disciplines and

projects4<http://www.bmj.com/cgi/content/full/336/7652/1072#REF4>instead of

beefing up public health capacity that could have controlled

transmission.5<http://www.bmj.com/cgi/content/full/336/7652/1072#REF5>Only 10%

of the $9 billion (£4.5 billion; [image: {euro}]5.8 billion) a year dedicated to

fighting HIV is needed for the free treatment programme for the two million

people taking those treatments. Much of the rest funds ineffective activities

outside the health sector.

These fractures in the structure of exceptionalism are now obvious.

Less obvious is the possibility that it is exceptionalism, not rural Africans,

that drives stigma and

discrimination.6<http://www.bmj.com/cgi/content/full/336/7652/1072#REF6>Managers

of Médecins Sans Frontières's pioneering treatment project in South Africa

fretted about what to call the centres providing the treatment, fearing that

stigma would deter clients, so they called them infectious disease clinics.

Patients had no such inhibitions, however, and within days were queuing to get

into the " AIDS clinic. " 7

<http://www.bmj.com/cgi/content/full/336/7652/1072#REF7>But relentless

promotion of HIV as different can only have reinforced stigma, the equivalent of

a public health " own goal. "

It is no longer heresy to point out that far too much is spent on HIV

relative to other needs and that this is damaging health

systems.8<http://www.bmj.com/cgi/content/full/336/7652/1072#REF8>

9 <http://www.bmj.com/cgi/content/full/336/7652/1072#REF9>

10<http://www.bmj.com/cgi/content/full/336/7652/1072#REF10>

11 <http://www.bmj.com/cgi/content/full/336/7652/1072#REF11> Although HIV causes

3.7% of mortality, it receives 25% of international healthcare aid and a big

chunk of domestic expenditure. HIV aid often exceeds total domestic health

budgets themselves, including their HIV spending. It has created parallel

financing, employment, and organisational structures, weakening national health

systems at a crucial time and sidelining needed structural

reform.12<http://www.bmj.com/cgi/content/full/336/7652/1072#REF12>

13 <http://www.bmj.com/cgi/content/full/336/7652/1072#REF13> Massive

off-budget funding dedicated to HIV provides no incentives for countries to

create sustainable systems, entrenches bad planning and budgeting practices,

undermines sensible reforms such as sector-wide approaches and basket funding

(where different donors contribute funds to a central " basket, " from which a

separate body distributes money to various projects), achieves poor value for

money, and increases dependency on aid.

Yet UNAIDS is calling for huge increases: from $9 billion today to $42 billion

by 2010 and $54 billion by 2015.

UNAIDS is out of touch with reality, and its single issue advocacy

is harming health systems and diverting resources from more effective

interventions against other diseases.

Steadily, the demand is increasing for better healthcare systems, not

funding for HIV. Mozambique's health minister stated: " The reality in many

countries is that funds are not needed specifically for AIDS, tuberculosis, or

malaria. Funds are firstly and mostly needed to strengthen national health

systems so that a range of diseases and health conditions can be managed

effectively. " 14<http://www.bmj.com/cgi/content/full/336/7652/1072#REF14>

Guyana's national health sector strategy notes the need " to convince our

development partners (who support us with external aid) that some of the money

they provide us with should no longer be earmarked for their favourite diseases,

mainly HIV, but must be spent to improve our general health services so that we

can handle all diseases better and according to our actual disease

priorities. " 15 <http://www.bmj.com/cgi/content/full/336/7652/1072#REF15>

HIV exceptionalism is dead—and the writing is on the wall for UNAIDS. Why a UN

agency for HIV and not for pneumonia or diabetes, which both kill more people?

UNAIDS is scurrying to reposition itself in the face of these realities and will

no doubt soon join the Global Alliance for Vaccines and Immunisation (GAVI) and

the Global Fund in claiming expertise in how to strengthen health systems.

But continuation of a dedicated HIV organisation can only distort healthcare

financing and delivery systems. UNAIDS should be closed down rapidly, not

because it has performed badly given its mandate,

which it has not, but because its mandate is wrong and harmful. Its

technical functions should be refitted into WHO, to be balanced with those for

other diseases.

Putting HIV in its place among other priorities will be resisted strongly.

The global HIV industry is too big and out of control. We have created a monster

with too many vested interests and reputations at stake, too many single issue

NGOs (in Mozambique, 100 NGOs are devoted to HIV for every one concerned with

maternal and child

health),14<http://www.bmj.com/cgi/content/full/336/7652/1072#REF14>too

many relatively well paid HIV staff in affected countries, and too many rock

stars with AIDS support as a fashion accessory. But until we do put HIV in its

place, countries will not get the delivery systems they need, and switching $10

billion from HIV to support

general health budgets would make a big difference—roughly doubling health

workers' salaries in the whole of sub-Saharan Africa, for example (or trebling

them, if you don't include South Africa).

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Source: http://www.bmj.com/cgi/content/full/336/7652/1072