Zarni Htun, Yingxi Zhao, Hannah Gilbert, Chunling Lu
BACKGROUND: The Global Fund has been a major funding source for HIV/AIDS programs in Myanmar. In this qualitative study, we aim to understand the impact of Global Fund on national HIV/AIDS response in Myanmar during the era of Millennium Development Goals (MDGs). METHODS: We conducted individual in-depth interviews by recruiting key informants through purposive snowball sampling. The respondents were engaged in the national/subnational response to HIV/AIDS in Myanmar and worked for the United Nations agencies, non-governmental organizations (NGOs), and civil society. Interview questions were organized around the role of Global Fund in strengthening national response to HIV/AIDS in the six building blocks of the Myanmar's health system. Transcripts from the key informants were synthesized into specific themes through a deductive approach. RESULTS: We found that the Global Fund has provided substantial support to (1) finance the national HIV/AIDS response in Myanmar, and (2) strengthen leadership and governance at the central level through improving coordination and collaboration, including more stakeholders (e.g. civil society, NGOs) in decision making process, and catalyzing policy changes on scaling-up key interventions. Yet, its role remains limited in addressing new demands at the township level in terms of capacity building, staffing, and medical supply resulting from rapid scale-up of HIV interventions and decentralization of service delivery in the public sector. CONCLUSION: There was a missed opportunity for Myanmar to capitalize on the use of the Global Fund's funding to strengthen the health system. Deliberate planning is required to optimize the use of those scarce resources to provide universal coverage for HIV/AIDS.
Vanessa T. Siy Van, Jhanna Uy, Joy Bagas, Valerie Gilbert Ulep
In recognition of the role of reproductive health in individual and national development, the Responsible Parenthood and Reproductive Health (RPRH) Law of 2012 was passed in the Philippines after 30 years of opposition and debate. Seven years later, this article examined the cohesiveness of national multi-sectoral governance among state and non-state actors and identified challenges in coordination as part of the first comprehensive evaluation of the landmark policy. Using a qualitative intrinsic case study design and guided by the World Health Organization's systems checklist for governing health equity as our theoretical perspective, we conducted 20 semi-structured interviews with national implementers from health agencies (n = 11), non-health agencies (n = 6) and non-state actors (n = 3) that included civil society organizations (CSOs). Key themes identified through thematic analysis were supported with document reviews of policy issuances, accomplishment reports and meeting transcripts of the RPRH National Implementation Team (NIT). The study found that despite aspirations for vibrant multi-sectoral coordination, the implementation of the RPRH Law in the Philippines was incohesive. National leaders, particularly the health sector, were neither able to rally non-health sector actors around RPRH nor strategically harness the power of CSOs. Local resource limitations associated with decentralization were exacerbated by paternalistic financing, coordination, and monitoring. The absence of multi-agency plans fostered a culture of siloed opportunism, without consideration to integrated implementation. This case study shows that for neutral policies without conflicts in sector objectives, the interest and buy-in of non-health state actors, even with a national law, cannot be assumed. Moreover, possible conflicts in interests and perspectives between state and civil society actors must be managed in national governance bodies. Overall, there is need for participatory policymaking and health-sector advocacy to set health equity as an intersectoral goal, involving subnational leaders in developing concrete action plans, and strengthening NIT's formal accountability systems.
Nisha Bhat, Peter H. Kilmarx, Freeman Dube, Albert Manenji · 6 authors
BACKGROUND: We conducted a case study of the Zimbabwe National AIDS Trust Fund ('AIDS Levy') as an approach to domestic government financing of the response to HIV and AIDS. METHODS: Data came from three sources: a literature review, including a search for grey literature, review of government documents from the Zimbabwe National AIDS Council (NAC), and key informant interviews with representatives of the Zimbabwean government, civil society and international organizations. FINDINGS: The literature search yielded 139 sources, and 20 key informants were interviewed. Established by legislation in 1999, the AIDS Levy entails a 3% income tax for individuals and 3% tax on profits of employers and trusts (which excluded the mining industry until 2015). It is managed by the parastatal NAC through a decentralized structure of AIDS Action Committees. Revenues increased from inception to 2006 through 2008, a period of economic instability and hyperinflation. Following dollarization in 2009, annual revenues continued to increase, reaching US$38.6 million in 2014. By policy, at least 50% of funds are used for purchase of antiretroviral medications. Other spending includes administration and capital costs, HIV prevention, and monitoring and evaluation. Several financial controls and auditing systems are in place. Key informants perceived the AIDS Levy as a 'homegrown' solution that provided country ownership and reduced dependence on donor funding, but called for further increased transparency, accountability, and reduced administrative costs, as well as recommended changes to increase revenue. CONCLUSIONS: The Zimbabwe AIDS Levy has generated substantial resources, recently over US$35 million per year, and signals an important commitment by Zimbabweans, which may have helped attract other donor resources. Many key informants considered the Zimbabwe AIDS Levy to be a best practice for other countries to follow.
BACKGROUND: Robust health systems are required for the promotion of child and adolescent mental health (CAMH). In low and middle income countries such as Uganda neuropsychiatric illness in childhood and adolescence represent 15-30 % of all loss in disability-adjusted life years. In spite of this burden, service systems in these countries are weak. The objective of our assessment was to explore strengths and weaknesses of CAMH systems at national and district level in Uganda from a management perspective. METHODS: Seven key informant interviews were conducted during July to October 2014 in Kampala and Mbale district, Eastern Uganda representing the national and district level, respectively. The key informants selected were all public officials responsible for supervision of CAMH services at the two levels. The interview guide included the following CAMH domains based on the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS): policy and legislation, financing, service delivery, health workforce, medicines and health information management. Inductive thematic analysis was applied in which the text in data transcripts was reduced to thematic codes. Patterns were then identified in the relations among the codes. RESULTS: Eleven themes emerged from the six domains of enquiry in the WHO-AIMS. A CAMH policy has been drafted to complement the national mental health policy, however district managers did not know about it. All managers at the district level cited inadequate national mental health policies. The existing laws were considered sufficient for the promotion of CAMH, however CAMH financing and services were noted by all as inadequate. CAMH services were noted to be absent at lower health centers and lacked integration with other health sector services. Insufficient CAMH workforce was widely reported, and was noted to affect medicines availability. Lastly, unlike national level managers, lower level managers considered the health management information system as being insufficient for service planning. CONCLUSION: Managers at national and district level agree that most components of the CAMH system in Uganda are weak; but perceptions about CAMH policy and health information systems were divergent.
