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Does HIV/AIDS still require an exceptional response?
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The Lancet Infectious Diseases August 2008; 8:457
"we consider HIV to be a challenge still deserving of an exceptional response"
Several issues will be hotly debated at the XVII International AIDS conference in Mexico this year (August 3-8), not least the ongoing debate around HIV exceptionalism: does HIV/AIDS still deserve the substantial extra resources it receives compared with other health issues, the extra political commitment, and even its own UN agency-UNAIDS? HIV programmes consume around a quarter of international health-care aid, leading some to caution that the discrepancies in donor responses are now too wide when you consider global burden of disease rates, in which HIV/AIDS accounts for around 4% of deaths. And UNAIDS are asking for even more-US$33 billion more-by 2010.
Some critics-most notably Roger England (Health Systems Workshop, Grenada)-say this disease-specific approach is at best outdated and, at worse, doing more harm than good. Giving resource-poor countries substantial sums of money ring-fenced for HIV/AIDS, he argues, weakens health systems because it creates parallel systems for financing and employment, and this in turn disincentivises countries that should be working towards sustainable health systems. Bringing HIV into mainstream primary health care would mean a stronger system overall, enabling countries to prioritise other key diseases-pneumonia for example-which would ultimately save more lives. He concludes: "We have created a monster with too many vested interests and reputations at stake, too many single issue NGOs, too many relatively well paid HIV staff in affected countries, and too many rock stars with AIDS support as a fashion accessory".
Others argue that because HIV/AIDS remains a leading cause of death in high-prevalence settings and represents a global health and development emergency, it rightly deserves to be prioritised. At a recent meeting hosted by the Institute of Tropical Medicine at WHO (Geneva, Switzerland; May 28) experts concluded that although there have been some negative effects of the global AIDS response on health systems-for example, parallel HIV programmes have in some instances diverted physicians from key primary care services because of salary disparities-criticisms that it has substantially harmed primary health care are unfounded. Indeed, they concluded that the overall effect on health systems has been a positive one. According to Medecins Sans Frontieres, the expansion of HIV treatment has done much to improve national laboratory services, drug-supply chains, and general health-care infrastructure, as well as reducing the burden on local hospitals. Furthermore, don't forget that it was AIDS activists that put global health on the map in the first place, with some spectacular successes that changed the international context as we know it.
We need to take the many lessons learned from the HIV/AIDS story and apply them to other diseases, and work towards maximising the positive effects of HIV funding to date. Acknowledging that, fundamentally, it is chronic global underfunding of health care at the core of this debate would be a good place to start; HIV is certainly a long way off being considered overfunded. A Newsdesk article in this issue identifies a key role for donors here, and finds that attitudes may well already be changing. Donors are showing signs that they are committed to a new approach, which ensures that disease-specific funding and broader health-service strengthening in hard-hit countries are better aligned. WHO will be launching its HIV "positive synergies" campaign in Mexico this month.
We fully support calls for increased health-care funding and action on global health across the board, yet we consider HIV to be a challenge still deserving of an exceptional response. HIV/AIDS is a complex disaster and despite best efforts almost 7000 people still contract HIV every day. Prevention measures are still too ineffective and treatment coverage remains unacceptably low-25 years on and 70% of individuals in need of antiretroviral treatment still don't get it. In worst hit countries like Malawi, where AIDS represents over half of all clinic consultations, discussions about whether to focus on HIV or primary care are a meaningless dichotomy. Care must therefore be taken to ensure that any new approaches do not divert funds away from HIV nor place too many demands on existing HIV programmes. Ensuring that HIV-specific initiatives identify up front their broader impact on health systems, and that these impacts are quantified, is essential, as is exploring opportunities for greater synergy between AIDS and other services, for example tuberculosis services. Ultimately HIV activism needs now to be broadened out to global health in general-although we may lose a few rock stars along the way.
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