It has been exactly 30 years since HIV/AIDS was identified, and 10 years since the UN General Assembly Special Session on HIV/AIDS convened. To review progress, world leaders and experts on HIV AIDS will take part in a high level UN meeting in New York from June 8-10.
Ahead of this meeting, in a Health Policy published Online First by The Lancet, a group of HIV experts propose a new investment model intended to support better management of national and international HIV/AIDS responses than exists with the present system. The new model proposes a paradigm shift in the way AIDS funding is approached, with a greater emphasis on priority setting and optimization of AIDS responses, a shift to community mobilization to deliver programmes and greater synergies between programme elements. Implementing the model would require 30 per cent more funding than currently available when expenditure would be projected to peak, in 2015. The Health Policy is by Dr Bernhard Schwartländer, Joint United Nations Programme on HIV/AIDS (UNAIDS) Geneva, Switzerland, and colleagues.
The authors say: "Substantial changes are needed to achieve a more targeted and strategic approach to investment in the response to the HIV/AIDS epidemic that will yield long-term dividends…We propose an investment framework to support management of national and international HIV/AIDS responses, encourage transparency in programme objectives and results, and enable decision makers and financiers to galvanise support for effective action."
They add that, until now, advocacy for resources has been done on the basis of a commodity approach that encouraged scaling up of numerous strategies in parallel, irrespective of their relative effects. But the authors propose a more targeted approach. Basic programme activities in the framework range in complexity and consisted of procurement, distribution, and marketing of male and female condoms; activities designed to prevent mother-to-child transmission; promotion of medical male circumcision; integration of activities addressing key populations, in particular sex workers, men who have sex with men, and harm reduction programmes for injecting drug users; behaviour change programmes that target reduction of the risk of HIV exposure through changing of people's behaviours and social norms; and antiretroviral therapy programmes.
The new framework also stresses the importance of so called 'critical enablers'. that fall into two categories, social enablers that make environments conducive for rational HIV/AIDS responses possible and programme enablers that create demand for and help improve the performance of key interventions. Social stigma, poor health literacy, and a punitive legal environment hinder implementation of basic HIV/AIDS programme activities and adversely affect programme priorities by stifling of adoption of evidence-based policies and best practices. Complementary 'critical enabler' strategies to increase the effect of basic programme activities are therefore crucial to the success of HIV/AIDS programmes.
The authors conclude: "The yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US$22 billion*. Implementation of the new investment framework would avert 12•2 million new HIV infections and 7•4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29•4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone."
Dr Schwartländer** adds: "With a more focused upfront investment we could really turn the HIV epidemic around … it's not a question of whether we pay now or later. It is rather a question of whether we pay now or forever."
Dr Bernhard Schwartländer, Joint United Nations Programme on HIV/AIDS (UNAIDS) Geneva, Switzerland. T) +41-22-791 4902 E) SchwartländerB@unaids.org
Journal
The Lancet