Open access
Mental Health Treatment and Access
Child and Adolescent Psychosocial and Emotional Development
In 2010, the fourth decade of the HIV pandemic arrived during a time of unprecedented success in HIV prevention. Globally, UNAIDS estimated that new HIV infections fell by 33% between 2001 and 2011; new infections among adults and adolescents fell by 50% or more in 26 countries (more than half of these countries were in sub-Saharan Africa), and new infections among children worldwide dropped by 52% [1,2]. The declines in new HIV infections are particularly evident in countries with sustained and more strategic investments, which take into account the specifics of local epidemics, increased political leadership and community engagement in response to the HIV epidemic, and scale up of HIV prevention and treatment programmes [2]. The rapidly growing delivery of antiretrovirals to women and infant feeding–based prevention programmes has resulted in a sharp decline in new HIV diagnoses among children. The encouraging declines in HIV infections can also be attributed to the improved effectiveness of combination antiretroviral treatment (cART), an expanded range of improved medications, the declining prices that make cART more accessible to people in low-income countries, growing coverage with HIV testing, and improved access to prevention and treatment services (particularly for women and young people in low-income countries). Global investment in the AIDS response jumped from US$3.8 billion in 2002 to US$18.9 billion in 2012. The new decade also saw a revolution in HIV prevention with ground-breaking scientific advances in HIV biomedical prevention, and specifically, proof that microbicides containing an antiretroviral agent can reduce sexual transmission of HIV to women by 39% [3], that earlier start of treatment by HIV-positive people (treatment as prevention or TasP) can reduce the risk of onward transmission by as much as 96% [4], and that consistent, correct use of a daily antiretroviral tablet by men who have sex with men (MSM) can achieve substantial reductions in HIV infections (pre-exposure prophylaxis or PrEP) [5]. In response to the excitement and optimism surrounding the preventative effects of antiretroviral medications, the UN member states considered and unanimously approved the new Political Declaration on HIV/AIDS at a special session of the General Assembly in New York in 2011 [6]. At the core of the 2011 UN Political Declaration are ambitious new HIV prevention targets calling on governments to commit to reducing sexual transmission of HIV by 50%, reducing HIV transmission though injecting drug use by 50% and eliminating mother-to-child transmission of HIV by 2015. These targets are aimed at reinvigorating the commitment towards achieving the Millennium Development Goal #6 to combat HIV/AIDS [7]. In the past two years, research on HIV biomedical prevention has focused on adapting the new prevention strategies to the context of local HIV epidemics [8]. There have been equal measures of optimism and pessimism expressed about the ability of new prevention strategies to halt the HIV pandemic. Based on the evidence that starting treatment earlier can increase health benefits and extend life for people with HIV [9,10], many clinicians are already recommending early treatment for both medical and TasP purposes. Regarding PrEP, the widespread reaction is caution in recommending this strategy. Such reluctance is based on concerns about the common adherence issues in the studies of PrEP [11], the obvious relationship between level of adherence to daily medication schedule and its preventative effect [12] and side effects and drug-resistant HIV [13], among others. Despite little evidence that PrEP use can affect behaviour, many concerns have been voiced about the future of safe sex practices, particularly condom use among MSM, if new biomedical prevention strategies are introduced. More research is needed to investigate this issue using appropriate study designs. In its current form, daily PrEP may benefit only a small number of people with very high and ongoing risk for HIV infection, and other PrEP regimens must be explored. The overarching concern about new prevention strategies, particularly PrEP, is that the cost and burden of providing them are currently unacceptable for most, even high-income, countries. As a result, there have been calls for more evidence and a very slow progress in implementing these two new exciting HIV prevention developments. Regarding PrEP, only two countries to date have prescription guidelines for people at high risk of HIV infection [14,15]. We now have the knowledge and new tools to revolutionize HIV prevention, and we have the bold new Political Declaration with ambitious targets. It must be acknowledged that the task of bringing HIV infections down to zero seems daunting from where we stand now in late 2013. Despite the global success in lowering the HIV infection rates by 33% [1], sub-Saharan Africa has seen only a 25% decline [16]. Some regions have seen increases (8% in Eastern Europe and central Asia [17], 19% in East Asia [18] and 37% in the Middle East and North Africa [19]). This lack of progress has been associated with insufficient resources, inadequate coverage of women with antiretroviral treatment and HIV testing programmes not reaching the population groups at high risk for HIV infection. While sexual behaviour has changed to become safer in some countries and populations, sexual risk taking has increased in other settings. This is the case in most high-income countries in North America, western and central Europe and Australasia, where MSM are central to local HIV epidemics. In these countries, both high-risk sexual practices among MSM and HIV infections have been on the rise [20,21]. Condom use has increased in some countries, but declined in others. Proven effective interventions (e.g., prevention of mother-to-child transmission (PMTCT) and needle- and syringe-exchange programmes) have not achieved sufficiently high coverage in many countries [1]. Although trends in risky sexual practices have been linked to the trends in HIV incidence [22] and population-level behaviour change to the reduction in HIV prevalence, there are still challenges in linking behaviour-change programmes to specific HIV outcomes on the population level [2]. While new expectations have been raised about the role of antiretrovirals for HIV prevention, mixed progress was observed in access to cART, and only 61% of people eligible for treatment under the 2010 WHO guidelines received it (this is as little as 34% under the 2013 WHO guidelines). The Political Declaration has for the first time named and acknowledged the importance of such population groups as MSM, people who inject drugs and sex workers for HIV prevention, but in many settings, stigma and access to treatment and prevention services for these groups are still important challenges. Many low- and middle-income countries have stepped up their local investments in HIV prevention [2], but, regrettably, the lack of resources has remained a major issue: only US$18.9 billion was available from all sources for the AIDS response in 2012, and this was estimated to be 16–26% short of annual need [1]. It is at this time of some successes in HIV prevention and challenges in how to optimize the available resources and tools that the aspirational Political Declaration of commitment to fight the pandemic is necessary. This year's International AIDS Day marks the midpoint towards the deadline set by the Political Declaration in 2011. It is an opportunity for governments and each of us to revisit and reinvigorate the universal commitment to bring HIV infections to zero. Like never before, we have good cause to expect the next generation to be AIDS-free and new HIV infections to move towards zero. In the face of the 75 million people who have suffered from HIV/AIDS and the many more affected, the international community should keep the promise and bring this HIV pandemic to an end. None were declared. The Kirby Institute receives project funding from the Australian Government Department of Health and Ageing. The views expressed in this publication do not necessarily represent the position of the Australian Government. IZ has prepared the manuscript and approved its final version.
Dermot Maher, Tido von Schoen-Angerer, Jennifer Cohn
The HIV epidemic is a leading global health challenge. While controversy has surrounded the best HIV prevention strategy, remarkable consensus has supported the campaign for universal access to antiretroviral therapy (ART) for people with HIV infection. As a necessary humane response to the epidemic, the moral imperative to provide ART to people with HIV infection has struck a chord of global solidarity. Much of the funding mobilised for the global response to HIV has supported successful expansion in ART access. Funding is now at a critical juncture as the global financial crisis bites and funders hesitate. Providing universal ART access is a steep hill only half climbed – faltering at this point risks rapid loss of recent gains, and the need to begin again an even steeper climb in future just to regain our current incomplete and perilous position. Against the background of overall efforts to roll back the HIV epidemic, we consider the implications of faltering finances for universal ART access and argue for additional funding, used efficiently. Progress towards universal ART access has individual and also potential community benefits. Although we focus mainly on sub-Saharan Africa as the region most badly affected by HIV and with the least resources to respond, other regions face similar issues. The seemingly inexorable rise in global HIV incidence during the first 30 years of the epidemic peaked towards the end of the 1990s. However, global HIV prevalence and deaths still remain at crisis levels, with 33.4 million people living with HIV and 2 million deaths in 2008 (1). The region most severely affected is sub-Saharan Africa, with 67% of HIV infections and 72% of HIV-related deaths worldwide in 2008 (1). Changing the course of an epidemic of a primarily sexually transmitted infection by changing sexual behaviour is difficult –‘king sex is an unruly monarch’. Demonstrating effectiveness and impact of behaviour change interventions has been difficult