Experts at 2009 HIV Implementers' meeting worry about sustainability of HIV programmes

This article originally appeared in HIV & AIDS treatment in practice, an email newsletter for healthcare workers and community-based organisations in resource-limited settings published by NAM between 2003 and 2014.
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“In the last several years, we’ve seen global funding for HIV/AIDS dramatically increase,” said Elizabeth Lule, Manager of the World Bank’s HIV/AIDS work in Africa, at a press conference before the start of this year’s HIV Implementers' Meeting in Windhoek, Namibia.

But now, Lule said, “the environment has changed.”

Indeed, the overarching issue of the HIV Implementers' Meeting was how to sustain the recent gains made in the fight against HIV/AIDS in resource-limited settings in a changing environment.

Glossary

morbidity

Illness.

“The meeting is happening at a critical juncture of our fight against HIV and AIDS,” said Professor Rifat Atun of the Global Fund during the meeting’s opening plenary. “Rather paradoxically, on one hand, we should be celebrating real success [of the scale-up of HIV/AIDS programmes] that are having visible impact, but we are at a juncture where globally we are experiencing the most difficult economic conditions since the Great Depression… and where the influence of the adverse condition on the countries is not yet known. We’re not sure what the impact might be.”

Other experts at the meeting worried about other important shifts in the environment: namely there has been a decrease in donor interest in funding HIV/AIDS and an increasing preference for support of general health systems strengthening; and that changes in political leadership — in the US and elsewhere —are translating into a loss of the political will to continue treating HIV/AIDS as an emergency.

Meanwhile, the increasing numbers of people with HIV progressing to AIDS, and the ongoing failure to curb the incidence of new HIV infections mean that the numbers of people needing care will continue to grow and grow — making HIV programmes in resource-limited settings even more difficult to sustain.

Consequently, the official theme of this year’s HIV Implementers meeting, ‘optimising the response, partnerships for sustainability,’ became something of a warning for those working in countries that they should batten down the hatches, make sure to get the most out of what they have, and do whatever else they can to keep their existing programmes afloat in an era of dwindling resources and waning global interest.

Was the expansion of AIDS care and treatment during the last decade merely a brief anomaly?

In the past decade, billions of dollars have been disbursed to perform a health care miracle that many said would be impossible in resource-constrained settings only a decade ago — the national scale-up of projects to prevent mother to child transmission (PMTCT) of HIV and the launch of HIV treatment and care programmes reaching millions of adults and children, including the rollout of antiretroviral therapy to 3.4 million people. The demonstration that a public health approach to HIV treatment could indeed be implemented in resource-constrained settings led UNAIDS and activists to designate universal access to HIV treatment by 2010 as the new goal for advocacy.

Each year, the HIV Implementers’ Meeting serves as a forum for those working in the trenches to share the lessons they have learned about what does and doesn’t work delivering HIV prevention, treatment and care. It also provides funders and sponsors (who this year included the US President’s Emergency Plan for AIDS Relief (PEPFAR); the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); UNAIDS; UNICEF; the World Bank; the World Health Organization; and the Global Network of People Living with HIV (GNP+) an opportunity to showcase their initiatives and the progress that has been made. 

For instance, there were several presentations from representatives of the meeting’s founding co-sponsor, PEPFAR, which was launched in 2003 as a five-year commitment and quickly became the largest public health initiative ever dedicated to a single disease. To date, the US government has contributed ~ $25 billion to the global fight against HIV/AIDS through PEPFAR, and is also the largest supporter of the Global Fund.

While some of PEPFAR’s prevention work has been rather controversial (with ring fencing of funding for faith-based abstinence and being faithful projects, and the ‘anti-prostitution loyalty oath’ for instance), it has had great success catalysing HIV treatment and care programmes in the original 15 ‘focus’ countries.

Consequently, in 2008 PEPFAR was reauthorised for an additional five years to the tune of $48 billion. It is important to note however, that reauthorisation does not guarantee that the Obama administration or Congress intends to follow through with funding commitments (see below).

