/ 21 September 2012

HIV budgets come under pressure

South Africa has the heaviest burden of HIV – there are 5.6-million people infected.
South Africa has the heaviest burden of HIV – there are 5.6-million people infected.

This was the message to the 23 767 participants from 183 countries at the July 2012 Washington International Aids Conference.

The past 15 years saw dramatic successes in the fight against HIV. Between 2001 and 2009, funding increased almost ninefold. Organisations, primarily the Clinton Health Access Initiative, negotiated lower drug prices. Programmes to prevent mother-to-child transmission substantially decreased the numbers of children infected. In South Africa, the health department’s most recent antiretroviral tender process has brought prices down to between R96 and R112 a patient a month for first-line treatment, resulting in savings of about  R4.7-billion. Large-scale HIV testing programmes are bearing fruit and an increase in life expectancy is  finally evident.

The international response to HIV is shrinking and commitments are uncertain because of the global economic crisis, donor fatigue and other factors. In 2011, the Global Fund was forced to cancel round 11 because of donors falling short of commitments. By 2015, UNAids estimates $24-billion will be needed for a comprehensive response, but according to current projections only $17-billion will be available. New pledges made in Washington added less than $300-million. Where will money come from? There has been some growth, but largely from domestic sources in low- and middle-income countries, with South Africa leading the way.

This will be the trend. Govern­ments have to take more fiscal responsibility for HIV. Recently UNAids suggested a financing system according to which African governments would set levels of investment for Aids, based on what they could raise and on the level of the disease in their countries. If they could demonstrate they had made progress in reaching the goals, international donors would make up the rest.

South Africa has the heaviest burden of HIV – there are 5.6-million people infected. But the country is financially sound, has good fiscal policies and health is receiving more in the budget. According to treasury data, total spending on HIV was R16.9-billion for 2010/11, of which R5-billion was from donors. But as donor funding is scaled back, South Africa will still be able to pay for its antiretroviral programme, unlike many poorer nations.

“The lives of more than 80% of the people who receive Aids treatment in Africa depend every morning on whether or not a donor writes another cheque,” Bernhard Schwartlander of UNAids said.

Good economics
More recently economists have entered the ranks of the key HIV decision-makers. Good economics is all about making the best choices when resources are scarce, and that did not happen during the “emergency era” of funding. The co-ordination of donors was poor, the funds were not budgeted for and governments had little incentive to provide them systematically, and the resources were often spread thinly to pursue many objectives. There is now an increasing emphasis on investing strategically and directing resources where they will have the greatest impact and provide the best value for money. Governments should spend on what has been shown to work.

Preliminary results of the first South African national Aids spending assessment show what many have suspected – the antiretroviral budget is dwarfing all other spending on HIV. Care and treatment costs dominate South Africa’s HIV spending, followed by spending on social protection (which includes a proportion of the child support grants), prevention, research and programme management and co-ordination.

Overall, too little is being spent on prevention. The assessment data shows about 10% of South Africa’s total spending on HIV was on prevention. Mozambique, Swaziland, Zambia and Zimbabwe are all spending proportionately more on prevention than South Africa.

Prevention is also not receiving the same attention in all the provinces. The Eastern Cape, Free State, Gauteng, KwaZulu-Natal and Northern Cape are all spending less than 10% on prevention. Per capita spending on prevention is not higher in the provinces with higher rates of HIV.

The mix of prevention measures is also very different among the provinces. For example, changing behaviour receives more than 10% of the total prevention spending in Mpumalanga and North West, but very little is spent on it in other provinces.

Prevention strategies
The large variations suggest the provinces find it difficult to establish which are the best strategies to adopt, and spend a little on every­thing. Provincial health departments cannot be blamed entirely for this. Health economists and other researchers have not given prevention strategies the attention they deserve. Provincial health authorities need evidence of what works best and what the costs are to make sound decisions. But the problem is that it is much more difficult to evaluate the success of most prevention programmes than of treatment.

Until there is a much larger base of evidence about prevention, governments will be under pressure to go with those strategies whose benefits are easy to prove, such as the prevention of mother-to-child transmission and medical male circumcision. Science shows that putting people on antiretrovirals reduces the risk of passing on HIV. It is harder to show that a well-designed, properly run programme to change behaviour over 10 years can produce positive results because it is difficult to isolate the effect of the programme from all the other influences.

Spending effectively on prevention is an investment and we need to spend better. We need to get the most out of new prevention strategies, but we must not neglect the basics – communicating the need to change behaviours.

Health departments also need sound guidance to make strategic choices. Spending now on effective prevention will save expensive, life-long treatment in the future.

Nicola Deghaye is a researcher at the health economics and HIV/Aids research division of the University of KwaZulu-Natal and Alan Whiteside is the director