and there is little agreement on which specific interventions most effectively change behaviour. Male circumcision is one of few interventions shown in randomised trials to be effective in decreasing HIV transmission risk (2–4), but programmatic delivery is limited and long-term results are awaited. Thirty years’ advances in HIV virology and immunology have been a tremendous scientific success, but have not yet resulted in widely available HIV prevention technologies. The high variability of HIV envelope glycoproteins has frustrated attempts to develop an effective vaccine. After nearly 2 decades of research which failed to find an effective vaginal microbicide (5), the recent finding that tenofovir gel decreases risk of HIV acquisition by 39% is promising (6). Scientific advances have, however, resulted in widely applied HIV diagnosis and treatment technologies. Diagnostic HIV tests are widely available, rapid, easy-to-use, accurate and relatively cheap. Antiretroviral (ARV) drugs can effectively contain HIV even if a cure is not yet possible. Prolongation of life by ART – a tribute to science and technology – has transformed the previously bleak outlook for people with HIV infection. The impact of improved ART access on HIV-related mortality at the population level has been shown in countries with high income, e.g. UK (7) and low income, e.g. Malawi (8). The 10-fold expansion in access to ART in low- and middle-income countries over the 5 years up to 2007 is a tremendous achievement (9). However, the uphill task is not even half completed. The five million adults and children with HIV infection in low- and middle-income countries receiving ART by the end of 2009 represented only 36% of those in need (based on 2010 WHO guidelines) (9). This progress demonstrates proof of principle – that with political and financial commitment universal access to ART is possible – but an unfinished agenda remains. Faltering political and financial commitment threatens to stall progress towards universal ART access. Starting in 2008 the shock waves of the global financial crisis emanated quickly from the USA around the world. The myriad effects of the crisis include threats in developing countries to health services, including ART provision (much of which is funded by donors). The health infrastructure which has been painstakingly built up for ART provision can be easily dismantled in a funding downturn. Developed nations have responded to the ‘credit crunch’ and the collapse of banking systems by allocating vast national resources to bail out financial institutions and industries while their economies contract. Under domestic pressure to curb spending, donor governments are cutting back on development assistance, which may account for a significant proportion of health service expenditure in developing countries. Developing country governments under fiscal constraint may also squeeze health sector expenditure. The global economic downturn therefore compounds the problems of diseases of poverty (e.g. HIV, tuberculosis and malaria) by a double whammy – as socioeconomic conditions which favour the spread of these diseases deteriorate, funds for the health sector response are restricted (10). After substantial yearly increases since 2002 in support for ART access, the USA and other donors have stalled in their funding commitments, with disbursements decreased for 2009 (11). Already by 2009 UNAIDS reported an adverse effect of the economic crisis on ART programmes (12). The Global Fund replenishment pledges for 2011–2013 reached $11.7 billion, far short of the $20 billion needed to expand programmes and even short of the $13 billion needed to keep existing programmes running (13). Although the latest WHO guidelines recommend a CD4 cell count of 350 cells/μl as a starting threshold for ART (14), many centres in Africa continue to use a threshold of 200 CD4 cells/μl because of insufficient ARV supply (15). Medecins sans Frontieres have reported ART rationing to the sickest patients in developing countries, directly contradicting the evidence of benefits of earlier treatment and WHO guidelines (16). Consequences of failure to maintain even the existing ARV drug supply include: more HIV-related diseases and deaths that could have been prevented; without treatment people becoming more infectious, with increased risk of transmission; and increased drug resistance generated by treatment interruption, necessitating more expensive second-line therapies to prevent HIV progression. Financially squeezed ART programmes may further compromise the quality of ART provision in Africa, where mortality is high in the first year of ART because of health systems delays in ART initiation and the quality of care (17). The funds invested in achieving the current level of ART access are a platform for further progress. Additional investment in progress towards universal ART access benefits people with HIV infection, and also potentially the community through improved HIV prevention and improved health systems. Early ART initiation improves patient outcomes and also reduces HIV infectiousness (18) and transmission (19,20), with the potential for ‘treatment as prevention’ (21). Early ART with cessation of viral replication and subsequent immune restoration has benefits for the individual (less risk of HIV-related disease) and also potentially for public health (improved HIV prevention) and for society (increased productivity and decreased costs of HIV-related care) (22). The strategy of universal voluntary testing with immediate ART, which in a mathematical model could eliminate HIV transmission (23), needs evaluation in practice (24). Achieving universal ART access is easier if HIV incidence decreases. This is urgent as the rate of new HIV infections is greater than the rate that people with HIV start ART. Additional investments in implementing combined prevention interventions will decrease HIV incidence, thus facilitating ART provision. Progress towards universal and early ART access could become a virtuous cycle, as the more (and the earlier) that people start ART, the greater is the potential impact in decreasing transmission, with fewer incident cases and fewer people needing ART. Progress in ART provision requires investment in strengthened health systems as well as in the health system elements most directly involved in ART provision. The reasons why HIV has had a much greater impact in Africa than other regions include deficiencies in the region’s health systems. Such deficiencies lead to failure to recognise emerging health problems, diagnose cases, provide quality care, manage surveillance, promote a safe healthcare environment and gain public confidence. Lack of preparedness increases vulnerability to future emerging health problems, unless health systems are strengthened using adequate resources. Investing in ART provision while strengthening health systems is a win-win situation for people with HIV infection and the community. Additional funding generated for improved ART access must be used more efficiently (25). In developing countries, a built-in cost-efficiency is that ARV drug costs fall as coverage increases. Proposals for maximising cost-efficiencies include a cross-cutting agenda for global health to meet the challenges of the financial crisis (26). Disease-specific health initiatives and funding programmes should agree on a cross-cutting agenda to reform the global health architecture and maximise cost-efficiencies, instead of advocating and competing for their own stake in the limited and diminishing pool of donor funds. At country level, greater integration of HIV and other programme activities, e.g. tuberculosis, could improve efficiency and strengthen health systems (27). Scaling-up home-based ART (28) and clinically driven rather than routine laboratory monitoring of ART side-effects (29) can improve ART programme efficiency. ‘How to do more with less’ is a research priority for extending ART access in low-resource settings (30). Finding efficiencies in healthcare delivery is important but does not replace sufficient, predictable financing by donors and domestic funding from low- and middle-income countries. Measures to ensure the lowest possible ARV drug prices facilitate cost-efficiencies. Changes in wealthy nations’ trade policies are urgently needed to avoid creating new barriers for generic drugs. Generic competition has been critical to lowering drug costs and will be critical to also lower the prices of newer drugs needed for long-term survival (31). The free trade agreement with India pursued by the European Union, for example, will further increase monopoly protection, although India has already changed its patent law in compliance with World Trade Organization agreements (32). Donor countries’ support for policies to contain ARV drug costs should complement their commitment to fund ART provision. Achieving universal access to ART is an uphill task but feasible if funding is increased and used efficiently. The choice is stark – to build on progress or to embrace defeat and consign the global movement for universal access to the fate of Sisyphus (33). Note: The views expressed by Dermot Maher are not necessarily those of the Medical Research Council (UK). We thank Brian Williams for his encouragement –“The struggle itself towards the heights is enough to fill a man’s heart” (Camus). DM is a clinical epidemiologist and researcher with extensive experience of the global HIV epidemic as a clinician, public health expert and field researcher. TvS-A has extensive experience of the global HIV epidemic and is a leading advocate on behalf of Medecins sans Frontieres for universal access to HIV prevention and treatment. JC has extensive experience of HIV/AIDS policy and advises the Médecins sans Frontières Campaign for Access to Essential Medicines. DM had the idea for the article which he developed in discussion with TvS-A and JC. DM took the lead in drafting the article and all authors contributed to the development of successive iterations. The sources of information for the article were relevant papers from the peer-reviewed literature. DM is guarantor for the article. TvS-A is employed by, and JC is a policy adviser to, the Médecins sans Frontières Campaign for Access to Essential Medicines, which advocates for universal access to HIV prevention and treatment.
