среда, 14 мая 2008 г.

wallwriting

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

The writing is on the wall for UNAIDS

Roger England, chairman, Health Systems Workshop, Grenada

roger.england@healthsystemsworkshop.org

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 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 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 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 instead of beefing up public health capacity that could have controlled transmission.5 Only 10% of the $9 billion (£4.5 billion; {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 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 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 9 10 11 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 13 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 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

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 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).

References

  1. De Cock KM, Abori-Ngacha D, Marum E. Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century. Lancet 2002;360:67-72.[CrossRef][ISI][Medline]
  2. Demographic and Health Surveys. www.measuredhs.com/start.cfm.
  3. Piot P. "Why AIDS is exceptional" (speech given at the London School of Economics, London, 8 Feb 2005). http://data.unaids.org/Media/Speeches02/SP_Piot_LSE_08Feb05_en.pdf.
  4. World Bank Operations Evaluation Department. Committing to results: improving the effectiveness of HIV/AIDS assistance. www.worldbank.org/oed/aids/?intcmp=5221495.
  5. England R. Coordinating HIV control efforts: what to do with the national AIDS commissions. Lancet 2006;367:1786-9.[CrossRef][ISI][Medline]
  6. Jewkes R. Beyond stigma: social responses to HIV in South Africa. Lancet 2006;368:430-1.[CrossRef][ISI][Medline]
  7. Kasper T, Coetzee D, Louis F, Boulle A, Hilderbrand K. Demystifying antiretroviral therapy in resource-poor settings. Essential Drugs Monitor 2003;32:20-1.
  8. Halperin D. Putting a plague in perspective. New York Times 2008 Jan 1. www.nytimes.com.
  9. England R. Are we spending too much on HIV? BMJ 2007;334:344.[Free Full Text]
  10. England R. We are spending too much on AIDS. Financial Times, 2006 Aug 14. www.ft.com.
  11. Foster M, Gottret P. Scaling up to achieve the health MDGs in Rwanda: a background study for the high-level forum meeting in Tunis 12-13 June 2006. www.hlfhealthmdgs.org/Documents/June2006ScalingUptoAchievetheHealthMDGsinRwanda.pdf
  12. England R. The dangers of disease specific programmes for developing countries. BMJ 2007;335:565.[Free Full Text]
  13. Health Systems 20/20. Systemwide effects of the Global Fund: evidence from three country studies. Bethesda, MD: Health Systems 20/20, 2007.
  14. Garrido PI. Women’s health and political will. Lancet 2007;370:1288-9.[CrossRef][ISI][Medline]
  15. Ministry of Health of Guyana, National health sector strategy 2008-12. Georgetown, Guyana: Ministry of Health, 2008.

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Rapid Responses:

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AIDS remains an exceptional issue
Paul De Lay
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Do not undermine the international response to HIV
Mark Harrington
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Misreading the Writing on the Wall
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Otwoma Tom Otwoma
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Prevailing stigma demands continued leadership from UNAIDS
Christo Greyling
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Roger England was clearly right about one thing
David Rasnick
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Response to AIDS and Strengthening of Health Infrastructure are not mutually exclusive
Lesley-Anne Knight
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Fighting Aids is not in opposition to strenghening health systems
Mariangela Simao
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England needs nuance
Alan W Whiteside
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