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FEATURE: Roger England Are we spending too much on HIV? BMJ 2007; 334: 344 [Full text]

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We are underfunding poverty alleviation.

Joan L Woods   (16 February 2007)

its only numbers

Jeffrey C McILwain   (16 February 2007)

Are we spending too much on HIV or are we not?

Mukosha B Chitah   (17 February 2007)

The real crux of the matter

Labib A Nassim   (21 February 2007)

Are we spending too much on HIV?

John Lwanda   (21 February 2007)

It is how we spend on HIV in Africa,, not how much we spend that counts.

Joseph A Sonnabend   (21 February 2007)

The world should increase Total health budgets, NOT cutting HIV budget

Joseph Ana   (23 February 2007)

We are underfunding poverty alleviation. 16 February 2007
Joan L Woods, HIV/AIDS Technical Advisor 6969 Kabang Road Lusaka, Zambia Send response to journal: Re: We are underfunding poverty alleviation.	Given the huge numbers of individuals working on HIV/AIDS, I am sure that the editorials by Roger England and Paul de Lay et al will provoke an avalanche of responses ("Are we spending too much on HIV?) England correctly states that HIV/AIDS funds often end up segmenting the health sector rather than supporting it. There needs to be greater emphasis placed on strengthening existing institutions and systems rather than creating parallel programmes. And, certainly, it is odd that this late in the pandemic, we have to argue for integrating HIV/AIDS into antenatal care, family planning, child health and other basic services. There is a critical need to look at how HIV/AIDS funds are used within the health sector. Criticizing multisectoral activities as "the emperor's new clothes of public health", England states that funds could be more effectively used in preventive interventions through public health. This ignores years of failure in HIV prevention, as the public health sector attempted to change behaviour through broad information dissemination and social marketing. HIV/AIDS is not exclusively a health issue and individuals are put at risk through complex factors such as poverty, gender inequality and violence. To assume that these can be tackled solely through the health sector ignores common sense as well as previous experience. Infant mortality takes greater numbers of lives than AIDS-related illness (ARI). Clearly, infant mortality in developing countries in unconscionably high and more needs to be done to address this. Infant deaths cause heartache for a family and often result from grave injustices in access to health care, nutrition and social capital. However, from a development and economic viewpoint, a death from ARI leads to a more broadly felt impact. In the highest prevalence countries, the majority of those dying are in their 20's, 30's and 40's. Any investment in education, health care and other social services made in such an individual is lost. People become sick and die during what should be their most productive years. Any contribution they might have made to food production, intellectual endeavors or service provision is lost, both to their families and to society. Often, they leave behind children who have no means of supporting themselves. England states that HIV/AIDS affects the middle classes more than the poor in high prevalence countries and that this is one reason for the push for high levels of funding for HIV/AIDS. This is incorrect. Early in the pandemic, those people with highest education (the upper and middle classes) were more likely than those with no education to become infected. This was probably due to the fact that they were to travel more and attract more sexual partners than the less educated. However, as the epidemic matures regionally and spreads outside of high risk groups, the poorly educated lower classes are disproportionately burdened. Middle class families can now afford ART and they access health care of a reasonable standard so that they get interventions such as PMTCT drugs and treatment of opportunistic infections. Among the middle and upper classes, HIV/AIDS is more a chronic disease to be managed much like diabetes. HIV/AIDS is now a disease of the poor. It is the poor who are most vulnerable to infection and the poor who are most likely to suffer and die without access to life-saving drugs or even pain relief. Perhaps the greatest shortcoming in England's thinking is that he seems to see the response to health problems, and indeed to poverty alleviation, in poor countries as a zero sum game. It is true that much money is being spent on HIV/AIDS. It is true that more money is needed for addressing other diseases as well as for assisting countries and individuals to develop sustainable agriculture, curb environmental degradation, increase access to quality education, decrease population growth and ensure the basic rights of all to live in dignity. This does not mean that too much money is being spent on HIV/AIDS. The funding for poverty alleviation overall is much too small. Many countries pledged to devote just 0.7% of their GDP on development assistance to reach the Millennium Development Goals. Perhaps the most egregious underfunder is the United States, which contributes much less than this, but manages to spend billions of dollars on the military. For those concerned with addressing the great problems of the poor, we need to work together to ensure adequate funds and a level playing field in terms of trade. Rather than squabbling about which disease or issue should get more funding, we need to demand that the wealthy countries pay what they have pledged. And then some, if needed. Competing interests: Work in the education sector for an NGO which recieves HIV/AIDS funding.