But under PEPFAR II, the plan at least is for the US government to support: treatment for 3 million people, prevention of 12 million new infections, care and support for 12 million people (including 5 million orphans and vulnerable children), in partnership with host countries around the world. To meet these goals, PEPFAR has also committed to support the training of at least 140,000 healthcare workers in HIV/AIDS prevention, treatment and care, including new cadres of healthcare workers. 

The question is now, whether the current administration will continue the ‘emergency’ response.

An expanding epidemic and a shrinking pot of money?

Over the last year, the leadership in the US, and many other industrialised countries have become preoccupied with the global economic crisis. The crisis makes it look less and less likely that the industrialised world and multilateral funding partners will sustain current levels of aid for health in the resource-constrained settings, not to mention to meet their commitments to support universal HIV treatment access by 2010.

“This is the biggest single issue facing the global AIDS movement at the moment,” said Dr Fareed Abdullah. director of the Global Fund's Africa unit. “Our level of coverage for antiretroviral therapy is presently quite low and by all accounts we don’t have enough money on the table, between PEPFAR, the Global Fund and national governments to put the people who need it on treatment.”

Indeed, in Africa alone, there are 3.9 million people living with HIV in immediate need of treatment under current guidelines. Because of recent data showing dramatic reductions in mortality when treating people with CD4 cell counts below 350 (rather than waiting for their CD4 cell counts to fall below 200), there are moves afoot to bring the eligibility requirements for ART closer to the norm in industrialised countries (starting treatment when the CD4 count falls to 350 rather than 200). This could indeed save lives and may also result in a reduction in onward HIV transmission, but it would also increase the numbers qualifying for treatment dramatically.

It should be noted however that most people with HIV are not being identified or coming in for treatment until their CD4 cell counts are already very low so it is not clear what the impact of changing eligibility requirements would actually be —earlier treatment may, in fact, lead to a reduction in utilisation of other health services, such as hospital beds, diagnostics and treatment of opportunistic infections.

Even if eligibility requirements for ART aren’t changed, the numbers needing treatment will continue to increase each year.

“Because of the numbers of new patients who are moving from HIV to AIDS, our level of coverage next year may be even lower than it is now,” said Dr Abdullah.

On top of this, there is the unrelenting tide of new infections.

“There are about 33 million people with HIV globally, but about 4 million people are added to the ranks each year,” said Helen Jackson of UNAIDS. “In countries like South Africa, where over 400,000 people each year are infected, this has clear implications for the sustainability of the HIV programme.”

“We cannot beat this epidemic with treatment alone,” said Dr Tom Walsh, Acting Deputy US Global AIDS Coordinator during the opening plenary. “In some areas, there are five new infections for every two people who are newly added on treatment. Without effective prevention for those not yet infected, more and more will face the risk of death — and be in need of treatment. And without successful prevention and treatment, the number of children orphaned by AIDS will continue to grow.”

And yet, by most accounts, prevention programmes are most likely to suffer in the economic downturn.

“Prevention efforts are at most risk, more than ever, because countries will emphasise investments in treatment, to reduce the mortality,” said Lule. “A recent World Bank and UNAIDS survey of 71 countries showed that nearly half of those nations — representing at least 75% of people with HIV/AIDS — expect prevention programs for people most at risk to be affected by the economic crisis. And this is extremely worrying because less prevention and more new infections will mean higher future treatment needs with larger future cost implications.”

Without a renewed commitment to funding for HIV/AIDS, it will be impossible to keep up with the demands for treatment. Worse, it may not even be possible to sustain existing programmes.

“If the funding flow to fight HIV/AIDS were to be constrained, much of the achievements to date and all the efforts we have made so far could potentially be undermined,” said Prof. Atun.

 “The Global Fund estimates that our own funding gap is about $4 billion, not all of that is for ART but a significant proportion is,” said Dr Abdullah. “We need to join hands to ask from a world where cash is short for more money for treatment. That’s a big ask right now but …it’s not an option to tell people there is no money for their treatment.”

“In some countries we’ve already seen in the newspapers that moratoriums have been put on new people for treatment,” said Lule.

The host country of this year’s conference,Namibia, stands out for reporting great progress on providing treatment and care to its people with 80% of those qualifying for ART on treatment. However, they are 60% dependent upon donor funds.

