This is a joint post with Jonathan Jay, bioethicist and senior writer at MSH. Previously affiliated with Georgetown University and the National Institutes of Health, Jay’s work on HIV policy has appeared in the Journal of the American Medical Association and The Lancet.
“If you want to go fast, go alone,” says an African proverb. “If you want to go far, go together.”
It’s been thirteen years since the international community adopted the Millennium Development Goals, an ambitious, self-imposed “report card” for global development that helped focus attention and resources on issues like HIV and AIDS. Since then, the global HIV response has gone fast. In 2002, just 300,000 people with HIV were receiving antiretroviral therapy in developing countries; today, UNAIDS reports, treatment reaches nearly 10 million.
This rapid scale-up is an incredible achievement by any measure. A range of stakeholders, including the international community, the governments of high-HIV burden countries, and AIDS activists around the world, have all stepped up to make it possible. Still, the unmet needs are daunting: In addition to the ongoing human rights issues surrounding HIV and the barriers to effective prevention, many people who need ART aren’t getting it. Ten million on treatment is just two-thirds of the U.N.’s commitment to cover 15 million people by 2015.
Plus, the goalposts keep moving, as earlier initiation of ART gains traction worldwide. Already, developed countries recommend starting treatment as soon as somebody is diagnosed with HIV, which has proven better for patients’ health and reduces dramatically their risk of transmitting the virus. Last month, the World Health Organization revised its recommendations for developing countries to promote an earlier start to treatment. Under the new guidelines, the number of people eligible for ART jumps to 26 million worldwide.
“Raising the bar” to treat them all would substantially curb new HIV infections and would help bring the epidemic under control, but it’s a formidable task at a time when donor countries’ global health budgets are flatlining and new health priorities continue to emerge. The global AIDS movement has got far to go, and to continue its progress, it must join counterparts to strengthen health systems in developing countries — a change of course for a movement that has been highly successful, often moving fastest when it moved alone.
Since PEPFAR, the U.S. government’s AIDS response, was launched in 2003, HIV and AIDS has been a special category of international assistance. Its funding has dwarfed all other health areas.
Even so, the global AIDS community has been fiercely protective of its resources, sometimes antagonizing efforts aimed at maximizing health writ large. U.S. President Barack Obama, for example, has taken heat from AIDS activists for his approach to global health, which has integrated global health initiatives but hasn’t continued increases in PEPFAR funding. When bioethicist Ezekiel Emanuel questioned “Is PEPFAR worth it?” compared to other global health priorities, he was roundly panned by the AIDS community.
The MDGs themselves reinforced this mentality: by measuring health improvements around a handful of critical health problems, the MDGs fostered a race for limited resources. HIV and AIDS won a majority of the pie. Now, for everyone’s benefit, that pie needs to grow.
Renewing the development agenda
The United Nations has already begun deliberations around the Sustainable Development Goals, which will replace the MDGs when they expire in 2015. A major question has been whether to embrace goals that would emphasize a more integrated approach to global health. Key players have advocated universal health coverage (UHC) as a target which would encourage governments to reform their health systems, providing more comprehensive services and better equity. (UHC is generally defined as everyone having access to the health services they need, without financial hardship, but also refers to the systems which enable this outcome.) UHC supporters include WHO director-general Margaret Chan, World Bank President Jim Yong Kim, and a growing movement of African NGOs.
Most health advocacy groups, however, are organized around specific health problems; predictably, most have focused their post-2015 advocacy on getting their issue recognized in the SDG framework. Yet some have supported a UHC goal as well, including leading voices on malaria, non-communicable diseases, and tuberculosis. UHC reforms would likely expand prevention and treatment for these conditions, while financial protection would help alleviate the poverty that fuels these epidemics. For these groups, supporting UHC is practically a no-brainer.
For the AIDS movement, the calculus is more complex. HIV care is already widely available in many developing countries. Financial protection is less relevant because HIV care is often free. Expanding services for UHC will take money — and AIDS budgets might appear a likely source. It’s no surprise that AIDS groups have doubted this agenda, because nobody’s made clear: What’s in it for the AIDS movement?
Better health systems for HIV care
If you think HIV care is all that really matters for HIV patients, talk to those 10 million people on ART. For the majority, who achieve viral suppression — meaning they don’t experience physical illness, day to day — life goes on, and other needs arise. Mark Dybul, director of the Global Fund to Fight AIDS, TB and Malaria, is talking not just about lives saved but about lives durably saved. Why fight to put a young woman on effective ART without, for instance, managing her risk of dying in labor? Among other risks, HIV-positive people on ART face elevated rates of deadly chronic disease. Integrated health services, a core component of UHC systems, are the only efficient way to address a wider range of health risks — for example, using ART follow-up visits to screen for cervical cancer, high blood pressure and other conditions.
From a financing standpoint, it’s all about increasing the size of the pie. UHC can provide more money for HIV — and for health as a whole — by mobilizing the full range of resources, both global and domestic. UHC represents an ambitious, yet tangible and inspiring goal that a coalition of advocates could use to encourage donor governments to give more. Domestically, this mobilizing effect has already been visible in countries like Ghana, which uses a value-added tax to finance its UHC initiative, and the Philippines, which recently instituted an alcohol and tobacco tax to fund expanded health coverage for the poor. Nigeria — a country which could provide ART to every HIV-positive citizen if it achieved its Abuja Declaration commitment for health spending — is considering airline and cell phone taxes to fund national UHC initiatives. Leaders want to bring better health to their countries, and in rapidly growing economies, especially in sub-Saharan Africa, tapping domestic resources is the key to long-term sustainability.
Strengthening local health systems could be pivotal to achieving universal ART. As country leaders take over health service delivery, then PEPFAR, the Global Fund and other international partners can gradually shift towards a more focused role of providing financing and technical assistance. Within a more effective health system, a greater share of donor resources earmarked for HIV could go towards antiretrovirals, enabling scale-up towards universal ART. The transition to a more focused donor role is already occurring in South Africa, where the government’s planning to take over HIV service delivery over the next few years, and could work elsewhere as African economies continue their steady growth.
A shared agenda for global health
After a decade of steadily growing resources, the ”golden age” of international assistance funding has just ended. The AIDS community, along with counterparts fighting other global health problems, faces a tough new funding environment. These movements can struggle to keep their share of what’s left, or they can partner for long-term gains.
The next era of global health should not be defined by winners and losers, but by ambitious, systematic, country-led reforms that maximize health and eradicate poverty. AIDS groups, in particular, should put their considerable weight behind this shared agenda, advocating a UHC target along with HIV targets in the post-2015 framework. UHC in developing countries means more resources, better utilized, for better health. For HIV patients and for everyone else.
The “go fast” era is over — with a long road ahead, the global health community must go together.
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