By Bernhard Schwartlander, UNAIDS | Thu., December 1, 1:15 AM | Comments ( 0 )
An activist from a non-governmental organisation (NGO) lights candles during an AIDS awareness campaign on the eve of World AIDS Day in Agartala, capital of India's northeastern state of Tripura November 30, 2011. REUTERS/Jayanta Dey
Bernhard Schwartlander is director of the Evidence, Strategy and Results Department at UNAIDS. The opinions expressed are his own.
Tremendous gains against HIV have been made over the past three decades, but to decisively break the trajectory of the HIV epidemic and achieve universal access to HIV prevention, treatment, care and support, a far more strategic approach to investment is needed.
We need to radically depart from existing approaches and instead put AIDS financing on an investment track, leading the way to a more targeted and strategic use of scarce resources.
To date, the approach to AIDS needs has been a “commodity” approach – interest groups and advocates of one or other aspect of the AIDS response have put forward their claim to funding and a total bill has been estimated on the basis of these atomised needs.
The failing in this approach is that the incentives lie only in maximising the claim for funding needs, and what it leaves out is any incentive for progammes to act as a whole to maximise results.
The alternative to the commodity approach is an investment paradigm which encourages countries to implement as a package the most effective programmes by capitalising on the best available evidence on what works in HIV prevention, treatment, care and support.
Countries can thus adopt more rational resource allocation based on country epidemiology and context.
UNAIDS and partners have put forward an investment framework whose goal is to mobilize and deploy funds in such a way that the end of the epidemic can be brought into view. This is ambitious but achievable.
The funding envelope required is surprisingly modest: a 10 percent year on year increase for five years will get the response over the hump.
Today, after a decade of strong funding increases that plateaued after 2008, around $15 billion is spent from domestic and international sources on AIDS in low and middle income countries.
The investment framework model requires an initial scaling-up from this funding base to reach a peak annual need of $24 billion in 2015, before declining to $19.8 billion in 2020.
At $1,060 per life-year gained, the additional investment required would be largely offset by savings in treatment costs alone.
Modelling of the framework’s impact shows that its implementation would avert 12.2 million new infections and 7.4 million HIV-related deaths between 2011 and 2020, and result in a gain of 29.4 million life-years.
At the core of the investment framework are a set of six basic programme activities, geared to the fundamental objectives of stopping new infections and keeping people with HIV alive.
The six basic programmes are the set of integrated activities addressing key populations, notably sex workers, people who inject drugs and men who have sex with men; elimination of new HIV infections among children and keeping their mothers alive; procurement, distribution and marketing of male and female condoms; programmes that reduce the risk of HIV exposure through a tight focus on changing people’s behaviour and social norms; treatment, care and support for people living with HIV; and promotion of medical male circumcision in countries where there is a generalized epidemic and the current rate of medical male circumcision is low.
In addition, national programmes need to pay attention to the critical enablers which create the environments conducive to rational HIV responses, create demand for programmes and improve their performance.
Unlike the basic activities whose content varies relatively little from setting to setting, the critical enablers are essential local and contextual in nature.
Politics, culture and social organization are all crucial determinants of programme success and in these areas there is very little that outside experts have to tell national actors about what will drive their response to greatest success.
The investment paradigm for the HIV response is based on fewer things done at a deeper level, with clear incentives to galvanise the power of critical enablers and maximise synergies with broader development goals. Grasp it, and the end of AIDS comes into view.
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