“What happens if the donors don’t come up with that money?” said Lule. “What is plan B for many of these countries?”

In many settings, if something isn’t done soon, according to Dr Abdullah, “we will start to see more and more drug shortages because of the funding gap.”

“So much is at stake,” said Lule. “A resurgence of mortality and morbidity; unplanned interruptions and curtailed access to treatment will increase HIV transmission rates because the viral loads will go up; future treatment failure and drug resistance is completely unaffordable. And of course, this means higher future fiscal costs or increased burden on health systems. We don’t want to go back to the earlier 1990s when many of the hospitals in Eastern and Southern Africa were just overcrowded with people dying from AIDS. We can’t afford to go back.”

Funding for HIV versus general health systems strengthening

At the same time, another issue is affecting how some donors are now approaching support of global health. Over the last few years, international agencies and academics have been embroiled in an ongoing debate about the wisdom of disease-specific aid (e.g. for HIV/AIDS) versus funding for general health systems strengthening.

Last week an extensive review of the evidence on the effects of global health initiatives published in The Lancet (the WHO-led Maximising Synergies project) concluded that global health initiatives have had both positive and negative effects on health systems. The authors, a group of more than 60 academics, programme chiefs and global policy makers, made five recommendations, based on their analysis of over one hundred studies:

  •  Infuse the health systems strengthening agenda with sense of ambition, the scale, the speed and the increased resources that have characterized the GHIIs
  • Agree on clear targets and indicators for health systems strengthening;
  • Promote country capacity for strong national planning processes and better alignment of resources with national planning processes;
  • Promote the meaningful involvement of civil society organizations in the governance of health systems and the delivery of health services;
  • Improve evidence-based decision making in health by building the capacity of countries to generate and use knowledge.

These nuanced and careful conclusions are likely to be used by both sides of the debate to justify their positions. Unfortunately the Maximising Synergies report does not provide much HIV-specific information.

However an independent review by the Global HIV/AIDS Initiatives Network, a global network of health systems researchers based at London School of Hygiene and Tropical Medicine, published this month in the journal Health Policy and Planning, provides some useful analysis. They note that while PEPFAR, the Global Fund and the World Bank Multi-country AIDS Program have been successful in supporting scale-up, in channelling funds to the non-governmental sector and in getting more stakeholders involved, they have also distorted national health systems priorities in some settings and created vertical systems.

But the researchers also point out that global HIV/AIDS initiatives should not be dismissed, and make some constructive recommendations about how to address current problems:

  • Global HIV/AIDS initiatives could do more to align with national health priorities, and should coordinate investment to strengthen national health systems;
  • Global initiatives should give countries sufficient flexibility to address health system weaknesses and strengthen implementation, espeically in human resources;
  • Better coordination of donor investment to meet national health priorities, with flexibility to allow global initiatives to support the areas they can fund, allowing other resources to flow elsewhere;
  • Global HIV/AIDS initiatives must provide long-term funding to address the shortage of public health sector staff;
  • Global HIV/AIDS initiatives must continue to fund the non-governmental sector, but should require NGOs to utilise and contribute data to national health information systems, to ensure a joined-up approach.

It should be a false dichotomy — health systems strengthening is essential for the optimal success of HIV/AIDS programmes, and HIV/AIDS support should and could be designed and delivered in a responsible way that strengthens health systems. Occasionally, it was necessary to pilot a service vertically to demonstrate it was possible in a setting, but the goal has long been to mainstream HIV/AIDS services into the public health system as soon as possible. Indeed, WHO launched the 3 x 5 initiative in 2003 specifically to promote the delivery of antiretroviral treatment through the public health system through standardised protocols that would eventually allow delivery through primary care.

Services have been shown to be most effective when delivered locally — as close to where the patient lives as possible — through the primary health clinic, community-based and home-based care. This has been the public health approach that HATIP has been describing for the last five years, and universal access is impossible without a generalised scale-up of the capacity of primary care.

“You can reach a certain level of coverage without addressing the health system’s weaknesses, but when you go to scale up, as we all want to with universal access, then the health systems become particularly critical,” said Dr Abdullah.

