Donors put a cap on Aids funding

Hard-fought gains against HIV/Aids are being threatened by international donors ‘flatlining” funding for treatment programmes, all but killing ambitious targets for universal access and forcing clinics to turn away dying patients.

The United States President’s Emergency Plan for HIV/Aids has informed some recipient governments and clinics to cap the number of new patients receiving life-saving antiretroviral therapy (ART), noting that its budget has been ‘flatlined” at an increase of only 2.2% for 2011, the smallest in the programme’s history.

This comes as the Global Fund to Fight Aids, TB and Malaria, the world’s largest multilateral health financing mechanism, faces a potential shortfall of $10-billion for the next three years. Both programmes have been successful in facilitating access to treatment, together saving an estimated 5 000 lives a day in the past decade.

Without a further increase in funding, achieving universal access to treatment targets outlined in the Millennium Development Goals will be all but impossible. Universal access requires that 80% of those who require ART receive it.

Currently only 42% of eligible patients worldwide have access. Donors cite the global economic downturn, the desire to decrease donor dependence, a shift towards prevention instead of treatment and a focus on other health indicators, such as child and maternal health, as justification for changes in funding.

The effects of such cutbacks are already being felt in many African countries, most notably Uganda. The ‘poster child” for Aids treatment programmes, the country has made significant gains in access through ambitious targets funded by international donors, specifically the President’s Emergency Plan.

Approximately 70% of Ugandan patients receiving ART do so through the programme. But in 2009 clinics received memos from the US government to say that new patients should only be started on ART when another patient dies, placing the rest on waiting lists.

A flatlined programme has resulted in treatment shortages, with doctors having to turn dying patients away. Uganda’s Dr Peter Mugyenyi, writing in a recent report published by the International Treatment Preparedness Coalition, noted that ‘lowerthan- anticipated funding support — has forced many facilities to turn away new HIV-positive patients seeking ART.

Individuals already on treatment — are worried that insufficient funding could force a rationing of care that would lead to some patients having their ART access revoked unless they pay for it — Given the costs of ARVs and high levels of poverty, that is not an option for most people in Uganda or elsewhere in the developing world.”

The Open Society Institute estimates that 800 patients are leaving clinics empty-handed each month, with less than half of all those in need of treatment receiving it. Aids activists contend that funding shortages could potentially reverse decades of work to increase testing, as well as to combat stigma and discrimination.

According to Paula Akugizibwe of the Aids and Rights Alliance of Southern Africa, a non-profit advocacy group focusing on HIV and TB throughout the region, ‘stigma has been challenged based on the premise that I can live with HIV— and I can get treated — Once the treatment is taken away then the fight is pushed back. It’s taken us a really long time to get to where we are today.”

Uganda may prove to be the litmus test for funding shortages throughout the rest of the continent, with many international donations expiring in 2010 and 2011. Treatment shortages have already been noted in the Democratic Republic of Congo, Kenya, Nigeria, Mozambique and Zambia.

Chronic underfunding of the health sector by African governments is only exasperating diminishing donor commitments. African heads of state gave support for universal access to treatment in the 2001 Abuja declaration, pledging to spend 15% of their total budgets on health.

But nearly a decade later, the Global Fund estimates that only six of 52 states have done so. Less than half of African countries meet the minimum health expenditure as outlined by the World Health Organisation. The Ugandan government has not been able to absorb new patients as foreign funding diminishes.

In April the US advocacy group Health Gap reported that patients previously receiving ART from the President’s Emergency Plan were being transferred to government hospitals, ‘which did not have the drugs to handle them”.

Ironically, the countries that have made the greatest strides against the virus will face the largest treatment gaps, says Akugizibwe. ‘Uganda did a very impressive job. The government had a very aggressive testing drive over the past few years and so they had a lot of people [ready for treatment].

‘Countries [that] have done a great job [with] — programmes that are scaling up at a good pace will face these challenges because the funding isn’t going to be there,” she says. By flatlining budgets, international funders are ‘saying to governments: lower your ambitions or find your own money for your treatment programmes.

The health response is not being driven by scientific evidence; it’s being driven by money and budgets.” Akugizibwe worries that diminishing Aids treatment programmes will act as a model for underfunding other health interventions.

‘Funders are saying ‘it’s too expensive, we’ve changed our minds’. If this is what happens with HIV, then that sets the precedence for all other health needs.”

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