NYT on HIV/AIDS crisis: “You cannot mop the floor when the tap is still running on it”

UPDATE 4:10pm 5/11: Bill responds to Gregg Gonsalves' comment on this post, at the END of the post. The New York Times ran not one but two articles (edit: make that four) on the global fight against HIV/AIDS last Sunday. As these pieces tragically recount, the international community’s hard won successes against HIV/AIDS are in danger. There is not enough funding to meet the demand for treatment among sick patients in Uganda, and expiring grants, frozen funds, and drug shortages have already or are expected soon to spread to Nigeria, Swaziland, Botswana, Tanzania and Kenya.

The last decade has been what some doctors call a “golden window” for treatment. Drugs that once cost $12,000 a year fell to less than $100, and the world was willing to pay.

In Uganda, where fewer than 10,000 were on drugs a decade ago, nearly 200,000 now are, largely as a result of American generosity. But the golden window is closing.

The reasons given for current and projected shortages include the global recession; a “growing sense” among donors that more lives can be saved more cost-effectively fighting other diseases like malaria or pneumonia; and the disappointing failure of the scientific community to find a cure or vaccine.

The most devastating breakdown of all comes down to failure to prevent enough new infections and a simple, brutal equation:

For every 100 people put on treatment, 250 are newly infected, according to the United Nations’ AIDS-fighting agency, Unaids. … “You cannot mop the floor when the tap is still running on it,” said Dr. David Kihumuro Apuuli, director-general of the Uganda AIDS Commission.

UPDATE 4:10pm 4/11 from Bill: I am responding to Gregg Gonsalves’ comment below

Dear Gregg,

First, on the complementarity between treatment and prevention, let’s clear up some things. There is some complementarity, conceivably a lot, but it’s definitely not perfect. Treatment is not necessary and sufficient to do prevention. Prevention will remain a separate goal that needs at least SOME direct attention even if there is a lot of complementarity.

Second, I think to move forward we all have to move out of our defensive positions.

You see my plea for attention to prevention as an attack on treatment programs. There is some justification for this, as I and others have argued, and still would argue, that treatment was used as an excuse by aid and political actors in both the West and Africa to ignore prevention. This is because prevention is both politically and technically more difficult than treatment. But suppose you disagree with this argument – that’s fine. Suppose we all even gave up that argument and said let treatment programs alone. Suppose that none of us blame treatment at all for the inattention to prevention.

Could you then discuss prevention without spending most of your effort defending treatment? Prevention is now not working, as you acknowledge yourself. You are right that there are no obvious new solutions now, but some solution must be found sooner or later – bottom up, top down, or sideways – because you acknowledge that prevention has to work to end the AIDS tragedy. Could everyone involved in AIDS therefore agree there needs to be a new focused conversation and effort on prevention?

Regards, Bill

The War of the Causes in Aid

The development industry seems to be riddled with people whose main job is to divert money to their good cause. The advocates are united by a strong belief in the priority that should be given to their sector (education, water, AIDS etc). They convince themselves that they are speaking for real interests of the poor… Within many aid agencies there is a permanent state of low intensity bureaucratic warfare for resources…{staff} fight to defend and expand funding for the causes they work on. They deliberately stoke up pressure in private alliances with civil society organisations – many of whom they fund – to raise the political stakes through conferences, international declarations, and publications with the aim of committing funders to spend a larger share of aid resources on their issue.  ….But for the aid budget as a whole these are zero sum games, and everyone would be better off – and many lives would be saved – if it stopped.

This quote comes from a blog post by Owen Barder which is now several months old. For some reason we’re just seeing it now, but thought it was still worth sharing with our readers too.

He gives AIDS in Ethiopia as an uncomfortable example of this kind of advocacy distorting aid:

According to the World Health Organisation (WHO), in Ethiopia about 65% of the population (52 million people) live in areas at risk of malaria. Malaria is the leading cause of health problems, responsible for about 27% of deaths; and malaria epidemics are increasing. The HIV/AIDS prevalence rate among adults is 2.1% (2007) – that’s about 1.6 million people living with HIV.

