Professor Alan Whiteside
January 2012
Introduction
This short paper looks forward at the big issues and the events facing those engaged in the HIV and AIDS epidemic in 2012. I have used my perspective to frame the paper: this is writing as an economist, with 25 years’ experience, leading a social science-based research group working in southern Africa which is engaged in global debates and leadership.
The paper is a mixture of a roadmap of upcoming events (chief is the Washington International AIDS Conference (IAC)); and a crystal ball: much is uncertain in the response. We know in most of the world the HIV epidemic is under control: there are specific groups at risk, mostly those who are marginalised. In eastern and southern Africa, AIDS remains the challenge to the wellbeing and existence of some nations. The need to respond to particular epidemics rather than a global, homogenous reaction is problematic. AIDS is exceptional but just not everywhere, and this nuance needs attention.
Funding
A major issue as we enter 2012 is funding. By the end of 2011 it had become clear that international donor funding was declining. This is due to a number of factors: the financial crisis in Western nations; changing priorities - new governments want to make their own mark (particularly the case when there is a change in political party); and a perception that AIDS has been at the top of the agenda long enough and may have been overfunded.
We need money for treatment: many millions of people are being kept alive with antiretroviral drug therapy, in some countries there are simply not domestic resources available if international funding is cut. But prevention must remain a priority: it is only by reducing the number of new infections that the epidemic will be beaten. The UNAIDS Strategic Investment Framework set out the levels of resources that will be required.i What is less clear is where this will come from. It is worth remembering the United States has been the most generous donor to HIV for many decades, but there are growing signals this may not continue – both obliquely from the government and more directly from think tanks.ii
The questions are:
- How much is needed? (UNAIDS provides pointers).
- Where will it come from? We need to look at domestic resources in some countries.
- How will decisions be taken about allocating increasingly scarce resources?iii
- Can services be expanded or are we going to battle just to maintain existing levels?
Prevention
There will not be any technological breakthroughs in 2012. Circumcision campaigns will continue (64% protection for uninfected men), but microbicides seem less feasible than a year ago. Work on vaccines will continue but is unlikely to yield anything in the short term. The International AIDS Society (IAS) is stepping up its ‘Towards an HIV Cure: Global Scientific Strategy’ and this will be on the agenda at the Washington IAC. In the absence of scientific breakthroughs we will have to rely on the slower, more complex social, economic and political interventions. There is evidence these work, but are long term, attributing causality is complex, and they lack appeal for donors. Of great concern to outsiders is the existence of two HIV prevention working groups: one led by UNAIDS and the other championed by the Bill and Melinda Gates Foundation (BMGF). This seems to be unnecessary duplication and a distraction.
There is a growing need to understand the epidemic in terms of gender relations; underlying cultural norms; economic status especially issues of equality; and political leadership. All of these are potentially fuzzy concepts and difficult to deal with but this is where the smart money is needed, (and it will not be a huge amount).
Health Systems
In the past 18 months issues of Health Systems (HS) have become an international priority. In order to deliver services, be they prevention or therapy there is a need for reasonable, working health services. This is especially the case as international donors reduce funding and move away from vertical programmes. Much work needs to be done in this area. There is an event we can work towards: The Second Global Symposium on Health Systems Research in October 2012 in Beijing. The theme is Inclusion and Innovation Towards Universal Health Coverage see www.hsr-symposium.org This is not an HIV/AIDS meeting. The only bilateral organisation on the Executive Committee is the UK Department for International Development. The steering committee has better representation. The need in HS is to understand what is happening in a country and develop realistic, effective and efficient interventions.
Global Health Governance
There are concerns with regard to health governance generally. The World Health Organisation is still struggling to identify its comparative advantage in a crowded environment, and without significant resources. Of anxiety are the number of new initiatives developing and being housed in the organisation, each with their champions. The strategy for AIDS activists is to get the epidemic considered in each of these agendas.
UNAIDS is undergoing reorganisation and this always creates uncertainty – here a supportive and watching brief is critical. A great concern is the role of the Bill and Melinda Gates Foundation (BMGF). They are seen as so important and with such great resources that few are prepared to challenge their role and actions (speak truth to power). The 2011 appointment of Trevor Mundel, as President of the Global Health Program, and the imminent arrival of Christopher Elias from PATH as the new President of Global Development should lead to new thinking and strategies.