Ongoing scale-up of HIV programs in an era of leveling funds for health require that each dollar is spent efficiently and effectively. From 2004 to 2009, the number of people on antiretroviral treatment (ART) grew from 700 000 to 5.2 million, with a 30% increase realized in 2009 alone [1]. At the same time, for every person starting therapy two others get infected, and the unmet need continues to grow. At the end of 2009, there were 9 million HIV-infected people who were eligible for ART but had not yet started treatment [2]. The Joint United Program on HIV/AIDS (UNAIDS) estimates that in 2009 US$ 15.9 billion was available for HIV/AIDS control globally, US$ 10 billion short of what was needed. There is also a recognized need to re-prioritize other areas of health, notably maternal and child care [3] and to reach universal health coverage [4]. Medium and long-term solutions require significant investment in health systems, increasing the money for health and maximizing health outcomes from available money [4]. As the level of international health financing stabilizes, high-HIV prevalence countries must increase HIV funding from domestic budgets [5], and continue to demonstrate the value for money of their AIDS response strategy to secure sustained donor funding [6,7]. Against this background of changing global health funding and priorities, HIV programs need to monitor and maintain the 5.2 million people currently on therapy, expand treatment initiations to people in earlier stages of infection according to WHO's 2010 guidance [8], and transition to less toxic but more expensive (tenofovir-based) antiretroviral regimens that may be more effective for chronic treatment [9]. Clear evidence on what works is vital for prioritizing program activities and budget allocations. The study by Phillips and colleagues [10] is timely to address the important question of the role of viral load monitoring in preventing the spread of antiretroviral drug resistance. Against the hypothesis that delaying the roll-out of viral load monitoring would result in a worldwide escalation of viral resistance, their modeling suggests that postponing the introduction of routine viral load monitoring will have limited consequences for resistance transmission: 12.4% of new HIV infections are predicted to have primary antiretroviral resistance in 2020 if clinical monitoring is used throughout, compared with 5.4 and 6.1% if viral load-guided switching were introduced in 2010 or 2015, respectively. Phillips and colleagues' findings strengthen the policy consensus and WHO recommendation – so far based on individual patient outcomes and cost-effectiveness in the shorter term [11,12] – that resource-poor countries need not delay ART roll-out because of limitations in laboratory capacity [13]. This is good news, especially for the next few years when HIV programs in many low-income settings are forced to ration new treatment initiations [14], and other ART-supportive activities such as patient adherence support remain underfunded [15]. In high HIV prevalence African countries where a viral load test costs $45–80 and overall delivery of first-line ART $600 per patient-year [12,16,17], omitting viral load monitoring (at one or two tests per year) would allow 8–27% more patients to initiate first-line therapy. In addition, routine viral load testing is associated with an average 40% increased rate of early switching to – more expensive – second-line regimens [18]. In the Phillips' model, introduction of viral load monitoring increased the proportion of patients on second-line regimens by four-fold after 10 years [10]. While improving health outcomes by a small extent [11,12], viral load testing might therefore indirectly increase the average cost per patient by 20–40% or more [19]. Reports by National AIDS programs to the WHO and UNAIDS show large variations in patient monitoring strategies, in rates of switching to second-line regimens, as well as in expenditures per patient [1,2,20]. Several middle-income countries such as Brazil use 3-monthly CD4 and viral load monitoring and a large number of first-line and second-line regimens. Low-income country Malawi, in contrast, implements the WHO-recommended Public Health approach [13], relying on clinical patient monitoring alone and providing a minimum set of WHO-recommended antiretroviral regimens [17]. The marked reductions in AIDS deaths documented in Malawi within years of its ART roll-out since 2004 [20,21] illustrate what can be achieved under a highly simplified medicinal and patient monitoring approach. Delaying the introduction of routine viral load monitoring is in keeping with UNAIDS' Treatment 2.0 strategy [22], an extension on WHO's Public Health approach that aims to further simplify delivery and improve effectiveness of ART. An improved profile of antiretroviral regimens (one pill a day containing a regimen that is forgiving of suboptimal adherence and nontoxic, thus minimizing the need for laboratory monitoring) should allow decentralized community-based treatment delivery. The strategy also promotes an enhanced focus on HIV testing, and on linking treatment delivery with behavioral change communication, to maximize prevention effects. Whereas the antiretroviral regimens envisaged for Treatment 2.0 remain to be developed, ongoing evaluation of the program performance and health impact of public health ART approaches such as in Malawi and Uganda [23] should critically inform global policies. In 2011, Malawi will adopt the WHO recommendation to initiate ART at a CD4 threshold of 350 cells/μl, and transition to tenofovir-based first-line regimens – while for the moment maintaining its practice of minimum patient laboratory monitoring [17]. As patients accumulate years on ART, notably when started at higher CD4 cell counts, longer-term health outcomes and viral resistance surveillance [2,24] will also prove or disprove model predictions – which remain a main guidance at the moment. In the long term, ART programs should aim to expand routine viral load monitoring to prevent viral resistance and preserve the effectiveness of antiretroviral regimens. This will become more affordable and more cost-effective as prices of viral load tests and of second-line antiretroviral drugs continue to decrease. In the short term, while high-prevalence countries continue prioritizing the roll-out of HIV testing and counseling and ART initiations, supportive interventions could focus on effective antiretroviral procurement and distribution to minimize health system-induced treatment interruptions, and on patient adherence support to improve retention and survival on first-line regimens [2,24–26].
Kathryn Church, Korrie de Koning, Adriane Martin Hilber, Hermen Ormel · 5 authors
Current attempts to address the high burden of sexual health morbidity and mortality in developing countries remain limited in scale due to a range of health system constraints. We conducted a literature review of the policy and programmatic issues that influence the integration of sexual health into primary care services in developing countries. Forty-seven reports were identified from a search of both peer-reviewed and gray literature. Key issues identified were intersectoral and intergovernmental coordination; management and organizational issues including decentralization, health sector reform, logistics, and referral systems; human resources, including training and support required to increase service scope; relationships between the public and private sectors; and scaling-up and financing issues.
Introduction There is global consensus on speeding up action against HIV/AIDS to mitigate the impact of the epidemic as rapidly as possible. However, there are no common blueprints on how to organize and manage accelerated HIV/AIDS prevention, care and support programmes to be followed by countries. Countries have tried to develop their intervention measures on the basis of local realities and international experiences available to them. The Ethiopia HIV/AIDS programme implementation process involves a high degree of the learning-by-doing approach, which capitalizes on positive lessons learned further to speed up action against HIV/AIDS. This article is a modest contribution and an example of what can be done in Africa in response to the epidemic in terms of project preparation and implementation (Table 1). It is hoped that some of these experiences can provide useful lessons for the preparation and implementation of HIV/AIDS prevention and control programmes in other countries.Table 1: Landmarks in the history of HIV/AIDS interventions in Ethiopia. Brief history of HIV/AIDS in Ethiopia and rationale for intensified action AIDS is now the leading killer in sub-Saharan Africa. Globally, Ethiopia has the sixteenth highest prevalence of HIV/AIDS and the third largest number of people living with HIV/AIDS (PLWHA), after South Africa and India. The primary modes of transmission in Ethiopia are sexual contact (heterosexual) and perinatal/mother-to-child transmission. Although the magnitude of the problem has yet to be sufficiently assessed, harmful indigenous practices and unsafe needle injection may be considered to be mechanisms for the spread of the virus in view of the wide practice in Ethiopia. The first evidence of HIV in Ethiopia was noted in 1984, and the first two AIDS cases were reported in 1986. HIV prevalence remained low in the 1980s, but has increased rapidly since the early 1990s. HIV prevalence increased from 3.2% in 1993 to 7.3% in 2000 (Fig. 1) [1]. During the same period, increasing trends were noted among women attending antenatal clinics in sentinel surveillance sites with notable regional variations. Estimated adult HIV prevalence according to the Ministry of Health in November 2000 was 16.8, 13.4 and 5% for Addis Ababa (capital city), other urban areas and rural areas, respectively.Fig. 1.: Ethiopia – adult HIV/AIDS prevalence.Initial HIV/AIDS-related activities in Ethiopia A National Task Force for HIV/AIDS was established in 1985. Two medium-term HIV/AIDS prevention and control plans were designed and implemented between 1987 and 1996, with the emphasis on information, education and communication, condom promotion, surveillance, patient care and the expansion of HIV screening laboratories in different health institutions. However, the interventions were limited in scope and there was little involvement of communities, sector ministries, non-governmental organizations (NGOs) including religious organizations and private organizations. The extent of interventions did not correspond to the fast spreading nature of the infection. Factors leading to organizational changes in the management of HIV/AIDS programme Global evidence of the adverse effects of unchecked HIV/AIDS epidemics on the socioeconomic situation of countries and the international movement to scale up action against HIV/AIDS have in no small way influenced the Ethiopian government to take accelerated action against the HIV/AIDS epidemic. Also, the First International Conference on AIDS in Ethiopia held in Addis Ababa on 7–10 November 1999 provided an additional forum for generating the support and commitment of high government officials to enhance HIV/AIDS interventions in Ethiopia. The government of Ethiopia became conscious of: (i) the devastating effects of the increasing infection rate that had reached epidemic proportions; (ii) the devastating impact of HIV/AIDS with the huge number of deaths severely straining the traditional social coping mechanism (the EDIR, a social organization created by communities to support families during funerals); (iii) the weaknesses of the existing organizational set-up to handle the rapid progress of the infection; and (iv) the common understanding that if the epidemic is left unchecked, it will alter the trajectory of the country's development by retarding growth, weakening human capital, discouraging investment, exacerbating poverty and increasing inequality. Ethiopia, therefore, in August 1998 approved a comprehensive HIV/AIDS policy to provide guidance and direction to the preparation of a multi-sectoral and multi-partner HIV/AIDS prevention and control programme. A National HIV/AIDS Council composed of ministers, regional heads of state, civil society, religious leaders, NGOs and PLWHA was established under the chairmanship of the President of the Federal Democratic Republic of Ethiopia in April 2000. The National Council has appointed the National Advisory Board, which meets monthly to provide direction and guidance to the implementation of the multi-sectoral HIV/AIDS control and prevention programme through the National HIV/AIDS Secretariat and its Project Coordinating Unit (PCU). Regional and local coordinating bodies were also established to facilitate the implementation of HIV/AIDS interventions at the community level. Influence of global HIV/AIDS movements on HIV/AIDS programmes in Ethiopia Globally, HIV/AIDS is now treated as an economic crisis and not merely a health problem. Successful HIV/AIDS interventions under such circumstances require actions as broad as the epidemic itself and intense enough to respond effectively to the level reached by the epidemic. The resource needs of such massive interventions are too enormous to be sufficiently addressed by many developing countries. A number of international agencies have expressed readiness to increase their commitment substantially in the fight against HIV. In order to realize this commitment, an International Partnership Against HIV/AIDS in Africa was formed, and UNAIDS was established co-sponsored initially by UNICEF, UNFPA, UNDP, UNESCO, WHO and the World Bank. The number of co-sponsors has since increased. The co-sponsors and UNAIDS secretariat met in Annapolis, Maryland, USA, on 19–20 January 1999, and agreed to work together to slow the spread of HIV in Africa drastically, and enhance a sustainable political and social mobilization at an unprecedented scale in order to reduced HIV transmission and suffering and to mitigate the impact of HIV/AIDS. The World Bank, conscious of the crisis created by the epidemic and the consequences of inaction, and convinced that it could play a greater role in HIV/AIDS prevention and control, prepared a strategic document in May 1999 [2] entitled ‘Intensifying action against HIV/AIDS: responding to a development crisis'. The Bank's new strategic plan placed HIV/AIDS at the centre of its development agenda to combat the epidemic, in partnership with African governments and UNAIDS. To stimulate and support the implementation of the strategy, the World Bank took three major actions: (i) established a multi-sectoral AIDS Campaign Team for Africa (ACTAfrica); (ii) directed all bank projects to include an HIV/AIDS component; and (iii) made available an initial US$500 million fund to be drawn by African countries to scale-up their HIV/AIDS interventions. A second amount of US$500 million was recently approved by the board of the World Bank. The global mobilization efforts have to a great extent encouraged the government of Ethiopia to intensify the action against HIV/AIDS to reverse the tragic situation. Enabling environments (internal and external) created to scale-up HIV/AIDS interventions in Ethiopia The global movement to accelerate and expand action against HIV/AIDS has created a potential for the increased availability of essential resources to developing countries. In Ethiopia a number of international and bilateral donors (e.g. WHO, UNICEF, UNDP, UNFPA, UNAIDS, ILO, USAID, DFID, GZT, DANIDA, Irish Aid, Norway, the Netherlands, Italy, the World Bank) have either provided support or are finalizing their project support. The government of Ethiopia approved a multi-sectoral and comprehensive HIV/AIDS policy that created an enabling environment for a wide range of HIV/AIDS prevention and control activities. The establishment of the National HIV/AIDS Council, the Advisory Board, National and Regional HIV/AIDS Secretariats, and their decentralized bodies have established potentially appropriate organization and management structures to lead expanded and intensified HIV/AIDS interventions throughout the country (Fig. 2).Fig. 2.: Organizational structure for HIV/AIDS management programme. NGOs, Non-governmental organizations.The World Bank has made funds available to countries including Ethiopia to draw from its initial allocated fund for HIV/AIDS. The Ethiopia Multi-sectoral HIV/AIDS Project (EMSAP) finances a 3-year (2000–2003) government HIV/AIDS strategic plan that is estimated initially to cost US$63.4 million [3,4]. The World Bank has approved US$59.7 million to help pay for the project, of which more than US$28 million is earmarked to support civil societies and community-driven HIV/AIDS initiatives. The process undertaken during the preparation of the Ethiopia Multi-Sectoral HIV/AIDS Project After formulating the national HIV/AIDS policy and preparing the National HIV/AIDS Strategic Framework [5], the Government of the Federal Democratic Republic of Ethiopia requested the World Bank to support its efforts to accelerate and expand action against the epidemic of HIV/AIDS in the country. As the request was in line with the global commitment and strategic plan of the Bank, the Bank agreed to the Government's request as long as there were institutional arrangements in place, such as the formation of a National AIDS Council, the establishment of the National Secretariat and the appointment of a National Task Force to lead the process of project formulation and development. The National HIV/AIDS Council was inaugurated in April 2000, and the appointment of the head of the National Secretariat was announced in the same forum. The preparation of EMSAP started in July 2000. Again at the request of the Government of Ethiopia, a multi-donor HIV/AIDS identification and preparation mission was undertaken to facilitate the preparation of a fundable project for an HIV/AIDS prevention and control programme in Ethiopia. A preliminary consultation workshop was held early in July 2000 to assess the prevailing HIV/AIDS situation in the country, and suggest the scope and actions to be undertaken to address the epidemic. The participants included members of the newly formed National HIV/AIDS Council, representatives of major sector ministries, regional state representatives, NGOs, and members of the civil society (women, youth, PLWHA, religious organizations, academic institutions) and donors. On the basis of the briefing on the status of HIV/AIDS and discussions that followed, the meeting agreed on actions that needed to be taken to mitigate the effects of the epidemic rapidly. The meeting stressed the following points during its deliberations: That HIV/AIDS activities should be guided and directed by the highest authority in the Government and the National HIV/AIDS Secretariat should be directly under such an authority that commands respect for its directives by all concerned. HIV/AIDS activities should be community based and driven. A special emergency grant fund should be created to support civil society and community-based initiatives. The fund should flow directly to communities, circumventing the normally bureaucratic financial system of the Government. The establishment of such a financial system would help ensure a fast flow of funds to support communities to engage rapidly in scaled-up HIV/AIDS interventions. NGOs, private organizations, community-based organizations and PLWHA should be actively involved and supported to expand their HIV/AIDS interventions by directly providing grant funding to support their activities. The project should be designed in a way that provides flexibility. The participants of the meeting outlined the objectives, components and logical framework for EMSAP. On the basis of the strategic plan and the logical framework, the National AIDS Secretariat Task Force, with technical support from World Bank staff and other donors, developed a draft multi-Sectoral HIV/AIDS Programme. The main objective of EMSAP is to help reduce the spread of the HIV/AIDS epidemic, alleviate its impact, and increase access to treatment, care and support for those infected and affected by HIV/AIDS. The components of the project were identified as including: (i) capacity building of public and private institutions; (ii) the Government multi-sectoral (iii) the response of communities, NGOs and the private sector to mitigate the and (iv) project and A draft project document was prepared and to a second The draft document was also for to of the during the initial meeting and an international mission composed of UNAIDS and bilateral institutions. The draft document was on the basis of the and provided by and a document was which the Government for funding to donors. Brief of components and activities The project components the scope of activities that have to meeting the agreed The country has a limited public capacity to the newly HIV/AIDS programme. It was to the institutional capacity of Government civil society and the private sector at and to accelerate the implementation of the HIV/AIDS programme. in this include the of human and other to the national and regional and and HIV/AIDS bodies in the were on EMSAP and were to the Project and other and the multi-sectoral implementation response of government agencies The of this is to support the multi-sectoral response of government organizations to scale up their interventions in the fight against the expansion of HIV/AIDS. The initial interventions prevention condom and and and care and support for those infected and affected of financial and support to PLWHA and in this government organizations at the level have established HIV/AIDS and their work plans and for and by the National Advisory the work plans and were approved and funds have to of (Table approved and for projects by non-governmental organizations, private organizations and people living with HIV/AIDS by the National HIV/AIDS The Ministry of has held and and HIV/AIDS for and and is the formation and of The Ministry of has up condom availability and the and of The authority has not the of HIV/AIDS interventions as and condom infection and as of the with but also is in the process of HIV/AIDS interventions among its and work regional sector have developed and their work plans and to the regional HIV/AIDS fund The emergency HIV/AIDS fund is an of EMSAP. A number of NGOs and community-based organizations in the country are to potential that could be by providing additional and including The is designed to support NGOs, the private religious organizations and community-based