The right way forward for global HIV/AIDS response?

Almost thirty years exactly after the first official AIDS diagnosis on 1st June 1981, and 10 years since the landmark UN General Assembly Special Session on HIV/AIDS, member countries meet once again to review the global response to HIV AIDS at the UN General Assembly High-Level Meeting on HIV/ AIDS from 8–10 June in New York. Before the national representatives will be a declaration, formulated by UNAIDS (the Joint United Nations Programme on HIV/AIDS). Known as the “zero draft” (zero infections, zero discriminations, zero Aids related deaths), the declaration is publicly available (see below) and has already been widely discussed by member countries. The scale-up of provision envisaged by the declaration has serious cost implications, as well as implications in the realm of intellectual property rights (TRIPS) where these affect pharmaceutical products. Elements of the declaration are known to be strongly resisted by some developed countries. The recently published (2nd June) UNAIDS report AIDS at 30: Nations at the Crossroads (p.105) places a figure on the proposed scale-up of $22-23bn by 2015, as compared with the current $16bn – in other words a global increase of about a third in order to “decisively alter the course of the epidemic in the next decade”. The message coming out of the UNAIDS Report (published a week in advance of the conference) is that the world would be well advised to commit to the financial implications of placing global resourcing on a more rational and sustainable footing. The necessary up-scaling of global and national efforts is a rational investment and will pay off in the middle- to long-term.
Simultaneously with the UNAIDS report there appeared a health policy paper in the Lancet, Towards an improved investment approach for an effective response to HIV/AIDS. The latter is authored by Bernhard Schwartlaender (principal author) of UNAIDS and other researchers from UNAIDS and a wide range of other organizations “on behalf of the Investment Framework Study Group”. Irritatingly for the general medical reader, its natural constituency, the Lancet paper gives no account of the history of this group and fails to make, within the context of the paper itself, any explicit link to UNAIDS or other international organizations. (How, after all, are we to read a “health policy” paper without situating it in the context of contemporary “health policy” developments?) However, the UNAIDS Report (p.105) appears to refer to the framework proposed in the Lancet paper as “a 2011 investment framework proposed by UNAIDS and its partners”.

Towards an improved investment approach for an effective response to HIV/AIDS
The paper points to the shortcomings of the “prevailing commodity approach” which targets discrete interventions rather than overall results. It proposes to replace it with an “investment framework” incorporating a range of social as well as medical interventions synergizing with general development objectives. The first section of the paper describes the investment framework. The second examines the resource implications as these emerge from a modelling exercise based on the investment framework, estimating resource needs and returns on investment for 139 low- and middle-income countries.
The investment framework is characterized by a concern to give due weight to the social and behavioural aspect of programme activities – e.g. behavioural change especially in connection with “key populations” (e.g. men who have sex with men and intravenous drug users) and community approaches in support of HIV testing and ART adherence. In addition, the model factors in complementary strategies (“critical enablers”) – both in the area of wider social policies conducive to “rational HIV/AIDS responses”, such as stigma reduction and human rights advocacy, and in the more health specific area of incentives for programme participation or methods to improve ART adherence. Thirdly, the model factors in synergies with other development goals, such as the potential of HIV funding to act as a catalyst for the promotion of rational investment across various sectors.
Running the model based on this investment framework gives the figure of $22bn at which the authors predict resource needs will peak in 2015. Thereafter, these needs are expected to decline for three reasons: target rates for interventions will have been reached; efficiency gains will be achieved; and new infections will begin to decrease resulting in decreased need for services. The model puts figures on expenditure not only in the area of basic programme activities, but also in the area of critical enablers, and even development synergies. A case is made for the proposed framework in terms of return on the investment: the $46.5bn invested over the period 2011 – 2020 will, according to the authors, be offset by savings incurred from avoidance to treatment costs estimated at a conservative cost of $40bn.

AIDS at 30: Nations at the Crossroads.
Aspects of the proposed up-scaling of the global response, as set out in Chapter 3 of the Report, are in line with the approach already discussed in relation to the investment framework, and build, of course, on existing UNAIDS policies (see below: UNAIDS Strategy:2012-2015:Getting to Zero). In relation to resource implications, the Report actually refers to the investment framework (p.105) and the projections for resource needs given in the Lancet paper. The Report’s articulation of these issues could have been better organized. But the general tenor of what is proposed is captured in the slogan “sustainable outcomes”. The aspect of sustainability reflects the need for an upscale of global funding, and an increased domestic investment on the part of “high-burden” countries, consonant with their ownership of the programmes. (If current domestic investment by countries were in proportion to the disease burden and size of their health budgets, the Report tells us, investment in sub-Saharan Africa would be double what it is). The aspect of outcomes suggests a shift from an “outputs”- dominated mentality. It reflects the aspiration to a more holistic approach and “smarter metrics” which evaluate the true effectiveness of interventions, leading to investment of resources where they will bring most benefit. Ownership of programmes, their integration within the wider context of health and social policy and synergy with related development goals are consistently emphasised.
Chapters 1 and 2 of the Report offer an overview of the past decade. They chart the success of countries in meeting those targets, recording the gains in treatment access, and the reduction of vertical transmission, as well as difficulties encountered in such areas as reducing HIV stigmatization, targeting interventions at “key populations”, and communicating the safe-sex message to those at risk. Chapter 1 offers a global survey; chapter 2 provides a break-down by region (Africa; Asia and the Pacific; Eastern Europe and Central Asia; Latin American; the Caribbean; the Middle East and North Africa). Chapter 4 provides “score-cards” for individual countries in regard to: HIV incidence; ARVs to prevent new child infections; ART coverage; HIV progress indicators.

Bernhard Schwartlaeder et al., “Towards an improved investment approach for an effective response to HIV/AIDS”, The Lancet, published online, 3rd June 2011

AIDS at 30: Nations at the Crossroads, Joint United Nations Programme on HIV/AIDS, June 2011

Zero Draft, 28th April 2011

Complete HLM HIV/AIDS Zero Draft Compilation 19th May 2011 10:00pm

Getting to Zero: Strategy 2010-2015: Joint United Nations Policy on HIV/AIDS, 2010

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