Of $5.15 per head provided in aid for health to Ethiopia in 2007, about $3.18 per head was earmarked for HIV  while about $0.26 cents per head was allocated to malaria control.  Given the relatively low burden of HIV, earmarking 60% of health aid for HIV is excessive relative to other needs for health spending.

Of course it is right that we should try to make sure that everybody with HIV has access to medicines to keep them healthy, and … to prevent spread of the disease. But we should also make sure that people have bednets and drugs to stop malaria, provide childhood vaccination to prevent easily preventable diseases, ensure access to contraception and safe abortions, and, above all, enough funding to provide basic health services that would save thousands of lives and suffering.  Yet we are not willing to provide enough money to do all of this.  It is in this context that it is damaging to earmark 60% of health aid to HIV.

Owen is equally blunt about the way forward:

we should, as a development community, heap scorn and opprobrium on anyone caught advocating for more resources in their sector.  We need stronger social norms in development that frown upon this kind of anti-social behaviour.

Area Man's Starbucks Purchase Finally Ends African AIDS Epidemic

by Jeff Raderstrong at the blog Change Charity:

After deciding to add a bag of (Starbucks) RED brand coffee on top of his vente mocha latte order, area man Bill West completed the final piece of the puzzle to end the AIDS epidemic in Africa...

"This is a great day for humanity," said Michel Kazatchkine, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, where Starbucks made the $1 donation--taken from West's purchase--needed to rid the continent of the disease that had crippled it for decades. "All of our work, all of our time, all of our hopes are now validated by this one last push to end AIDS in Africa."

...Bono, humanitarian activist and U2 front-man, reached out to the broader global community to recognize the efforts of the people that made it possible.

"It is important to remember what went into this momentous occasion," said the rock star, one of the founders of the Product RED brand. "The Product RED line successfully mobilized Western consumers to go out and buy things they either already had or only moderately desired under the guise of social responsibility. With out these compassionate consumers, or the compassionate Starbucks marketing directors who decided to give up razor-thin amounts of their profit margin to the Global Fund in exchange for the Product Red partnership, this debilitating disease would still be destroying Africa."

Who gets the Last Seat on the Plane? Why Aid Hates Economics

Not long ago, I was returning home from a trip when the airline bumped me from my flight due to overbooking. The airline rep was very sympathetic, but I didn’t want her sympathy, I wanted A Seat On the Plane. She had traded off my wishes against those of other passengers, and I lost. Economists are unpopular because we say there is always SOME resource that is overbooked in aid, and aid is Forced to Choose: who is going to get the Last Seat on the Plane?

Politicians and advocates try to argue their way out of the Scarcity and Tradeoffs, using one or another of these proven strategies:

(1)   There really is no scarcity

This is Sachs’ central argument for more money in aid –you should never be forced to choose who should live and who should die, so you should always ask for more aid money. This has been effective as advocacy, but still doesn’t make aid money an infinite resource – there is still a limit on how much rich people will give. And the scarce resource is not only money – it is also political capital, rich peoples’ attention, or effective and accountable aid workers in the field. So using AIDS as an example, sure you should do some of both treatment and prevention – but how much of each? In the end, they are still competing for limited Seats on the Plane.

(2)   Our project doesn’t use any scarce resources

This argument is usually made by omission. The Millennium Villages don’t advertise that they are dependent on one extremely scarce resource -- Western experts -- perhaps it would then become obvious that they are neither scalable nor sustainable. And of course there is a big tradeoff between the Millennium Villages and better projects you could do with this scarce Western expertise. A better project replaces the scarce foreign expertise very soon with more abundant local expertise and labor – such as training programs to transmit foreign technical skills to locals, who will in turn pass it on to other locals.

(3)   My cause actually is the same as your cause

Advocates of one cause often argue many other causes NEED their cause. If the necessity is absolute, then indeed the tradeoff disappears. If it is less than 100 percent absolute, there is still a tradeoff. Hey, Other Passenger who took my seat: don’t claim that You are so Important that it’s pointless for Me to get on a plane without You! Unless You are the Pilot.

In summary, there really is scarcity and aid really is forced to make intelligent choices. Be sure to give a seat to the pilot.

