Investing wisely in HIV/AIDS

The Lancet Infectious Diseases

Ahead of World AIDS Day on Dec 1, 2011, WHO, UNICEF, and UNAIDS launched the Global HIV/AIDS Response 2011 progress report on Nov 30. The report is the fifth such annual report published since 2006. As John Zarocostas reports in this month's Newsdesk, the latest edition contains much good news on treatment and prevention, but the gains made by past efforts are jeapardised by the ongoing global financial crisis and dwindling funds.

The number of people receiving antiretroviral therapy (ART) is increasing, with over 6·65 million patients in middle-income and low-income countries receiving treatment at the end of 2010. In the same year, nearly a half of pregnant women living with the HIV received prophylaxis to prevent mother-to-child transmission of HIV. Being on treatment has an impact on prevention as well. In sub-Saharan Africa, clinical trials have shown that if an HIV-positive person receives ART the risk of transmitting the virus to a partner is cut by 96%. Increased access to HIV-care services resulted in a reduction of new infections from 3·1 million in 2001 to 2·7 million in 2010, and a 22% decline in AIDS-related deaths in the past 5 years.

Despite the promising data contained in the report, funding for HIV/AIDS care is a concern. At their meeting on Nov 21—22 in Accra, Ghana, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria decided to cut its present round of funding and to postpone funding for new projects until at least 2014. The move was prompted by a lack of financial support from donors and has caused dismay around the world. The Global Fund has established a transitional funding mechanism to provide emergency relief to current recipients who will run out of money before 2014. However, this will not allow countries to scale up their interventions to improve HIV care. Reduced funding will mean less support for HIV/AIDS support programmes and put at risk the goal of universal access to treatment by 2015.

At the end of 2010, the total amount of money made available by both International agencies and domestic funding bodies for HIV was US$15 billion. But international assistance for HIV care declined from $8·7 billion in 2009 to $7·6 billion in 2010. Economic uncertainty threatens the future of people who still do not have access to treatment, many of whom do not even know that they are infected with HIV. Social and political marginalisation of certain groups means that programmes to reach them might be most at risk in the face of funding cuts, but in many cases these groups are now the stronghold of the epidemic and key in the fight against it. Particularly vulnerable groups include adolescent girls, people who inject drugs, men who have sex with men, transgender people, sex workers, prisoners, and migrants. For example, in eastern Europe ART coverage is low at 23%, and the most affected people—those who inject drugs—are most likely to be unable to access care.

The amount of money invested in the AIDS response from donor countries has fallen by 10% in 2010. Therefore, all countries must figure out how best to provide intervention with decreasing available funds. UNAIDS has recently established an investment framework with the intention to better manage national and international responses to HIV. The aim is to show that money sensibly invested and well spent can have a huge effect by reducing new infections and keeping people alive. This framework can be used by countries to refine current national programmes. Countries such as Brazil and Cambodia have looked at their own budgets and revised their current programmes. Other countries are encouraged to use the investment framework to revise their national efforts. Even with the optimisation approach suggested by the framework, investments needed to achieve and maintain universal accesss to ART would continue to rise, peaking at $22—24 billion in 2015, but this investment would avert 12·2 million new HIV infections, including 1·9 million infections among children, and 7·4 million AIDS-related deaths between 2011 and 2020.

The 2011 HIV/AIDS report shows successes in the HIV response. But after years of international investment, just when we seem to have the right technologies, drugs, and approaches to keep the epidemic under control, success hangs in the balance. Universal access to treatment by 2015 is certainly an ambitious goal, but a realistic one if donor governments can maintain their commitment and if recipient nations adopt strategic and sustainable approaches in their HIV/AIDS programmes. Money well spent today means less money spent tomorrow.

The Lancet Infectious Diseases, Volume 12, Issue 1, Page 1, January 2012

doi:10.1016/S1473-3099(11)70357-7Cite or Link Using DOI