I recently participated in a meeting co-sponsored by the Institute of Medicine (IOM) and ASSAF on Envisioning a strategy to prepare for the long-term burden of HIV/AIDS: African needs and US interests. Amid continuing debate on US global health strategy, I thought it might be useful to share some of my thoughts.
As Mead Over from the Center for Global Development recently commented, it is very unlikely that we can treat our way out of the HIV/AIDS epidemic. One of the statistics floating around is that for every 2 people put on treatment, another 5 become infected. Thus he suggests a renewed focus on prevention. But regardless of the relative balance of prevention and treatment, HIV/AIDS still requires a significant level of resources.
The question is now who will pay for it.
Northern countries, particularly the US, are pointing to African governments. A letter from the US Global AIDS Coordinator to US Ambassors in PEPFAR countries notes,
Moving in this direction reaffirms the long-standing goal for each country to assume primary responsibility for the national responses to HIV/AIDS, both strategically and financially.
Or as one expert has described it, ‘Governments need to put more of their own money into HIV/AIDS, or they are letting their people die.’
But is it really this simple?
In the debate about how to develop a long-term sustainable response to HIV/AIDS in Africa, the behaviour of donors has to be taken into account. So too does the difficult question of who should decide and be responsible for how public funding is allocated within a country.
In my view, the US government, when launching PEPFAR, did not make a five or ten year commitment to Africa. The US made a longer-term moral commitment to keep providing treatment to those on antiretrovirals, and while there is a push to ensure that governments finance treatment domestically, this is likely to swamp budgets and leave governments with little space to fund other key priorities such as child health and nutrition. HIV/AIDS budgets are already increasing dramatically in richer countries such as Brazil which provides free first- and second-line treatment and in India which provides free first-line treatment and might be moving to second-line (see my paper with Eduardo Gomez on Health Financing in Brazil, Russia and India).
The global community, particularly the US given the crucial role it plays in financing HIV/AIDS in Africa, needs to be aware that it cannot create a huge number of assets and just leave. It has a moral responsibility to ‘stay the course’ and ensure that governments are not left with the bill for a programme that was designed and created in Washington DC with little thought as to an exit strategy. The health needs within Africa are only going to rise as the burden of chronic disease increases, and countries will be forced to make allocative funding decisions which have direct consequences for who lives and who dies.
It is not clear to me what the way forward is. But there needs to be space created for frank and open dialogue about a long-term strategy- the distinguished members of the IOM Committee are starting to explore this challenging issue- and I know that many are awaiting their final report.