The critics of HIV/AIDS funding frequently point to dated examples of the early HIV/AIDS response as a separate vertical system — suggesting that this will go on indefinitely and that “far too much is spent on HIV relative to other needs and this is damaging health systems.” But the critics forget that AIDS services are also rescuing health systems that were (and would be) inundated with people ill or dying of AIDS and TB.  And they ignore the dynamic nature of the HIV/AIDS response and that HIV implementers have demonstrated capacity to adapt their practices and integrate services to make them more effective.

But the accusation that HIV/AIDS is getting too large a share of international aid for health seems to have taken hold and in an important sense, has helped the critics of HIV/AIDS funding win the rhetorical debate.

One indicator of the shift is how funding is being redirected from HIV/AIDS to general health systems strengthening. According to sources at WHO, the HIV Department has suffered a dramatic reduction in funding, with donors such as the Scandinavian countries now redirecting their funds to general health systems strengthening.  But there is a real danger that, in the current economic climate, the debate will simply provide a convenient excuse for industrialised countries not to honour their commitments to supporting universal access.

PEPFAR insiders have told HATIP off the record that they are extremely worried that the debate is beginning to diffuse PEPFAR's focus on HIV/AIDS.

HIV/AIDS funding critics have adopted one particularly insidious tactic by pitting the needs of ‘innocent children’ against people living with HIV, arguing that infant mortality is receiving insufficient attention due to the emphasis on AIDS, and that many lives could be saved with inexpensive measures to prevent or treat diarrhoea and pneumonia.

Ezekiel Emanuel, brother of White House chief of staff Rahm Emanuel, while accepting that the US must continue to meet its responsibilities to people already on treatment, explicitly criticised further increases in PEPFAR spending on HIV/AIDS in a recent commentary in the Journal of the American Medical Association, arguing that "doubling or tripling PEPFAR's funding is not the best use of international health funding ... By focusing so heavily on HIV/AIDS treatments, the United States misses huge opportunities. By extending funds to simple but more deadly diseases, such as respiratory and diarrheal illnesses, the U.S. government could save more lives - especially young lives - at substantially lower cost."

“They have more DALYS,” a PEPFAR insider told HATIP, referring to Disability Adjusted Life Years or the sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability — meaning many more years of life could be saved with MCH interventions than by the relatively expensive HIV/AIDS interventions.

“But they forget that HIV/AIDS is striking adults at the prime of their lives. These are the workers, the family providers. HIV/AIDS threatens the security of families and the economic system —and it disproportionately affects teachers and healthcare workers upon which the educational system and health system relies.”

Low-cost interventions to save the lives of children from easily treatable and preventable illnesses should of course be made more widely available.

However, it is important to point out that maternal-child health is a perennial issue for which host governments must be held directly responsible. The health systems in these countries have indeed been weakened, but the main culprits for this were the disinvestment in health systems dictated by the structural adjustment policies of international financial institutions (such as the IMF) in the 1970s, 80s and 90s, and the subsequent failure of developing countries to allocate sufficient resources to health.

Debt forgiveness and policies that enable developing countries to invest in their own health systems may be the best way to strengthen general health systems in a way that is ‘home-grown’ and sustainable.

But it is another issue entirely whether funding should be directed away from the HIV/AIDS pandemic, which is indeed an unprecedented emergency that many high-burden countries are poorly equipped to manage and which does in fact require an exceptional response.

But has the debate affected US government policy?

“A big priority for the Obama administration is to continue our support for HIV/AIDS but to look at it in a broader context of public health issues around the world. So he recently launched something called the global health initiative, committing to spend $63 billion over the next 6 years (70% of which is for HIV/AIDS, TB and malaria),” said Michelle Moloney-Kitts, Assistant Global AIDS Coordinator for the US government at the opening press conference. “He is hoping that we can use the platforms PEPFAR has developed to look at other issues that affect families such as diarrhoeal diseases in children, maternal mortality, neglected tropical diseases, and that this comprehensive approach will in fact be more responsive to what people really need in the field and in the country and that will also contribute to the long-term sustainability of our programmes.”

