Earlier this year, on 25 February, the government of Botswana announced that if the global recession continued, it would have to freeze the provision of treatment for its HIV-positive population.1
Botswana’s treatment programme, which reaches an estimated 19 out of 20 people who need lifesaving HIV drugs, is the envy of Africa. But the country is dependent for its prosperity on one export – diamonds. And this year, people can’t afford bling. After a decade during which diamond sales increased by 10% every year, Botswana will produce half as many diamonds as it did last year.2
Botswana has saved enough money for HIV treatment for the next seven years. But the head of its AIDS programme, Robson Dimbungu, has said that – after 2016 - the country would only be able to maintain on treatment those who already had HIV, not treat any more. “For those who are going to be infected after 2016, I think it is going to be very tough for them,” he said.
By that time Botswana will have had a decade of HIV treatment. A decade during which, stigma apart, the one in four of its inhabitants that has HIV will have been able to function as an equal citizen. It would be devastating for Botswana’s people to lose their access to lifesaving HIV treatment.
This may turn out to be politically inadmissible, but HIV advocates and policymakers are concerned that at the very least, in order to sustain HIV treatment programmes, the global economic recession may mean that every other aspect of the global effort against HIV care – prevention, advocacy, social support and anti-discrimination work, for instance – will vanish in the process.
In April, the World Bank issued a gloomy report which predicted that the continuity of HIV treatment may be threatened for around 70% of people currently on treatment in sub-Saharan Africa, 50% in Asia, and 25% in Russia and central Asia.3 The economic crisis is already beginning to bite: Tanzania has already cut its AIDS budget by 25%.
Thirty-four of the 47 countries surveyed by the World Bank, representing three-quarters of the people with HIV in the world, expected prevention work to suffer in particular. The global region most expected to be starved of prevention help for groups vulnerable to HIV was on our own geographical doorstep, in Eastern Europe and central Asia.
The drive to treat the world for HIV has been an astonishing success story. Global funding for AIDS rose from $1.6 billion in 2001 to $13.7 billion in 2009. But financing for global HIV programmes is fragile. Eighteen of the 47 countries surveyed by the World Bank relied on grants from the Global Fund to Fight AIDS, TB and Malaria which end in 2009 or 2010. The Global Fund faces a funding shortfall of $4 billion. In the USA, HIV campaigners have been bitterly disappointed by President Obama’s decision to give $5 billion to the President’s Emergency Plan for AIDS Relief (PEPFAR) global HIV initiative, an amount representing a 30% shortfall of Bush’s funding, which Obama pledged to maintain in campaign speeches.
Overseas development assistance (ODA) – which includes all that HIV treatment money - is incredibly fragile and can suddenly vanish. At a meeting on 20 April, Robert Greener of UNAIDS pointed out to the European AIDS Treatment Group that economic growth in the form of gross national income has risen steadily in recent years, doubling between 1984 and 2007, with only mild slowdowns during economic busts such as the currency crisis of 1992 and the dot-com bubble of 2000.4 In contrast global ODA fell in real terms by 25% between 1992 and 1997. The pool of international health funding could vanish as fast today.
We are by no means proof against this in the developed world, where global recession and questions about the efficiency of HIV prevention and advocacy programmes have coincided with a third factor: the deprioritisation of HIV as a subject for funding by the pharmaceutical industry. Lisa Power of the Terrence Higgins Trust does not expect to see HIV treatment programmes cut in Barnet any more than Botswana. But she does expect the money for prevention and advocacy to suffer.
“So far the recession hasn’t hit statutory bodies, though it has most certainly hit charities like the THT, largely because of a dramatic fall in private donations,” she says. “But as we start to pay off the government’s debts, primary care trusts and health boards will have less money to spend overall.
“Public health will be at the bottom of the pile when it comes to what the NHS spends money on in hard economic times and sexual health will be at the bottom of that.”
As global, so local: “The time to make a difference is now; all the power of deciding how the money gets spent is now at the local level so it’s important to lobby people like your local MP. Patients can have real influence this way.”
Some hard questions will have to be asked. “Should we be pushing harder for reductions in treatment costs in countries like the UK as well as Africa? And how do we join up services so that older people with HIV or people with co-infections get all their needs met in one place?”
The whole HIV sector is going to have to turn on a sixpence to justify its very existence, Power predicts. “If we think it’s been tough in the last few years,” she adds, “we ain’t seen nothing yet.”
1. PLUS News. Botswana: Bleak outlook for future AIDS funding. 20 February 2009. See www.irinnews.org/report.aspx?ReportId=83054
2. Glasse J. Diamond sales slump could hurt Africa. VOA News, 25 May 2009.
3. World Bank. Averting a human crisis during the global downturn: policy options from the World Bank’s human development network. See http://siteresources.worldbank.org/NEWS/Resources/AvertingTheHumanCrisis.pdf
4. Greener R. HIV and the financial crisis. Academic council debate on the financial crisis and public health, Swiss Network for International Studies meeting, 30 April 2009.