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.”