organizations to scale up their HIV/AIDS prevention and control activities in order to reduce the of the epidemic as fast as possible. The has two for and and the other for NGOs, private organizations, PLWHA and civil societies for all two with and NGOs religious and private organizations have from the of the fund (Table programmes and care and support to those infected and affected has increased in scale and scope in of the and communities supported by of funds by the Project Coordinating Unit to ministries, regional and HIV/AIDS Although there are in the country, International support for community-based programmes will be in for the There have to increase the number of support. The is not the of funds but the capacity to provide the support to The process of implementation also involves that require of the experiences the of an is to what has and what needs to be or The process involves a high degree of learning-by-doing a of experiences Project and management The main of this is to help develop a and management system that is of coordinating and the the National Secretariat is the management and is to a under the direction of the National HIV/AIDS Secretariat The is with structures that include programme and and The of funds to International Government of of NGOs, non-governmental National Project Coordinating people living with Regional The has established with the essential and The provides support to the establishment of the regional The has more than for funding at a national and has the of some funds to the appropriate A and has established and a and has appointed in an to a and system for HIV/AIDS in the country. process and impact have identified to help the and of the an HIV/AIDS system has developed with the of The Ethiopian and with support from the is actively involved in HIV/AIDS the support of USAID, Health International is a on HIV/AIDS. of these are to to and the effects of the interventions. of the Ethiopian project EMSAP is by communities, NGOs and donors. the US$63.4 the is US$59.7 million The is to be by donors, NGOs and The financial management system two of the funds is provided through the government fund flow and the other is directly to that have established and financial control the of the preparation of many expressed a to support the project, but the created an that in a After the of in the a number of donors have to support the Government's HIV/AIDS programme. became on January this the World Bank is the major to the The major and experiences in the implementation of the project National and regional and have established and The and have formed in the first of and were appointed and are in and coordinating community-based activities. have funds from the centre and have started up HIV/AIDS interventions. activities have is as by the increase in the number of HIV/AIDS is with by private and public in a of in the for HIV/AIDS is through the UNAIDS In briefing are by the to on the status of implementation of the The financial and system and organization and have prepared to the management of the project at and other have provided to the and the regional to facilitate and activities. have placed for the of and to and the of by health institutions. for have prepared and In view of the by the of the epidemic, the management of the national and regional had to be rapidly and in a There was little for the and to and the implementation process of the project In the project has a a number of and which made In view of these the progress in implementation is not as fast as for an emergency The project is implemented by many and decentralized and were prepared and to coordinating and bodies to the implementation of the project the have useful in the implementation However, there is a to ensure to facilitate the of the to different The project by massive involvement of NGOs, the private sector and community-based organizations to scale up HIV/AIDS prevention and control interventions to mitigate the impact of the epidemic rapidly. This epidemic a coordinating mechanism at all as the government would to facilitate the of these in the and management capacity of the and regional have the of all those to be actively The of government is an of EMSAP. Although it is to that some sector have expanded their HIV/AIDS a number of require and support to increase the scope of their HIV/AIDS interventions. The development of the and system was special from the of the composed of national and international organizations in and was established to and provide for and development. A national and was and in and held in South Africa. action is needed to the and system a in the of an appropriate and system will the process of project actions are taken by all to enhance the establishment of a and learned The Ethiopia HIV/AIDS project was prepared a fast project preparation a fast preparation process was by the to resources for an emergency situation that had started economic and a on the existing social coping The of the project has not increased but has also the establishment of management structures essential for intervention international partnership was in and generating government to take action against HIV/AIDS. The Government of Ethiopia established a comprehensive HIV/AIDS a HIV/AIDS strategic and a multi-sectoral HIV/AIDS National Council, under the of the President of the Federal Democratic Republic of Ethiopia. In the government established a National HIV/AIDS Secretariat under the a under the National and a policy that the of all of which are essential for up HIV/AIDS interventions in the country. The government has that of activities in limited areas are to slow the rapidly increasing epidemic, and has up regional and that are now leading a against HIV/AIDS It is that in the epidemic an expansion of community-based interventions. The Government of Ethiopia has taken unprecedented measures to interventions at a community level by a to funds to flow directly to communities, and public funds available to support NGOs and private organizations. This action has made the rapid of to communities to help the rapid implementation of community-based which would have slow if the flow of funds had followed government As a of such a rapid progress has noted in some of the communities as by the increase in activities and support to those affected and infected the to all the during the first was The to the number of to has created a forum for what a learning-by-doing an to assess the in the and to the and of the intervention measures during the first learned during the first of implementation were to some of the in the of The level of and capacity of communities is in terms of their to The that communities are provided with and is not should be supported by community-based NGOs or other development to in the The the government has an implementation in has encouraged many donors to in HIV/AIDS interventions in the country. than donors are now a new commitment to provide additional technical and financial support. EMSAP is of the first two HIV/AIDS programme projects by the World Bank in sub-Saharan Africa. The of project preparation and of implementation have for many other HIV/AIDS projects in with of the scope and of the epidemic, and the readiness of many of the to fast action at the project level is and However, rapid project preparation and implementation and that to be addressed as early as possible. EMSAP the of the of the implementation process in order to and early measures to the project to its the adverse consequences of and conscious of the limited capacity of the existing the World Bank has taken special measures to support the national and regional and to accelerate the implementation of EMSAP. In to the support provided by the and the at the country a bank was to support the and the regional This has substantially to project implementation at all The National Secretariat and have with regional to assess progress and on actions to be taken during the following such have and the discussions and taken in these have created common understanding on project implementation and common to during The and the taken to an HIV/AIDS programme in Ethiopia can provide and for other developing countries on this public health A of the major the actions taken and are in The fast preparation process undertaken by this project in Ethiopia was in funds available to scale up intervention activities by communities, NGOs, private organizations and the public sector rapidly. The project a learning-by-doing than to programme in during which would have by of major action taken and the process project funds were directly to NGOs, community-based organizations, and communities to scale up rapid HIV/AIDS interventions at the local the are the of the project and the of of the the during the first are not the HIV/AIDS project in Ethiopia, a number of national and international organizations have now developed a partnership with the government by providing financial and support to the project to be in Ethiopia, trends have in and the expansion of care and support at the community level. A number of World Bank staff and international organizations have to the preparation and implementation of the project, and it is to all and organizations. The to the special contribution of the following in the and implementation of and The would also to their of the and support by the national and regional the Project and the international and bilateral organizations. the special support and to the by World Bank President for and the have support and guidance to the preparation and implementation of the
Marjorie Opuni, Stefano Bertozzi, José-Antonio Izazola, Juan Pablo Gutiérrez · 5 authors
