This week the AIDS2018 Conference in Amsterdam kicked off with an explicit focus on diversity, key populations and young people. AIDS conferences are always a bit of a celebration, bringing together scientists and activists, politicians and social society, donors and implementers in an invigorating combination of evidence, practice and protest. This time however, things are different. Expanding needs, diminishing means, the emergence of populist, increasingly hostile and regressive policies, and the disengagement of rich countries from the fight against AIDS is causing worry in many quarters. In private conversations, you sense discouragement and sometimes even outright panic.
Where previously, the discourse was around mobilising domestic funds as additional resources for advancing progress on HIV and health, now the objective is to replace dwindling international funds. Challenged by the HIV community, donors were asked if now ‘flat-lining is the new increase’ and ‘reducing is the new flat-lining’. Yet, after years of assuming more can be done with less, the limits have been reached. UNAIDS, normally optimistic, says it is concerned. The GFAN more explicitly, says ‘we’re off track’. A surge in HIV transmission and the plateauing of mortality has already been reported.
The health economists’ pre-conference ‘Sustainable AIDS Response Results in the Era of Shrinking Donor Funding’, reflected this concern. Excellent presentations on political economy, including from the Netherlands and PEPFAR as bilateral donors, previous and current leaders of the Global Fund, UNAIDS and others, highlighted how transition away from international resources is now inevitable. Others focused on cost-effectiveness analyses and economic modelling, as possible instruments for optimising decision-making with a restricted resource envelope. However, the difficult choices that would be in real life the consequence of such theoretic modelling and investment comparisons were rarely touched upon, and nobody questioned the shrinking international and overall funding as a given. Some people were perhaps happy that sustainability was finally taking centre stage again, after 20 years of ignoring the reality of poor countries and weak health systems.
So what does planning for shrinking the AIDS response to a sustainable level really imply?
We know that restricted resources can result in competition between health issues, unhelpfully pitting diseases against each other, and leading to ‘Peter being robbed to pay Paul’. Within the HIV response , similar tensions are arising. More people surviving, means that ARV expenditure is increasing, creating fears about insufficient funds for other important expenses such as prevention or improved adherence measures. Stopping treatment initiation, in order to protect those who are already on treatment, is also under consideration, although it is known that doing so increases morbidity, pre-ART mortality and eventually costs. Are we willing to reverse recently adopted test and treat policies which show undeniable evidence of improved survival and viral suppression?
Take West & Central Africa, which lags behind on coverage and is facing a one third reduction of Global Fund (GF) allocations compared to the previous funding period. In Guinea, insufficient room for planned ARV scaleup within the current GF envelope and no other donors, means initiation will be restricted. The government is expected to take over the funding and procurement of ARVs for 14,000 PLHIV by 2020, yet uncertainty around the disbursement for ARV purchase and repeated experiences with ARV shortages, raise concerns around the country’s capacity to ensure the availability of ARVs at optimal prices and quality outside the pooled and prequalified circuit. In Mali and Sierra Leone too, ARV purchase is expected to shift from GF to government. If you think premature transition is only happening in Upper Middle Income countries, think again!
HIV/AIDS is rarely portrayed as the deadly epidemic and global health threat that it still is, and the Holy Grail of Sustainability has replaced Survival. In planning for the “end of AIDS” and modelling its economic feasibility, an insidious shift in political and practical commitment has occurred. Overconfident claims and international fatigue has led to early disengagement and a return to business as usual, breaking the momentum towards goals which were supposedly within reach. Yet, how ‘normal’ is an epidemic that causes nearly a million deaths per year?
In many countries the global response revolution has not begun, and in places like West and Central Africa, PLHIV face the continued burden of systemic barriers that delay, deter and discourage patients from accessing early and continued treatment. In Eastern Europe and Central Asia incidence is growing unchecked. Pre-treatment mortality is compounded by death among long-term users of ARV who experience treatment failure. AIDS still claims many lives, with recurring disease being detected late or not acted upon.
The conversation is shifting from the smart use of every dollar for effective scale-up, to the question of how to reduce harm for every dollar that is taken away, and little attention is given to the clinicians and health providers who must ration ARV, in a situation that is reminiscent of the early days when treatment availability in Africa was limited. Of course, death can be cost-effective, and the lives of vulnerable people can be sacrificed to broader political and economic considerations, however, this is a dangerous way of thinking.
This is no time to become complacent and we should not accept the idea that economic sustainability is more important than life!