A change in leadership and political will

At first glance, the global health initiative seems like a balanced approach. The problem really is in the maths: 70% of $63 billion is only $44 billion — and that’s over 6 years. PEPFAR reauthorisation was for $48 billion over 5 years. Simply put, it amounts to a cut.

“The only aspect of the plan that appears “new” is a dramatic decrease in funding for programs to address HIV, malaria and tuberculosis,” according to a Health Global Access Project press release.

“President Obama repeatedly committed to ensuring the US does its fair share to fight AIDS around the world. But this budget’s drastic cuts to funding for AIDS, TB and malaria shows that his promises were just rhetoric,” said Kaytee Riek, Director of Organizing for Health GAP.

An Irin PlusNews report concluded that the Obama administration was expanding the global health agenda, but not funding, and pointed out that this was pretty much in tune with the perceptions of the American public. A recent Kaiser Family Foundation survey reported that ‘71 percent of Americans do not believe their country can afford to spend more on global health when the US is experiencing a severe recession, and that the sense of urgency about the global HIV/AIDS epidemic had declined.’

Others think it is an indication that HIV/AIDS isn’t high on Obama’s agenda — with another sign being the long delay in appointing and getting Dr Eric Goosby confirmed as the next US Global AIDS Coordinator. In fact, in a feat of bad timing, Dr Goosby’s confirmation hearings in Washington started at the same time as the HIV Implementers’ Meeting.

“Regardless of what you thought of their politics, both President Bush and his wife were deeply engaged in PEPFAR,” one PEPFAR insider told HATIP. “That not only gave us a clear mandate, it protected PEPFAR from the predations of other agencies and competing interests in the government. We don’t have that protection anymore.”

Indeed, according to one PEPFAR official: "We tried really really hard to get Obama to record a greeting for the meeting. Either Hillary really wanted to do it, or he didn't."

Getting countries to pull their weight, and partners to harmonise efforts

Still, as  the exiting Director of the HIV/AIDS Department of WHO said in his opening plenary address “We cannot expect one country to carry the world's HIV treatment costs.”

Already, with the reauthorisation of PEPFAR, there is a drive to get countries to pull more of their own weight in the programme.

According to Moloney-Kitts, under PEPFAR II “there is a new emphasis on establishing partnership frameworks — a 5-year joint strategic framework for cooperation between the US, the partner government and other partners to promote long term sustainability of programmes, that strengthens country capacity, ownership and leadership of the HIV programmes, and harmonise efforts with other funding partners. Partnership frameworks are supposed to be transparent (and are to be posted online on the PEPFAR site), and to involve the active participation of civil society, the private sector, other bi- and multilateral partners, and international technical support organizations.

“We look to host country governments and our partners to also be more accountable for their contributions,” said Moloney-Kitts. “In many places key policies need to be put in place to advance and provide long-term sustainability to the achievement of our goals. A concrete example involves mother to child transmission — we know that we will never have a sustainable programme without opt-out and rapid testing. Governments need to commit to a policy on that. PEPFAR provides funding for equipment and lab tests, and the community based organisations commit to organising traditional birth attendants or a community surveillance support system for mothers. Then we can all work in a partnership where we are mutually accountable for what we are trying to achieve.”

Through the partnership frameworks, PEPFAR II means to expand well beyond the first 15 original focus countries. In fact, the US government has invited a long list of countries to develop partnership frameworks including: countries from the Caribbean region, the Central America region, the Central Asia region, Botswana, Côte d’Ivoire, the DRC, the Dominican Republic, Ghana, Guyana, Haiti, India, Indonesia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Thailand, Uganda, Ukraine, Vietnam and Zambia.

Malawi — notably, not one of the original focus countries, but a country which has set itself apart as a model for accomplishing a lot on a shoestring with a simple public health approach to HIV care — was the first to complete a partnership framework, which is already available online. Consequently, the US has committed itself to double the HIV/AIDS funding for the country to around $45 million.  Swaziland has also recently completed a partnership framework.