Introduction In the past 2 years, political commitment to respond to the HIV/AIDS pandemic has increased sub-stantially. The United Nations General Assembly Special Session on AIDS in 2001 and the recent creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria are two indicators of this commitment at the global level. At the regional level, HIV/AIDS has been an issue on the agenda of the Inter-American Development Bank, the Asian Development Bank, and the Organization of African Unity, to name but a few institutions. At the national level, low-income and middle-income countries, home to over 95% of people living with HIV/AIDS, have made important progress in HIV/AIDS planning and program development [1,2]. In this policy environment, the importance of information on resources for HIV/AIDS prevention and care has increased. More and more, policy-makers are looking for data on the level and flow of current allocations to HIV/AIDS. They want to know where money for HIV/AIDS prevention and care is coming from, the services and commodities that are purchased with these funds, and the population coverage of implemented interventions. At the same time, to identify gaps between what is and what should be and to plan strategically, policy-makers are seeking information on the scale of resources required to prevent the further spread of HIV and to provide adequate care for those people living with HIV/AIDS. Because the epidemic is so concentrated in low-income and middle-income countries, estimating HIV/AIDS resource allocations and requirements in these countries is key to responding effectively to HIV/AIDS world-wide. It is also in these countries that this task is most complicated. Program data, ideally produced by national health information systems, are required to monitor resource flows. In many of these countries, however, such systems are weak or nonfunctioning. Similarly, to derive estimates on resource needs, one requires a range of demographic, economic, and health data that are scarce or nonexistent in many developing countries. Notwithstanding these obstacles, significant progress was made during the past year in both monitoring the level and flow of current allocations to HIV/AIDS and estimating HIV/AIDS resource requirements in developing countries. The present article reviews the latest data and examines their policy implications. It identifies the gaps and limitations of current research. The article also discusses future directions to strengthen the quality of data on resources for HIV/AIDS prevention and care. Resources allocated to HIV/AIDS Few countries, whether low, middle or high income, regularly monitor resource flows to the HIV prevention activities conducted by government and nongovernmental institutions within their territory. To date, no country has developed a system that regularly tracks expenditures on HIV/AIDS care. The most well-established data collection activities documenting resource allocations to HIV/AIDS in developing countries are international initiatives. Each year, donors report their official development assistance (ODA) to HIV/AIDS and other sexually transmitted infections (STI) to the OECD Development Assistance Committee (DAC) [3]. Similarly, the Netherlands Interdisciplinary Demographic Institute surveys donors (annually) and developing countries (biannually) for UNFPA and UNAIDS on their HIV/AIDS/STI expenditures as part of their Resource Flows Project. The most detailed information on resource allocations to HIV/AIDS in developing countries comes from indepth country studies conducted on an ad hoc basis. Most recently, the Regional AIDS Initiative for Latin America and the Caribbean (SIDALAC) and the Partnerships for Health Reform have investigated HIV/AIDS financing in several countries using the National Health Accounts (NHA) framework [4]. The present section discusses the latest data from these sources. Table 1 presents the HIV/AIDS/STI ODA data reported to the Resource Flows Project between 1998 and 2000, with data reported to the OECD DAC imputed when no data was reported to the Resource Flows Project. Donor countries disbursed a total of US$ 454 million in 2000. According to reports to the OECD DAC, this represents 87% of the US$ 521 million that were committed or allocated to HIV/AIDS/STI projects during 2000. Total disbursements for 2000 represent a significant increase from the US$ 294 million and US$ 279 million disbursed by donors in 1998 and 1999, respectively.Table 1: HIV/AIDS/sexually transmitted infections official development assistance disbursements, 1998–2000 (US$ million)As in previous years, the United States was by far the largest donor of HIV/AIDS/STI ODA in 2000. However, when this ODA is broken down as a proportion of gross national income for each country, Luxembourg contributed the largest proportion of its gross national income (Fig. 1).Fig. 1.: HIV/AIDS/sexually transmitted infections (STI) official development assistance (ODA), 2000. Total amount obligated in US$ million and obligations per US$ million gross national income (GNI).What is revealed by these data and past surveys on HIV/AIDS/STI ODA [5–7] is that surveys provide reasonable information on these expenditures, albeit varying in comprehensiveness and accuracy. Past global surveys have also illustrated that questionnaires can provide relatively good data on HIV/AIDS resource allocations that flow into developing countries from the United Nations system and nongovernmental institutions in high-income nations. Although as HIV/AIDS is increasingly integrated into projects addressing broader health or development issues, HIV/AIDS expenditures are becoming more difficult to track even among these international institutions. However, questionnaires sent to national HIV/AIDS coordinating institutions to collect data on domestic resource allocations to HIV/AIDS are much less efficient tolls for gathering quality data. In part, this is because regularly updated information systems do not exist and it is difficult for national HIV/AIDS coordinating bodies to gather expenditure data from the many ministries and organizations implementing HIV/AIDS interventions in a country. In addition, for large portions of HIV/AIDS expenditure, data must be estimated with special studies. To estimate domestic expenditure on HIV/AIDS care, for example, studies costing selected services must be undertaken. Likewise, to capture how much individuals themselves spend on HIV/AIDS services (out-of-pocket spending), which in many countries constitutes the majority of overall AIDS spending, requires household or clinic-based studies of people living with HIV/AIDS. It is these information gaps that in-depth country studies using the NHA framework aim to fill. These studies attempt to account for all expenditures by looking not only at public sector financing, but also at spending within the private sector, including spending by individuals. They collect the data that are available and conduct special studies, such as limited household surveys, as necessary. Most of the studies on HIV/AIDS resource allocations using the NHA framework have been carried out in Latin America and the Caribbean (LAC) [8]. Referred to as National HIV/AIDS Accounts, they were first carried out in Brazil, Guatemala, Mexico and Uruguay in 1997/1998 [9–12], with substantial scaling-up of efforts occurring in the past year. SIDALAC recently completed studies in 12 countries (Argentina, Bolivia, Brazil, Chile, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, and Uruguay) and studies in three additional countries are underway (Costa Rica, the Dominican Republic, and Honduras)[13]. Total HIV/AIDS spending in the 12 countries in Latin America studied (representing 75% of the population of the region) [14] in 2000 was estimated at US$ 1.04 billion. This represents an average of US$ 2.70 per capita for the 12 countries, with individual country per-capita expenditure ranging from US$ 0.30 and US$ 0.60 in Bolivia and El Salvador to US$ 5.60 and US$ 4.90 in Uruguay and Argentina (Table 2). In terms of average expenditure per person living with HIV/AIDS (PLWHA) in the 12 countries, this translates into a little over US$ 1000 regionally, with over US$ 3000 spent per PLWHA in Uruguay and only US$ 175 per PLWHA spent in Guatemala.Table 2: HIV/AIDS expenditure in 12 countries of Latin America and the Caribbean, 2000.Overall, US$ 753 million (73%) of HIV/AIDS resources in the 12 countries were spent on care, with only US$ 283 million (27%) spent on prevention. This trend was true across countries with the exception of Bolivia and Nicaragua, countries with relatively lower prevalence rates, where only 34 and 36% of HIV/AIDS resources, respectively, were spent on care. Almost 72% of the resources spent on HIV/AIDS care in the 12 countries were spent on drugs, with the vast majority (almost 90% of drug expenditure) spent on antiretroviral drugs (ARV). Of course, social pressure for access to ARV in the region is high, and three of the 12 countries (Argentina, Brazil, and Uruguay) provide universal access to these drugs. However, this estimate does appear to be extremely high and may represent a bias since drug expenditures are easier to monitor than other components, especially when procurement of ARV is centralized through national HIV/AIDS programs, such as is the case in Brazil. With 60% of prevention expenditure on condoms and 14% on mass media campaigns, most of the prevention expenditure in the 12 countries was spent on interventions targeting the general population. This is notable in countries where HIV prevalence is still extremely low in the general population and the epidemic is concentrated among specific population groups [1]. In Mexico, Nicaragua and most of the Andean region, sex between men is the most prominent route of HIV transmission. Similarly, in Argentina, Chile, and Uruguay, injecting drug use is the main route of transmission. Given the epidemiology of the epidemic in the region, one would therefore expect that significant proportions of HIV prevention expenditures would be allocated to interventions targeting these population groups that are key to the expansion of the epidemic. However, only limited funds in the region (7% of prevention expenditure) were reported as allocated to such interventions. The major sources of HIV/AIDS funds also varied across countries. In Argentina, Brazil, Chile, El Salvador, Guatemala, Mexico, and Panama, the government health sector was the primary source of resources allocated to HIV/AIDS. In Paraguay, Peru, and Uruguay, private funds from enterprises, nongovernmental organizations and households were the primary sources of resources allocated to HIV/AIDS, while international sources provided most of the funding in Bolivia and Nicaragua. Even though studies using the NHA framework provide the most detailed estimates on resource flows in countries, they remain estimates that vary in completeness and accuracy. Although the studies attempted to account for all expenditures, the quality of the estimates depended on the availabilityand quality of financial and accounting data within relevant government and non-governmental institutions, and on the capacity of personnel within these organizations to formulate estimates where data were not available. It is probable, as mentioned earlier, that certain categories of expenditures, including spending on information, education and communication interventions, were underestimated because they were more difficult to track than expenditure on commodities such as drugs and condoms. It is also probable that expenditure by nongovernmental organizations, especially those that were community based, were under-reported since donated goods and services were not quantified adequately. Likewise, it is probable that in decentralized governments, with weak financial tracking at lower administrative levels, funds were missed or, alternatively, double counting occurred with expenditures being reported at higher and lower administrative levels. To estimate the expenditure on HIV/AIDS prevention and care for all countries in LAC, a regression was run to extrapolate the estimates for these 12 countries to the region. [A regression was run for these 12 countries with SIDALAC country totals as the dependent variable and the values from the care imputing exercise (described later) as the independnt variable.] The result is an estimate of US$ 1.4 billion for all countries in LAC. The only country outside of LAC where the NHA framework has also been used to estimate expenditures on HIV/AIDS is Rwanda. A study conducted for 1998 concluded that a total of US$ 10 million or US$ 1.27 per capita were spent on HIV/AIDS during that year [15]. This represents a total of US$ 25 per person living with HIV/AIDS, compared with the average of US$ 1000 per PLWHA in the 12 countries in Latin America already discussed. While spending in Latin America is large compared with spending in Rwanda (and presumably other countries in sub-Saharan Africa), even this expenditure is very small compared with expenditure by high-income countries such as the United States. The Federal Government spent US$ 10.8 billion on HIV/AIDS in the year 2000 [16]. If this amount is raised by the same proportion as that which prevails between public and total spending on health in the United States, then total HIV/AIDS spending can be estimated just below US$ 25 billion in 2000 [17,18]. This amount translates into nearly US$ 90 per capita, or just over US$ 30 000 per PLWHA. A check on the credibility of this seemingly high level of spending is provided by an analysis of spending on Medicaid-covered AIDS patients, which projected that expenditure would average almost US$ 36 000 per patient [19]. Resource needs for HIV/AIDS Similar progress was made in the area of estimating resource needs for HIV/AIDS over the past year. Two major studies of resource requirements estimates were published. The first, undertaken for the Commission on Macroeconomics and Health (CMH), estimated resources needed to scale-up a package of core interventions to address HIV/AIDS and other priority illnesses in 83 low-income and middle-income countries (including all of sub-Saharan Africa) by the years 2007 and 2015 [20,21]. The second, carried out in preparation for the UN General Assembly Special Session (UNGASS), estimated the cost of HIV/AIDS prevention and care needs in 135 low-income and middle-income countries in 2005 [22]. These two studies built on prior work on estimating resource needs for HIV/AIDS and used similar methodologies [23,24]. The methodologies used have been detailed previously [20–22]. Both studies included a selection of interventions that were costed based on published and unpublished project assessments (Table 3). Estimates were then made intervention-by-intervention and country-by-country using demographic, economic and epidemiological data to adjust the estimates to different country contexts. The main difference in methodology between the two studies was the inclusion in the CMH study of the costs for infrastructure strengthening necessary for scaling-up. In addition, there were differences in assumptions, with the most important being differences in target population coverage rates for the different interventions.Table 3: HIV/AIDS prevention and care interventions.The UNGASS study called for the annual spending of US$ 9.2 billion on HIV/AIDS prevention and care in low-income and middle-income countries by the year 2005, with up to US$ 6 billion coming from international sources. The CMH study concluded that, depending on coverage assumptions and price estimates, between US$ 13.6 billion and US$ 15.4 billion should be spent on HIV/AIDS prevention and care annually (including necessary infrastructure strengthening) in selected low-income and middle-income countries by the year 2007 in addition to what is already being spent, and that this should increase to between US$ 20.6 billion and US$ 24.9 billion by 2015. The ranges of the results within and across studies underline the fact that these are estimates with limitations. They underscore the data gap in low-income and middle-income countries and the many assumptions required while building each model to derive parameter estimates for which no data exist. As discussed further later, they should therefore be interpreted with caution and be seen as works in process that can be refined as new information becomes available on cost data, current intervention coverage estimates, and country capacity to expand services. Nonetheless, sensitivity analysis conducted usingthe UNGASS model confirms that study results provide a consistent estimate of the scale of resources needed. A probabilistic analysis that varied assumptions on intervention coverage, costs and country capacity to expand services produced a range of results that were comparable with the ranges reported in the CMH study. So, in short, the UNGASS and CMH estimates provide policy-makers with consistent information on the scale of the resources needed. But it would be inappropriate to use them to guide resource allocations among interventions at the national level. Although these two studies did differentiate across countries whenever possible, data limitations did not allow them to pay significant attention to individual country characteristics and the way in which those may affect overall costs. To improve the estimates so as to have them serve as tools for country strategic planning, both study teams recognized that additional country-level work would be necessary. This process has begun with individual country validations of the UNGASS estimates for the LAC region. The 10 countries to participate in a first phase of this effort were Brazil, Chile, the dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Mexico, and Trinidad and Tobago [25]. These countries increased the estimated resource requirement for HIV prevention by 15% and the estimated care requirements by 27%. The main differences in prevention estimates are accounted for by an increase in estimated resource needs for the social marketing of condoms and prevention of mother-to-child transmission, while the main differences in care estimates were due to important differences in the expected costs for highly antiretroviral Total expected resource needs for highly antiretroviral increased by compared with UNGASS To estimate the HIV/AIDS prevention and care needs for all countries in LAC, the estimates for these 10 countries were to the region using were run for the prevention and care estimates Because a was between the care data estimated by the countries and those estimated for used to the The used of to values for the countries that have not their The prevention exercise was similar in addition, it used the results of the care as an variable that was imputed with the regression than with the The UNGASS model called for US$ with US$ million for prevention and US$ million for care and prevention were refined the of the model estimates the estimate for Latin America and the Caribbean from US$ increased this by US$ million to almost US$ with US$ million for prevention and US$ million for care and the between the UNGASS estimates and those of the 10 is these estimates provide further for the overall of the To plan and to the policy-makers data on resources for HIV/AIDS prevention and care. a of public and private spending on the are to track and the of their to HIV/AIDS. estimate of the of resource needs to address the epidemic they are to plan and resources for the data that are available the for additional resources and for in the of those resources available. But to date, few policy-makers in low-income and middle-income countries countries that this information most have these data for their countries. are available on the annual official development assistance allocations to HIV/AIDS by high-income countries with limitations. These data that there was a significant increase in the flow of HIV/AIDS funding from high-income countries to developing countries in 2000, US$ represents only a of the estimated US$ billion in international resources required annually to respond to the epidemic in these countries. Similarly, in-depth country studies of which have been carried out in the vast in spending on people living with HIV/AIDS that exist These studies that an average of US$ 1000 per person living with HIV/AIDS was spent in Latin countries in 2000. This is more than estimates for sub-Saharan of people with HIV/AIDS of less than US$ and far less than estimates for the United States at over US$ 30 the results of the UNGASS model for LAC (almost US$ billion for the year with those of the National HIV/AIDS Accounts studies to the region (US$ 1.4 billion for further of the important policy that are raised by these of data. The higher estimates of current expenditure are due in part to the fact that the two estimates do not the resources with of interventions. The two also different assumptions on costs of and estimates of current intervention In addition, they are also based on different of countries and there are therefore different of in these estimates to the region. However, the difference in the assumptions made in the UNGASS model that the procurement of commodities such as and HIV is and that there is and in the of HIV interventions. The fact that estimates of current expenditure are higher than those for future resource needs in part the that result from that countries in the region to pay less for condoms and To strengthen the quality of HIV/AIDS financing data in developing countries, necessary the of studies to track National HIV/AIDS SIDALAC has that the process is The studies conducted in the region with the National Health Accounts by the Health Organization and the OECD have cost between US$ 25 000 and US$ 000 per year per country depending on country and This that in financial resources not be a to the of a system for monitoring HIV/AIDS resource flows. At the same time, estimates of country-level resource needs should be for all low-income and middle-income countries. are for the of the LAC region. Similar should be undertaken in sub-Saharan and one important HIV/AIDS prevention and care resources in developing countries is still estimates of resource needs should a not only resource needs, but also the provided by the resources on the expected from new would provide data to on the of resources within and across countries and The are to and of UNAIDS for the use of the HIV/AIDS/STI data reported to the Resource Flows Project. They the of the SIDALAC country from Argentina, Bolivia, Brazil, Chile, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, and Uruguay the data on the National HIV/AIDS They also of SIDALAC for assistance with the of the National HIV/AIDS Accounts data.
As of July 1994, there were 565,856 human immunodeficiency virus (HIV)-infected persons in South Africa, half of whom were 18-25 years of age, and 27% of the adult population is likely to be infected by the year 2010 if current risk behaviors persist. By 2005, the cost of acquired immunodeficiency syndrome (AIDS) to South Africa's health service could reach R18 billion. The newly established National AIDS Task Force seeks to prevent further HIV transmission by promoting condom use, improving control of sexually transmitted diseases, providing a safe blood supply, adopting universal precautions for skin piercing and surgical procedures, preventing intravenous drug use, providing information about prenatal transmission, promoting policies that raise women's status, and socioeconomic development. The personal and social impact of HIV infection will be ameliorated through comprehensive health care and counseling for AIDS victims and their families, protection of infected individuals from discriminatory practices, sustainable social services and benefits to meet the needs of those with AIDS, and promotion of policies that address the socioeconomic consequences of AIDS. On the administrative level, interventions are planned to promote intersectoral coordination, ensure adequate financing, promote community involvement, decentralize planning and management, ensure program monitoring and evaluation, forecast HIV trends, and share technical expertise.