Mit Philips on the ICASA conference: donor retreat and its consequences for patients and communities

The 2011 International Conference on HIV/AIDS and Sexually Transmitted Infections in Africa (ICASA) conference in Addis Ababa was an experience in contradictions. Presentations about promising new strategies created by scientific breakthroughs, and successful field experiences, even in some of Africa’s most disadvantaged communities, contrasted with growing fears that this optimism rests on empty promises and that most patients still desperately waiting for ARV treatment will remain excluded. 

The conference started with a tribute to George W Bush, creator of PEPFAR (US President’s Emergency Plan for AIDS Relief). The fight against HIV/AIDS clearly created a bond between Africa and the US—and the international community in general. But considering all the praise for Bush and PEPFAR, it was surprising to see so little protest against the current international funding crisis, and to hear repeatedly that African governments must mobilize the necessary resources in-country.

Against the backdrop of the Global Fund to fight AIDS, TB, and malaria (GFATM) board’s decision in November to delay new funding opportunities (and therefore new or expanded programs) until 2014, the “own, scale up and sustain” conference theme was confusing. The HIV/AIDS emergency in Africa is far from over—who really thinks it can be ended with domestic funds alone?

Misguided reliance on domestic resources for Africa?
I stand in solidarity with African health staff and patients who pressure their governments to increase funding for AIDS care. I too would like to see DRC President Kabila allocate more than 0.3% of his country’s budget to HIV care, since 85% of HIV positive people in DRC are still waiting to start life saving treatment. I support the 2001 Abuja Declaration, in which African leaders promised to commit at least 15% of their national budget to health. But this commendable long-term objective will (at best) only be achieved gradually.

Even where political will is strong, African domestic funds cannot meet all needs, especially in high burden/low income countries. Malawi spends 14% of its budget on health—but the total budget is small and the disease burden is high, so domestic spending covers only 1% of HIV costs. The global economic crisis is also taking a toll: for example, Lesotho, which took over responsibility for ARV drug purchasing, anticipates an HIV budget shortfall of $250 million in 2014. The bottom line is that African budgets cannot compensate for lost international funds; rather, these cutbacks will create even bigger funding gaps—at a time when any newly mobilized African resources should fund scale-up, not plug holes left by donors.

Also missing from the discussion: what if some African governments fail to prioritize health or HIV care? Their populations cannot simply be abandoned by the international community.

Too polite about funding crisis

Discussion of the funding crisis—attributed mostly to the economic problems of wealthy countries—seemed strangely muted at times. One exception was Stephen Lewis, whose sharp analysis did not mince words.  “It’s not a matter of the financial crisis, it’s a matter of human priorities,” and the cruel consequences that cancelling the next GFATM funding round will have for hundreds of thousands of people.

Unfortunately the GFATM itself seemed reluctant to admit that something is terribly wrong. The GFATM remains the best chance for millions of people awaiting treatment and a critical instrument for reaching the target of 15 million people on treatment by 2015  (half expected through GFATM funding). The world needs a strong, active GFATM supporting scale-up, not one stuck on hold, unable to expand its reach (or its results) until 2014. Paralyzing it now is a huge blow to the fight against HIV/AIDS just as science is delivering proven interventions that point the way towards ending the epidemic.  MSF is therefore calling on the GFATM board to hold an emergency donor conference aimed at raising resources for a new funding window by mid 2012.
Patients paying for funding crisis
At ICASA, MSF presented data on how funding constraints block several countries from applying WHO standards of care. Some patients are kept on drugs no longer used in the West because of their side effects, or treatment is delayed until patients become very ill and need more complicated and costly care. We also documented what ARV rationing looks like (e.g., in DRC) for health workers: dealing with complications rarely seen since the availability of ARVs, and losing patients because AIDS is too far advanced by the time they start treatment. I had conversations with caregivers who spoke of treatment having to be postponed until another patient dies. This is how living with HIV/AIDS in 2012 might look for a growing number of Africans:  a lifeline that comes only through someone else’s tragedy.

Mit Philips is MSF’s health policy and medical advocacy advisor. Her focus is on HIV/AIDS, financial barriers to healthcare, the crisis in human resources for health, and health systems policies.