its only numbers 16 February 2007
Jeffrey C McILwain, Consultant, Clinical Risk Management St Helens & Knowsley NHS Trust, Warrington Road, Merseyside. L35 5DR Send response to journal: Re: its only numbers	Both sets of authors play the numbers game of statistics, economy and modelling of the future. But, I guess none of the authors are HIV positive nor are doctors and so can sit safely behind a desk jettisoning numbers to the audience. HIV, tuberculosis and malaria are amongst the greatest killers of the poorest people in the world claiming about 1 million lives each per annum or 114 people every hour of every day, disabling the future economies and existence of the poorest nations. Yet, has the world conquered even one of the big three? If a glimmer of hope to save the future deaths came from heavy investment in immune damage from any of the big three, then every penny spent is worthwhile. To change public attitudes will take decades, unlike the immediate and positive effect of Princess Diana holding the hand of an AIDS patient before the media, and until then money must be invested in trying to stem the tide of death for today and tomorrow. To paraphrase; "Fiddling whilst Africa burns" is a common issue, when words from desk jockeys then take centre stage and engage debate and not action. No author brings a primary solution to the table but rather each mildly lambastes world authorities and nation leaders for fiscal mishandling. A weak debate. In the time it has taken you to read this another person has died of AIDS - a fact of life. Competing interests: None declared
Are we spending too much on HIV or are we not? 17 February 2007
Mukosha B Chitah, Lecturer University of Zambia, Economics Department Send response to journal: Re: Are we spending too much on HIV or are we not?	The article referenced in the title in the current issue of BMJ makes interesting reading. Interesting because it dares raise the questions that may appear taboo (Such as arguing that too much is being spent on HIV). These questions and arguments require to be made and rightly so, if only to ensure that the twin elements of transparency in expenditure as well as efficiency (and effectiveness) in expenditures are central to the competing use of resources and their outcomes. The basis of the argument inherently made on the basis of DALYs and cost - effectiveness of the interventions however, appears a little flawed. Flawed in the sense that the estimation of 5% of DALYs attributable to HIV appears to be an underestimate. The estimate for Zambia, under conditions of (gross) imperfect information is about 25%. Secondly, the issue of using cost - effectiveness as a basis for arguing resource allocation, also raises in both a practical and theoretical sense, the risk of doing exactly that. Whereas therefore the intereventions of immunisation are so apparent there need not be a debate or that the interventions for prevention or treatment of road traffic crash cases are also apparent, this need not necessarily be the basis for resource allocation. The issues of values and philosophical considerations (based on community, technical perceptions and considerations) invalidate the argument to some extent. Priority ranking of HIV in the community may not be as high as that of child health but it may not be less than that of road traffic related morbidity and mortality either. Cost of HIV Interventions The cost of ART is high. Placing even say, 60% of eligeble persons on ARVs is hardly affordable for any high prevalence country resource constrained country (refer various HIV Strategic Plans or Global Fund proposals). Of course the fact that ARVs have to be complemented appropriately have a lot to do with it (Costing of HIV, various). However consider that up until now, we do not have appropriate pediatric formulations. Condier that we hardly have 5% of the children that should be on ART and are not - there is marginalisation and discrimination in terms of deographic access!!! So, even though Zambia, for instance, may have 75,000 people of the estimated 250,000 or so on ART, the cost is the key constraint to access. Cost is in this instance manifest in a number of dimensions - Human resource, equipment and machinery, stigma and discrimination etc. So, although funding has risen, the available resources for major interventions has not. Recall the condom debate. Expenditures on prevention and other line items is high. There may be a fallacy of human behaviour and prevention messages. That is, change in attitude is not necessarily correlated with the quantity and cost of prevention IEC and BCC