The apparent meltdown in the Global Fund (GF) for AIDS, TB and Malaria is a major worry. The cancellation of Round 11 and conflict between the Executive Director and Board at the end of 2011 remains unresolved. The proposed appointment of a general manager is a ‘band aid’ solution for a festering problem. There is a perception that some want to see the GF fail.
All the US agencies are facing cuts and an uncertain role – this is why the IAC is so critical. Central will be to give the US credit for what they have done, and understand the constraints and the political landscape. The champions in the USA need support and activism needs to be tempered.
One new initiative that feeds across many areas, the proposed ‘Multi-stakeholder Consultation on National AIDS Programmes Effectiveness, Efficiency and Sustainability’, at present is scheduled for 19 -20 March in Nairobi. This will look at the importance of achieving greater efficiency and effectiveness of HIV programmes. The starting point is all donors, most national governments in affected countries and other stakeholders have the efficiency and effectiveness (E2), and sustainability of HIV programmes at the top of their agendas. This will bring in work done by IAS in Uganda. The concern is people engage and see it as important, which has not been the case.
The Washington DC International AIDS Conference
This meeting, being held from 22- 27 July, with the theme of Turning the Tide Together, is going to be critical: one of the seminal conferences in the history of the epidemic.iv In addition to the main meeting there will numerous pre-conference meetings and side events. This is most important for UNAIDS who will need to show strong leadership and produce a good global HIV report. It is the chance to show relevance and define the response for the next decade.
Treatment as Prevention
This will continue to generate a great deal of heat. The HPTN-052 study showed when a person is on treatment there is a 96% reduction in HIV transmission from an HIV-infected person to his/her sexual partner. This is seen as an argument for universal early treatment. I will not go into this further here other than to note it needs to be addressed and that the debate is happening at the global level. The question of what this means at country level for national governments in high prevalence countries is ignored. The reality in the poorer countries is national governments do what they can with what they have, (and expect donors will continue to fund existing streams of treatment, even if they are not expanded). This needs to be assessed as a matter of urgency. A key message from Dr Bertozzi of the BMGF is that we have to make choices. He suggests: “the well of treatment is infinitely deep” and if we continue drawing from it then we will have to decide which prevention activities we are going to stop.
Conclusion
In 2011 there were a number of meetings to mark the 30th anniversary of the identification of the AIDS epidemic. It was a time of reflections and retrospection. This year will see the community pause and reinvigorate the response. The next major event on the global development calendar will be the 2015 Millennium Development Goals. These will show how devastating AIDS has been in some settings – not just slowing but reversing certain development indicators. It should be on the agenda for the Washington conference and beyond. The one thing I would like to see are pilot and trial programmes being taken to scale across nations.
Major Meetings for HEARD in 2012
March 5- 8: 19th Conference on Retroviruses and Opportunistic Infections (CROI), Seattle: a scientifically focused meeting of researchers working to understand, prevent and treat HIV/AIDS and its complications. About 4000 people and very scientific.
March 19- 20: Multi-stakeholder Consultation on National AIDS Programmes Effectiveness, Efficiency and Sustainability’, Nairobi: Partners include IAS, World Bank, PEPFAR, and UNAIDS. This is still being planned and will be a small meeting.
July 21 – 22: International AIDS Economics Network Pre-Conference Meeting, Washington DC: small but fun for economists.
July 22 – 27: XIX International AIDS Conference, Washington DC: the big event in the global AIDS calendar with many pre-meetings and side meetings.
October 31 - November 3: The Second Global Symposium on Health Systems Research, Beijing:, don’t know much about it.
[i] Schwartländer et al, Towards an improved investment approach for an effective response to HIV/AIDS, The Lancet - 11 June 2011 ( Vol. 377, Issue 9782, Pages 2031-2041 )
[ii] See the speech by President Obama on World AIDS Day, and his commitment to put six million on treatment (up from 4 million) but no new money. The Centre for Strategic and International Studies December 2011 report How to Achieve a Successful PEPFAR Transition in South Africa is a harbinger of policy thinking. Reviewing this and other think tanks (Centre for Global Development) could provide a bellwether for trends.
[iii] See the innovative RethinkHIV for cost benefit analysis www.rethinkhiv.com
[iv] See the briefing document I prepared in November 2011, To Washington in 2012 and Beyond: Strategic Issues for the Global HIV and AIDS Response.
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