And perhaps in an effort to encourage countries and partners to dedicate more resources to HIV/AIDS, Dr Tom Walsh, Acting Deputy US Global AIDS Coordinator, spoke about how closely HIV/AIDS is linked to other development needs. “One lens through which to look at the impact of HIV/AIDS and our efforts to combat it is that of the Millennium Development Goals (MDGs),” he said.

However, asking resource-constrained countries to contribute more funding to the fight against AIDS during an economic downturn may be another example of poor timing because the financial crisis will reduce the ability of countries to contribute more to their own healthcare systems or make up for any funding shortfall.

“The consequences of the economic crisis are perhaps to be most felt by those who already had the least and suffered the most from both poverty and disease,” said Lule.

“We are going to see a slow down in human development gains unless we maintain the investments. We are beginning to see a slowing down of GNP growth — definitely in southern Africa. We are beginning to see declining private capital flows and reductions in remittances, which actually provide a big income for many of the countries. Tourism is going down in some of the countries.  We see weak commodity prices — the demand is going down; and the export markets are also declining.”

The synergies between the fight against HIV/AIDS and reaching the MDGs

“One lens through which to look at the impact of HIV/AIDS and our efforts to combat it is that of the Millennium Development Goals (MDGs),” said Dr Tom Walsh, Acting Deputy US Global AIDS Coordinator.

Many resource-limited countries and funding partners have eagerly taken up the challenge of reaching the Millennium Development Goals — eight international development goals that United Nations member states and at least 23 international organisations have agreed to achieve by the year 2015.

Addressing HIV/AIDS and other priority diseases is one of these MDGs, but Dr Walsh used most of his plenary talk at the 2009 HIV Implementers’ Meeting in Windhoek Namibia to discuss how closely HIV/AIDS is linked to development — perhaps to encourage countries and partners to re-prioritise HIV/AIDS as part of their strategy towards fulfilling several of the other MDGs.

Promoting gender equity and empowering women. “HIV disproportionately affects those who have less power and lower status, helping to explain why women and girls account for nearly 60% of the new infections,” said Walsh. Targeted HIV programmes are needed that focus on gender equity, address male norms and behaviours, reduce violence and coercion, increase women and girls access to income and productive resources, and increase women’s status and legal protection.  Effective responses to HIV/AIDS are thus responses that empower women and girls.

Universal primary education: HIV/AIDS increases the number of orphans, who are less likely to receive schooling than other children — especially girls, who at all ages are pulled from school to assume the role of caregiver after the death of a mother. Meanwhile, large numbers of teachers are dying of HIV/AIDS in some countries. Strong programmes directed at orphans and vulnerable children should reduce the risk that they will be denied education. Prevention, treatment and care programmes are also needed targeting teachers and other education professionals.

Reducing child mortality: Children now constitute 14% (370,000 of 2.7 million) new global HIV infections and 14% (270,000) of HIV/AIDS-related deaths annually. A Ugandan study has found that the expansion of HIV services led to a decrease of 81% in non-HIV infant mortality, in part because of the reduction of AIDS orphans.

At the same time, there is also a growing recognition that effective prevention of mother to child transmission (PMTCT) and early identification and treatment of HIV infected children can only be delivered by strengthening mother child health (MCH) services so that all the essential interventions to reduce child mortality can be delivered. It makes no sense to get a child onto antiretroviral therapy and then be unable to the child and its mother effective prevention or treatment for pneumonia or diarrhoea. The Obama administration’s global health initiative clearly seeks to address this issue by strengthening MCH services.

Improving maternal health: HIV/AIDS disproportionately infects and kills pregnant women. Women with HIV are four to five times more likely to die in childbirth but only 18% of pregnant women in sub-Saharan Africa receive HIV testing during their pregnancies, and less than 40% receive antiretrovirals for PMTCT. Effective responses to HIV/AIDS should positively affect maternal health — and HIV screening in PMTCT programmes can help women identify their own needs for treatment — providing a gateway for care and treatment. 

