With less
access to PMTCT, affected countries may also see an increase in the number of
babies born HIV-positive at a time when money for paediatric HIV treatment is
shrinking. The MSF report cites multiple examples of UNITAID support for
paediatric HIV treatment coming to an end in countries such as Swaziland, Uganda
and Zimbabwe.
The World
Bank, which is the second largest multilateral donor to HIV, is also phasing
out funding for the DRC, Malawi
and Mozambique
by 2012, as it takes on a more technical assistance role.
In Zimbabwe, Round
11’s cancellation coincided with the Expanded Support Programme’s end. Funded
by the United Kingdom, Sweden, Norway,
Ireland and Canada, this
programme will be replaced with the Health Transitional Fund, which will focus
on nutrition and on maternal and child health. According to MSF, this has
contributed to a treatment gap of about 66,000 HIV patients in the country who
will not be able to access treatment in 2012.
While UNAIDS’
Zimbabwe
operation is working with government to increase private sector investment into
the HIV response, it estimates this will take several years to take off. In the
meantime, it predicts, by 2015 about 360,000 people in the country will go
without treatment, according to OSF’s report.
More than ten
years ago, Zimbabwe
introduced an AIDS levy to compensate for decreased donor support. In 2010, the
levy collected US$20.5 million, representing almost a 260% increase in
collections over the previous year. This was primarily due to contributions
from industry, according to a statement released by the National AIDS Council
of Zimbabwe.7
According to
Asia Russell, Director of International Policy for activist group Health GAP,
Zimbabwean civil society is now advocating for its government to increase the
proportion of the levy spent on treatment from 50 to 80% in order to plug the
gaps.
In addition,
some countries – Zimbabwe
included – are reprogramming existing Global Fund grants away from HIV
prevention in order to shift cost savings towards essential HIV and TB
medicines and diagnostics, according to OSF.8
In 2011,
UNAIDS released its strategic investment framework.9 Premised on six
basic programmatic activities, including PMTCT, medical male circumcision (MMC)
and behaviour change, authors argue that – if implemented – the framework could
avert more than 12 million new HIV infections and almost 7.5 million
AIDS-related deaths between 2011 and 2020 worldwide.
While most
countries seem to be safeguarding biomedical prevention methods such as PMTCT
and MMC, the OSF research found that other aspects of prevention, such as the
framework’s so-called “critical enablers”, or programming in areas such as
human rights, community-based capacity building and retention in care, were
being deprioritised.
Deprioritising
prevention comes at a time when new infections continue to outstrip treatment
coverage.
Professor
Alan Whiteside is head of the Health Economics and HIV Research Division
(HEARD) at South Africa’s University of KwaZulu-Natal. “The problem with
prevention is it is seen as a poor relative to treatment - it is long term,
messy, and attributing results is difficult,” he says.
He adds: “My
big concern is [that] prevention will lose resources. Given there are still
more new HIV infections than people put on treatment, this will be a problem
until such time as we see the AIDS transition.”
The concept
of an ‘AIDS transition’ was developed by Center for Global Development (CGD)
senior fellow Mead Over. It plots a strategy to minimise HIV and argues that,
to end local epidemics, countries will need to sustain recent reductions in
mortality and bring down HIV incidence.10
PEPFAR
meanwhile is scaling back funding for some countries, such as South Africa.
Amanda Glassman comments that, ideally, PEPFAR would look to transition their
funding of non-governmental organisation (NGO) partners to government contracts
with these same organisations to facilitate continuity of care - but most
governments don’t have a PEPFAR-sized budget to do this.
With a goal
of initiating 400,000 people on ARVs annually, the South African treasury has
projected that maintaining this pace in the next four years will lead to
funding shortfalls.
Michael
Gerson says that, although President Barack Obama has moderately increased HIV
funding and made America’s
first multi-year commitment to the Global Fund, donations to the Fund are
unlikely to see large increases anytime soon.
He adds: “In
a political environment where bipartisanship is rare, AIDS has been a hopeful
example of co-operation and common purpose. But during the next four years,
regardless of who wins the next American presidential election, we are not
likely to see the scale of funding increases we’ve seen in global health during
the last decade.”