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Tighter Budgets Threaten HIV/AIDS Gains

Matthew O. Berger and Peter Boaz

WASHINGTON, Sep 28 2010 (IPS) - Although the world will miss the 2010 deadline for universal access to HIV treatment, some countries, notably in sub- Saharan Africa, have made real strides forward, three United Nations agencies reported Tuesday.

The goal was set in 2006, but, as the joint report lays out, only some countries will achieve universal access, defined as coverage of at least 80 percent of the population in need, by the end of this year.

As with many health goals, progress is marked by unevenness both between regions and between aspects of the treatment needed.

While prevention efforts to reach the most at-risk populations globally – sex workers, drug users and men who have sex with men – are still limited, for instance, the report points to steady progress in providing access to services meant to prevent mother-to-child transmission of HIV.

Over half of all pregnant women with HIV in low- and middle- income countries received antiretroviral treatment to prevent transmission to their children, said the report, by UNICEF, UNAIDS and the World Health Organisation.

Within that number, there are sharp disparities between countries. “There are countries, especially in southern Africa, that have made really encouraging progress, and in fact four of them have reached the universal access targets,” Jimmy Kolker, chief of HIV and AIDS at UNICEF, told IPS Tuesday.

But, he said, the same is not true in places like Nigeria, home to almost a third of the women globally who should be but are not getting antiretrovirals to prevent trasmission to newborns.

Half of that global unmet need, in fact, is in just four countries – Nigeria, the Democratic Republic of Congo, India and Uganda.

The report is based on 2009 numbers, so the final word on progress toward the universal access goal will come next year. New goals for how best to proceed in response to HIV/AIDS globally also will be set next year.

Within that discussion, Kolker said that there is now a sense that the 2015 goal should be elimination of mother-to- child transimission – a slight change in emphasis from the access-to-care goals of 2006 to 2010. “It would be measuring not input, which is giving drugs to the mother, but output, which is an AIDS-free kid,” he explained.

One obstacle toward both new and existing goals is the stagnation and even decline in donor funding over the past several years, largely attributed to the financial crisis. This is highlighted in the report, which said that the sustainability of many HIV programmes is being paradoxically put at risk due to lack of financial commitments at the same time that there is more evidence than ever before that such programmes are having a positive and growing impact.

How much is needed to keep these programmes afloat? Ten billion dollars, Bernhard Schwartlander, director of evidence, strategy and results at UNAIDS, told IPS.

Next week, donor countries are expected to reaffirm their commitments to the Global Fund to Fight AIDS, Tuberculosis and Malaria at a meeting at the U.N. in New York.

But, going forward, the fight will take more than donor largesse, said Kolker.

“Because of the financial situation globally and the fact that the money is unlikely to get larger, national governments [in developing countries] themselves need to pick up the slack,” he said. “The good news is that more of the AIDS expenditure proportionally is coming from national governments. Decisions in countries like Kenya, Botswana, South Africa, Namibia to pay for the antiretrovirals themselves is a huge step forward, and that needs to be encouraged.”

“We are not going to be able to reverse the epidemic unless national partners and especially national governments see this as a good investment of their own resources,” he added.

That investment will also likely need to be used differently and put to better use. “The problem is we defintely need more money, but we also recognise we need to be more efficient in the way we are doing business,” said Schwartlander.

Part of that is integrating HIV work better with work in other, related health areas. Kolker mentioned how the Global Fund and the U.S. fund known as PEPFAR began as emergency responses, but as the worst of the HIV crisis is brought under control they will need to address related issues like those relating to maternal health.

“Services will need to be integrated and not provided at different locations as unlinked services. The direction we are going in clearly is in integration of services,” he said.

And progress against the worst of the crisis is being made.

Though there are still 33.4 million people living with HIV worldwide and 2.7 million diagnosed in 2008 alone, the number of people receiving antiretroviral therapy in low- and middle-income countries increased by 1.2 million in 2009, representing the largest single-year increase ever and bringing the number to 5.25 million, according to the Tuesday’s report, entitled “Towards Universal Access”.

Still, two-thirds of the population in need remains without access to antiretroviral therapy, an estimated 60 percent of developing-world patients do not know their HIV status, and many prevention efforts continue to lag.

The report warns that national strategies must include special efforts to reach the poorest of the poor and those who are socially excluded and that efforts to reach Millennium Development Goal six – to halt and reverse the spread of HIV/AIDS and other diseases by 2015 – has spurred changes in many national health systems.

As Kolker explained, HIV treatment was originally introduced at central hospitals with specialised care, but “the universal access principal meant that had to be brought to the lowest level of care. In the case of mother-to-child transmission that meant going into the maternity clinics, the antenatal clinics, the village health units and that has largely been done…The effort to make this universally available has succeeded largely in almost every country.”

But, he warns, “access to facilities is not the same as actual prevention of a new infection.”

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