Debates on losing the AIDS War

We got some great comments in response to yesterday’s post How the war on AIDS was lost.  Much of the debate centered around three questions: 1) Isn’t treatment complementary to prevention?  And so there is no tradeoff?

While some agreed with the post’s overall assertion that prevention has been neglected in favor of treatment, Caitlin argued that this distinction is artificial: “in many places, the availability of treatment makes prevention possible.”

Gregg Gonsalves expanded: “ART can reduce viral load and transmissibility. In the absence of a vaccine or a microbicide and the difficulties in achieving behavior change in general in public health, can you afford to be so categorical about AIDS treatment? Might ART provision be an important part of HIV prevention strategies?”

OUR RESPONSE: We all agree that there should not be 100% of one and zero of the other. Beyond this, we disagree. Even if treatment does help prevention, this is only partial. (Treatment is not 100% necessary and sufficient for prevention).  And they are still two separate goals. So there is still SOME tradeoff between efforts that target treatment and those that target prevention.

2) Do we know how to do prevention? If not, why not?

Uganda is often cited as a prevention success story, but Justin added that “there is still a lot of debate over what actually accounts for the Uganda decline in infections, but even if we could narrow down the cause, it may not be generalizable to other countries because of different patterns and cultural practices. And even in Uganda, the trend is reversing.”

One problem is that while treatment shows obvious, life-saving results, there is more room for human messiness and error with prevention. Unsurprised wrote: “Prevention cannot be bought with aid dollars…The problem is NOT that more financial resources have gone to treatment rather than prevention, but that no one—especially local leadership—has ever been serious about sending the necessarily blunt and uncomfortable messages it takes to get people to change their sexual behaviors.”

Avam pointed to the downsides of a development economics-centric approach, and others emphasized the power of locals rather than global “experts” in figuring out prevention for their own communities. Caitlin said that many communities did “figure out” prevention in their own areas, but that these gains were not sustained or brought to other communities.

OUR RESPONSE: These are all good points, and Aid Watch is very familiar with the ideas that (1) money alone does not solve problems, including prevention, and (2) solutions arise from local people and are specific to each area. Our point was that the international effort could have helped contribute advice to prevention programs, but it didn’t because treatment effort crowded out prevention effort. In fact, Helen Epstein and Daniel Halperin have offered insights like the effectiveness of male circumcision to lower transmission and the importance of multiple long-run sexual partners in transmission in Africa. The international AIDS effort ignored them for a long time and is still not serious about applying these insights.

3) Who are the “Searchers” and who are the “Planners” in the quest for more effective AIDS treatment and prevention?

Caitlin took the post to task for leaving out local community leaders' explanations of  for how we got to where we are today. Gregg Gonsalves argued that the post pinned blame on well-known experts and funders, while “fail[ing] to acknowledge that most of the drive for treatment has been derived from local activism in Brazil and Thailand, first, then South Africa, then with help from activists most with small NGOs in the North…You ignore your own “searchers”– the “little” people who have been building up the AIDS response for 30 years and invest all the power in the planners…who come late into the game.”

OUR RESPONSE: You are right, I have been inconsistent about this. Solutions usually do arise from local searchers, and I should be more respectful of how the local treatment advocates responded to their own circumstances and found solutions, and I congratulate them on what they have achieved.

However, not all searchers have successful searches. Good economics and common sense should be injected into the debate that searchers participate in, and searchers are also influenced by the availability of resources and political capital. The result in AIDS is that there have been a lot of searchers in treatment, and far too few in prevention.

WE WONDER: Would treatment advocates now be willing to make a forceful statement about the critical urgency of prevention?

How the war on AIDS was lost

There was an alarming article in the Wall Street Journal on the reverses of previous advances in AIDS prevention in Uganda, plus running out of US funding for AIDS treatment. The war on AIDS is being lost. Here are the facts:

1. There were an estimated 2.7 million new infections worldwide in 2008; 1.9 million of them were in Sub-Saharan Africa.  The number of people added to treatment each year is also increasing rapidly, but not rapidly enough to keep up with new infections. Worldwide in 2008, 1.1 million people were added to treatment; 825,000 of them in Sub-Saharan Africa.
2. New global funding for AIDS has grown rapidly over the past decade, but funding from the US government for major programs  PEPFAR and the Global Fund (a large portion of total AIDS funding)  now appears to be leveling off.

