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AIDS Alert International: Prevention report finds worrisome financial gaps
International HIV experts provide analysis
Despite worldwide attention on sub-Saharan Africa and its AIDS epidemic, there is far too little access to HIV prevention services around the world, according to a recent report by the HIV Prevention Working Group.
"Our report shows that global access to prevention is severely limited in all regions, with one in five who have the need having access," says Helene Gayle, MD, MPH, director of HIV, TB and Reproductive Health Programs at the Bill & Melinda Gates Foundation. Gayle and other HIV experts spoke about the HIV Prevention Working Group report at a recent media teleconference.
In sub-Saharan Africa, only 6% of people have access to counseling and testing, and only 1% of pregnant women have access to treatment to prevent mother-to-child transmission, the report states.1
The HIV Prevention Working Group consists of a panel of 40 leading public health experts, clinicians, and researchers, and was convened by the Bill & Melinda Gates Foundation and the Henry J. Kaiser Family Foundation.
The prevention gap could be addressed once a funding gap is bridged, the report suggests.
Global funding for HIV prevention efforts, excluding the wealthier nations, amounted to $1.9 billion in 2002, which is only one-third of the estimated $5.7 billion needed to reach everyone who needs HIV prevention services, the report says.
"Without an immediate scale-up of HIV prevention services, we’re very likely to see an exploding of HIV in countries where HIV is emerging and a continuing devastation in many countries in Africa," Gayle says.
For example, in sub-Saharan Africa, the Working Group’s analysis shows that current prevention spending amounts to $927 million, against a need of $1.5 billion. And in Asia and the Pacific, where AIDS has not yet exploded, the spending gap is even more pronounced. The report estimates a need for $1.9 billion to be spent on prevention, while only $421 million was spent in 2002.1
The stakes are particularly high in China and India, where populations exceed one billion. For example, if prevention measures aren’t implemented immediately in China, there could easily be 10 million people infected with HIV by 2010, which is 10 times the number currently infected, says Yiming Shao, MD, of China’s National Center for AIDS/STD Prevention and Control.
"So the situation is really at a critical point," Shao says. "The good news is that the central government of China and the committee of the country have been alerted to the situation, and in the past two to three years, several positive things have been happening."
China has a new five-year AIDS action plan, and the government has permitted more intervention and prevention measures. Even though the country has been heavily hurt by the severe acute respiratory syndrome (SARS) epidemic, that is only a short-term emergency, Shao says.
In the long run, the public health sector will be strengthened by the SARS fight, and it may have a positive effect on the fight against AIDS, Shao adds.
India’s AIDS epidemic is poised to make an even more dramatic impact, according to the report.
Some U.S. intelligence reports project that up to 25 million new infections could occur in India between 2002 and 2010.1
The funding gap estimates were based on a lengthy analysis of current best practice prevention programs, an assessment of what HIV prevention services are available in low- and middle-income countries, and assumptions concerning program capacity in these countries, says Catherine Hankins, MD, of UNAIDS in Geneva, Switzerland.
"The cost of different prevention programs is the cost at the country level, and it doesn’t include funds to strengthen the infrastructure to deliver these programs," Hankins says. "This will provide life skills for teachers, but not money for training new teachers and new schools, so these are bare-bones estimates."
HIV Prevention Working Group members emphasize that the numbers are calculations based on their analysis.
"The numbers in this report are estimates, ballpark figures," says Drew Altman, PhD, president of the Henry J. Kaiser Family Foundation.
"But we felt it was best to do the best we could to generate some numbers, because without these estimates, we don’t know what we’re spending on prevention now or what we need to spend," Altman says.
"Does a roughly $4 billion spending gap sound unattainable?" he says. "It doesn’t to me, because I spend most of my life working on domestic efforts."
By comparison, it would cost the United States about $40 billion to provide prescription drug coverage to senior citizens, Altman says.
"Secondly, the report found that developing countries themselves spend about as much on prevention as the wealthy donor nations spend, so the developing nations are making a significant effort," Altman says. "With the possible exception of the United States and the United Kingdom, in absolute dollar amounts, the amounts given for prevention by wealthy donor nations are actually quite small, and they look like what you’d expect from a private foundation more than a major country."
For instance, the Kaiser Family Foundation spends more on HIV prevention than do Sweden and France, Altman says.
The problem is that by the time many wealthy nations begin to increase their prevention funding, the problem has already magnified to the point that even more funds are needed, Gayle says.
"For the range of money that we’re spending now, if we had invested that a decade ago, we could have cut in half the number of new infections we now have," Gayle states. "This epidemic isn’t going away, and we either pay now or we pay later."
If the wealthy nations had invested $1.5 to $1.9 billion annually 10 years ago, then it would have saved the world $90 billion in associated HIV/ AIDS costs, Gayle adds. "Our report says everyone should increase [funding], and it ought to be proportionate to their gross domestic product."
The goal of additional prevention spending would be to achieve across the world the same level of success that has been achieved in Uganda, the report suggests.
A very poor nation, Uganda’s HIV/AIDS epidemic had already spread to 11% of the women attending prenatal clinics by 1985. The next year, Uganda’s president spoke openly about AIDS and established the National AIDS Control Program, launching an AIDS awareness campaign, according to the report. Uganda’s prevention work has resulted in a reduction of AIDS prevalence from 15% in 1991 to 5% in 2001.1
The four key points of Uganda’s prevention efforts are leadership, prevention, fighting the epidemic early on, and providing resources to sustain the programs, says David Serwadda, MBChB, PhD, director of the Institute of Public Health at Makerere University in Uganda.
"The political leadership was very important in Uganda," Serwadda says.
Gold Fields adds to AIDS program
Gold Fields, a South African company that has taken a leading role in helping its employees with HIV/AIDS, says it plans to extend its existing wellness management program to include highly active antiretroviral therapy (HAART) as a treatment option for all of its employees living with AIDS.
Gold Fields previously provided antiretroviral therapy on a limited basis to prevent mother-to-child transmission of AIDS and as postexposure prophylaxis to rape victims and employees with occupational exposure to HIV.
Last August, the company launched a voluntary counseling and testing program and a wellness management program. The company said it intends to introduce HAART on a pilot basis at all of its South African operations as an extension of that program.
Since 1986, Gold Fields has been in the forefront of developing best-practice responses for both the prevention of infection and the care of people living with HIV/AIDS.