How a Great Power Falls Apart
Decline Is Invisible From the Inside
(Photo: hiyori13 / flickr.)
There was much to celebrate on World AIDS Day last week. Over the last decade, an unprecedented surge in donor support for HIV/AIDS treatment has lengthened and improved the lives of millions of people living with the disease. The number of people receiving antiretroviral treatment worldwide stands at more than six million in 2011, a 16-fold increase since 2003. Accordingly, those affected with HIV/AIDS are living, on average, longer lives than at any point since the dawn of the pandemic.
But celebration is premature. Success in treatment is great, but the underlying strategy of focusing resources on treatment is flawed. The rate of new infections now outpaces the rate of AIDS-related deaths, so the number of people living with AIDS -- and therefore the number of people needing treatment -- is growing faster than the funding needed to provide care. In 2010, some 1.8 million people died from AIDS-related illnesses, but about 2.7 million were newly infected, increasing the total number of people living with the disease by approximately 900,000. In other words, although there is no question that focusing on treatment prolongs lives, it's just not a financially feasible strategy to manage the spread of the disease -- much less to eradicate it altogether.
Read more at at Foreign Affairs' Special Report: Global Public Health.
It is unfortunate that so many have focused on treatment alone because there is a way to end the global scourge of HIV/AIDS: by conditioning the rate of expansion of treatment programs on the reduction of new infections. This much-needed shift would lead to what I call an AIDS transition -- the day on which the rate of new infections falls below the rate of AIDS-related deaths so that the number of people living with HIV/AIDS decreases year-on-year. Getting to the transition would require vast changes in policy and practice for donors, recipient governments, and health practitioners. But if these changes were made effectively, after about a decade of keeping new infections ever lower than deaths, we would see AIDS taking its place among treatable chronic diseases such as diabetes, cancer, and heart disease.
The number of people infected with HIV grew from a few million in 1981 to about 34 million by the end of last year. The number of annual new infections peaked at 3.2 million, in 1997, and has recently declined at a rate of about two percent each year. Meanwhile, annual deaths due to AIDS have slowed considerably -- from 2.1 million in the mid-2000s to 1.8 million in 2010. This is thanks to more widespread care: some six million individuals in low- and middle-income countries received treatment last year. Over the last decade, financing from the President's Emergency Plan for AIDS Relief (PEPFAR), with contributions from other bilateral donors and from the Global Fund to Fight AIDS, Tuberculosis and Malaria, catapulted the donor-financed AIDS treatment budget from a few million dollars in 2000 to more than four billion dollars in 2010. Eight countries, including two in sub-Saharan Africa, have achieved universal access to treatment. All this has created a narrative of success, so much so that last month U.S. Secretary of State Hillary Clinton declared, "The goal of an AIDS-free generation is ambitious, but it is possible."
It is, indeed. But not if treatment continues to take precedence over prevention. In recent years, HIV/AIDS advocacy has focused heavily on achieving universal access to treatment. Donor-funded programs followed suit, increasing the number of people receiving treatment in poor countries by more than 20-fold between 2001 and 2010. But in 2008, AIDS financing plateaued. Given the current global financial climate, that trend looks like it is here to stay. As new infections continue to increase around the world, the current scope of treatment will be difficult to maintain, let alone scale up. The prospect of expanding treatment beyond the six million who now receive it to most of the remaining 34 million is financially, not to mention logistically, impossible. As HIV-infected people live longer and require more costly second- and third-line treatments, the total cost of treatment will skyrocket, often in countries that lack good public health services to begin with.
Of course, treatment is not entirely distinct from prevention. Evidence shows that antiretroviral medication can prevent new infections by reducing either the infectivity of people with the virus or the susceptibility of uninfected people. But treatment works to reduce infectivity only if the patient adheres closely to the prescribed regimen, has enough food, and begins treatment within weeks of infection.
A way to think about an AIDS transition is to consider the demographic transition that took place in high-income countries after the Industrial Revolution. As health improved and life expectancy increased, countries seemed headed for unsustainable population explosions. It was not until birth rates dropped, due to a number of factors including higher educational attainment, women's entry into the labor force, and other social transformations such as access to family planning, that population growth dropped to sustainable levels.
A similar dynamic is at work with HIV/AIDS cases: the number of people living with the disease will continue to grow until the rate of new infections is finally brought down. And that would demand a revolution in policy at both the national and individual levels.
Specific policies will vary in response to local demands, but some principles apply across the board. Proposals for HIV/AIDS treatment programs should project not only the number of lives a program will extend but also the number of infections it will avert. Likewise, proposals for prevention programs should demonstrate that they are cost-effectively reducing the number of new infections, thereby freeing financial resources for treatment. Additionally, the transition should become an international milestone: donors should make a multiyear commitment to fund AIDS treatment only within the framework of a plan to push new infections below AIDS mortality by a specific projected date. Independently verified national monitoring will be required to provide planners the information they need to update their projections -- and to suggest how the AIDS transition could be reached more quickly.
Well-designed incentives are essential as well. At the donor level, incentives can be offered to countries that show they have accelerated the date of their AIDS transition -- and thus reduced the expected future costs of AIDS treatment -- by offering a portion of future savings to finance expanded access to AIDS treatment now. Such an arrangement would align the incentives of the donor and the recipient government, because both would gain financially from improved prevention. Donors and countries can also agree on a cash-on-delivery aid program that would reward the country with, say, $100 for every averted HIV infection, with the understanding that the country could use the reward to address urgent public needs in any sector.
Incentives can also work at lower levels of program implementation, both on the demand side, in the form of vouchers for HIV testing, or for transportation to AIDS treatment centers, and on the supply side, in the form of pay-for-performance contracts with HIV/AIDS treatment or prevention providers. A review of early evidence suggests that such incentives can be remarkably powerful at eliciting more socially responsible behavior. Rwanda, for example, has instituted incentive payments to doctors and nurses for HIV tests as well as other health services. USAID is including conditional cash transfers among the interventions to be tested in one of its trails of combination prevention. The World Bank has developed a new lending instrument called "results-based financing," which it would be willing to deploy for HIV/AIDS if recipient governments request it.
Washington and capitals in Western Europe are strapped for cash. Foreign assistance is on the chopping block. In turn, donor commitments to provide HIV/AIDS treatment to the 34 million in need is becoming more and more unrealistic. It would be a tragedy if donors responded to the infeasibility of these demands by turning their backs on the pandemic and consigning to early death the millions infected now and in coming years. An AIDS transition offers a reasonable, achievable, fiscally prudent, and necessary stepping stone toward a future where a world without AIDS will become a reasonable goal -- instead of the fantasy it seems to be today.