Combating HIV/AIDS, malaria and other disease: There was a greater focus on TB than any other previous Implementers’ Meeting, with the growing realisation that it is the most important cause of morbidity and death in people with HIV in sub-Saharan Africa. In many countries, the majority of TB cases occur in people with HIV — and it is clear that “HIV/AIDS is fueling a resurgence of TB including untreatable extensively drug-resistant TB (XDR-TB). As for malaria, two thirds of the cost of delivering insecticide treated bednets is the distribution system. Effective responses to HIV/AIDS must tackle TB… and should improve the platform [strengthen the health system] used by programmes focused on malaria and other tropical diseases,” said Walsh.

Dr Walsh stressed that HIV/AIDS programmes should expand and strengthen health systems overall — in reality, this is not something that can be guaranteed and certainly shouldn’t be taken for granted. However, over the course of the meeting, funding partners and programme directors demonstrated that they are putting a great deal more thought into how HIV/AIDS programmes could contribute to general health system strengthening “using the health systems we’ve built to deliver other high-impact, low-cost care,” as Secretary of State Hillary Clinton said in her videotaped address.

What can be done

The thrust is that programmes will have to learn to make the most of every cent they have.

“Only programmes that actually achieve prevention, treatment and care are worth the investment.  In a global environment of limited resources, the next five years must be a time of achieving increased effectiveness and also efficiency. We must all ensure that we are spending our dollars wisely and utilising our human potential responsibly,” said Dr Walsh.

 “Optimising the HIV/AIDS response and achieving sustainability will require an increased emphasis on more efficient use of available resources,” said Lule. “Because for the time being, we do have some money but it has to be used efficiently and effectively, we have to have better governance and also perhaps less — shall I mention the word? — corruption, in the system.”

The following day, an opening plenary by Dr Stefano Bertozzi, and a skills building session addressed strategies for increasing programme efficiency and effectiveness. These talks, as well as a tool developed by the World Bank to help countries prepare for the impact of the funding crisis — including how to identify funding gaps that could lead to supply interruptions — are addressed in a related article.

But Lule added that more funding must be made available, for the short term to help address urgent funding gaps in providing bridge financing to avoid cash flow and supply interruptions, and for the longer term.

“Sustaining the pledges that have been made for the Global Fund will of course be very critical. But it is also critical for the US Government to continue to increase what they are spending because the demands will keep going up,” she said.

“We know that optimising efficiencies can only go so far,” one PEPFAR official told HATIP. “We need to find more money in order to save the lives of the millions not yet on treatment.”

But he acknowledged that he didn’t know how this would be done in the current economic and political climate.

The role of activists and people living with HIV

“In our role as AIDS advocates, we must actively resist the notion that vital human investments must inevitably go down when economic growth declines,” said Paul DeLay, newly appointed deputy executive director of UNAIDS, during the opening plenary.

But something that politicians, healthcare policy specialists and implementers sometimes forget is that the HIV/AIDS movement comes with a constituency of millions — people living with HIV and their families.

People with HIV have mobilised before, and could well mobilise again to demand continued and equitable access to treatment.

This writer is reminded of a course that he took while in university on political revolutions. The professor told the class that the most successful revolutions do not occur while people are thoroughly and totally subjugated, but after they have had a little freedom, after they have been given a glimmer of hope, which is then snatched away. That is when people rise up to demand their rights.

The last decade has given hope and new life to millions of people, millions of people who have become treatment literate, who have beaten the odds, beaten stigma and become empowered. It would be best not to stand in their way.

“The demands for resources to fight HIV and TB in Africa are not arbitrary or exaggerated. The availability of resources for HIV/TB is the key determinant of whether or not the right to life for millions of Africans will be realised,” the Treatment Action Campaign and the AIDS Rights Alliance for Southern Africa declared in a press alert for a protest at the start of the World Economic Forum (WEF) in Cape Town held concurrently with the Implementer’s meeting in June.

“Millions of people who are living today only because billions of dollars were invested in ART to keep them alive. We refuse to have this progress undone. As world leaders gather in Cape Town to discuss the economic crisis and to “develop a new roadmap for Africa’s future”, activists around the region will be watching the outcomes of this meeting for evidence of political commitment to the rights of people living with HIV and TB on the continent, and will mobilize to ensure that these rights are protected.”

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