Despite the goal of “universal access to treatment” (a Millennium Development target that was supposed to be met by 2010),  only 44% of people in need of ARV treatment in Sub-Saharan Africa were actually receiving it. Now, as the WSJ story and other reports document, sick people are being turned away without treatment, and many who contract HIV in the future will have no hope of treatment.

Last year the WHO country representative in South Africa warned that "At the rate we are going, with new [HIV] infections rising it will be almost impossible ... to keep providing free treatment to those who need it."

How did this enormous tragedy occur? Perhaps because the global health community concentrated on AIDS treatment and neglected prevention (which they never figured out how to do). As was pointed out by David Roodman in Monday’s blog post, public attention and activism is a finite resource. In AIDS, virtually all of it was spent on treatment (led by the 3 Bs - Bono, Bill Clinton, and Bill Gates - and 1 W) and very little on prevention.

Despite AIDS  getting unprecedented amounts of funding, funding was never going to be unlimited.   So there was going to a treatment funding crisis sooner or later, as Mead Over recently pointed out.

This current crisis was anticipated by writers like Helen Epstein, Daniel Halperin, David Canning, and Over. All have issued pleas for emphasizing AIDS prevention and given practical advice on doing prevention. All have been ignored.

Will there at last be a new war on AIDS that emphasizes prevention, that saves the next generation?

Having fixed Africa and AIDS, Bono tackles filesharing (from BoingBoing)

Bono, in a New York Times top-ten essay filled with of Brilliant Ideas That Will Fix The World If Only They'd Listen To Moi, says "Intellectual Property Developers" are doomed because of filesharing...

From a post on the great blog BoingBoing.

I know the NYT is desperate to survive, but having Bono as a regular columnist is...OK, I give up. How about Lady Gaga writing on counter-terrorism?

World Bank AIDS Drive crowds out other health programs – but fails to make progress on AIDS

A report released today by the World Bank’s own Independent Evaluation Group faults the Bank for allowing AIDS to drive out many other programs to improve health. To make things worse, the Bank’s AIDS effort itself failed to accomplish much – only 29 percent of AIDS projects (and only 18 percent of AIDS projects in Africa) had a satisfactory outcome – while other efforts were much more effective (89 percent satisfactory project rate for other communicable diseases). Despite the poor results on AIDS and better results on malaria and TB, AIDS accounted for 57 percent of Bank projects on communicable disease during 1997-2006 (the period covered by the evaluation), compared to 3 percent for malaria and 2 percent for TB.

The report notes the large share of health funding earmarked for AIDS tended to pull scarce resources in the local health system such as nurses and doctors away from other health problems. Within overall constrained donor budgets, AIDS financing tended to crowd out projects that support overall health system reform, despite the urgency of the latter issue to get any good results on any health outcome.

“A case in point is Malawi: because of constraints in the availability of Bank budget for supervision, IDA funds were available for the health {sector-wide reform} or … AIDS… but not for both. The Bank opted to drop support for the health {sector-wide reform} and continue support for HIV/AIDS.” (p. 40) The Bank did this even though a lot of other donor funding was already earmarked for AIDS.

Another victim of the AIDS emphasis was nutrition. The share of projects with nutrition objectives dropped by half; Bank support for nutrition reached only a quarter of countries with high stunting. This is particularly sad because many nutritional interventions are relatively cheap and easy to administer (for example, nutritional supplements, which had a big payoff in the PROGRESA program in Mexico).

The AIDS crowding out troubled the independent Advisory Panel that IEG asked to comment on the report. At a time when international AIDS funding was surging, the Panel said, “we were surprised that the Bank did not provide a countervailing trend…there was a fall in nearly half in the share of projects with objectives to reform the health system.” (p. xxvv)

Given what looks to be irrational behavior, my guess is that the Bank made these choices for purely political reasons. It is extremely sad that such politics caused the Bank to neglect many other treatable and preventable health tragedies, without any countervailing benefit even for AIDS victims given the poor performance of the Bank’s AIDS projects.