How to Keep Promises: A Way Forward for Optimizing HIV/AIDS Care
Governments often cite compassion for and solidarity with those in need as the driving forces behind their generosity in response to global health challenges. The series of global commitments to universal access to health care enshrined in the Millennium Development Goals is perhaps the most far-reaching example of an increasing international political will to address today's global health crises. At the same time, however, those same governments often renege on their commitments, purportedly for reasons of cost-efficiency. While cost-efficiency certainly has its place in the field of health delivery, it should compare cost with health outcomes in both the short and long run to be truly convincing. It should study the efficacy of different health interventions rather than decide which group of people, or one disease, would be the most "cost-effective" to assist. Yet, policy makers in donor countries often apply the term in the latter sense.
Nowhere is this trend more apparent than in the international response to HIV/AIDS, where the cost-efficiency debate dominates controversy over AIDS' "exceptionalism," resulting in a decreased financial and political commitment. Ezekiel Emmanuel, an architect of US President Barack Obama's Global Health Initiative, has used cost-effectiveness arguments to promote mother and child health care over access to treatment for HIV/AIDS. Here, cost-effectiveness is not used to define the most optimal approach to address one particular health problem. Instead, it serves to arbitrate, based on so-called ethical principles, between patients and diseases.
As a medical actor, Doctors Without Borders/Medecins Sans Frontieres (MSF) strives to use our resources in the most cost-effective way, but our primary goal must remain to reduce the morbidity and mortality of our patients. Due to continued high levels or new infections and the impact of antiretroviral (ARV) treatment on the survival of AIDS victims, we observe an increase in the number of people living with HIV. And yet, the epidemic curve seems to be gradually declining, as reflected by a decrease of annual mortality starting in 2005. In a rural district in Malawi with high HIV prevalence where MSF has been treating people living with HIV/AIDS for nearly a decade, Beatrice Mwagomba, Rony Zacharia, and others recently reported in the medical journal PLoS ONE how scaling up HIV/AIDS care and treatment seems to have reduced mortality at the population level. This report shows how efforts to address HIV/AIDS can have a positive community-wide impact.
Nevertheless, despite significant improvements both at the clinical and public health levels, the epidemic is far from over. Indeed, ten million people are in need of immediate therapy today. The burden of HIV/AIDS remains colossal for states, organizations, and communities alike. We are, then, facing two major challenges: Where do we find the resources to address the health needs of HIV patients? And how do we ensure that these resources are invested in a way that guarantees the best possible health outcome, while remaining cost-efficient? Diverse funding sources, optimal care and treatment, and the alignment of trade policies with global health priorities are all components of an efficient and effective response to this and other global health priorities.
Diversifying Funding Sources
Economic justifications and a general donor fatigue alter a decade of unprecedented funding are unfortunate synergies for all those who believe that HIV/AIDS should continue to be addressed as an emergency. It is also unfortunate for those who would like more attention to be devoted to tuberculosis, neglected tropical diseases, childhood malnutrition, and maternal and child health. In the White House's proposed 2011 budget, the share for HIV/AIDS will remain at the same level of funding for the third consecutive year, despite authorization of a higher budget by Congress. …