efforts (cost wise). Socio - economic factors The epidemiology of the HIV prevalence and infections has been associated with socio - economic factors in the population. This in relation to the other sources of ill health appears valid. Proportionately anyway. And the various sources testify to this (Demographic and Health Surveys; Living Conditions and Monitoring Surveys, various). Having introduced this element in the article, naturally the equity issue becomes a part of the argument with respect to the resource allocation functions. Is it right to allocate resources to highly costly interventions which, are relatively more prevalent among the socio-economically better off sections of society than others? And why should this be so when the overall loss of productivity and lives saved is less than from alternative sources of ill burden? Furthermmore, the other aspects of this article that are raised are with respect to the very valid element of health systems. Health systems versus disease centred approaches This aspect of the discussions is probably the most pertinent that has been raised. Having been a part of each and every single "round" of the Global Fund's calls for proposals either for Zambia or some other Sub- SAharan African country, I finally could not help it but write to the Global Fund Fund secretariat to argue the case against the very vertical philosophy and practice of the planning and implementation process as well as funds flow mechanisms that were being expediously promoted and strengthened on a daily basis (or round by round basis by the Global Fund and its funders and trustees). This perhaps is the real issue or should have been the issue at the heart of the article. AS a matter of opinion, African health systems in general, and in the majority are being sytematically eroded through the re-emergence of vertical programmes for countries such as Zambia or being further strengthened in countries such as Namibia, Lesotho, Swaziland (Personal views having worked in those countries). Donor, for instance Presidents Initiative on AIDS (PEPFAR) of the united States Government and Global Fund focus on providing supporting through an entire parallel system with its negative consequences on human resources, misllocation of funds, sub optimal use of funds etc. The failure to provide services through an integrated approach that will assist strenthen the health systems and public and private health responses including th eso - called multi sector attributes relating to HIV such as issues of mainstreaming (which appear not to be understood by anybody in the public sector) other than the NAC officials is a major concern and threat to the development of public health systems and their capacities to effectively (impact) provide interventions,plan and management the sectors; as well as to the growth of a well governed private sector that is so desperately needed to augment public sector services,if done in a rational manner, mindful of the health inflationary and equity effects. The funding for HIV may not necessarily be too high, but it will yield little gains if current funding mechanisms are adhered to. Unless or until the current misguided funding flows that are rigidly vertical in nature are abandoned and a health system approach expeditiously put in place, the gains in the response to HIV, malaria and TB will inevitably last as long as the support lasts - on a diminishing rate of return basis, hence achieving less and less productivity and effectivess. There is an absorptio capacity constraint that arises from the inability of the vertical systems to broaden the system and in fact the current practice is regression in terms of the flow of human resources and as ably argued in the article the incopetencies, leading to waste in the delivery of services. Conclusion There are two elements: 1. HIV funding, because of the treatment aspect remain inadequate. this notwithstanding expenditure switches are possible that may not some programmes worse off than others e.g. prevention versus VCT. 2. Current donor and global funding mechanisms are inefficient and ineffective and therefore render current funding achieve less output and outcome than they otherwise would. In this context, the need to completely overhaul funding initiatives such as Global Fund, PEPFAR are inevitable if gains are to be achieved in a systematic and long term basis. At the same time LDC health systems must be made more transparent and accountable so as to optimise integration in funding flows. Mukosha Bona Chitah, Economics Department, University of Zambia, Lusaka Zambia 16 February, 2006 References Zambia: National HIV Strategic Framework National TB Strategic Plan National Malaria Strategic Plan Child Health Strategic Plan Global Fund Proposals for HIV, various Costing of HIV and AIDS, TB and Malaria Competing interests: None declared
The real crux of the matter 21 February 2007
Labib A Nassim, Software Developer 25 Ashey Road, Ryde, PO33 2UW Send response to journal: Re: The real crux of the matter	I must confess that I don't often read the BMJ. However, this week's striking cover obliged me to look at this article. Over 20 years ago, I patented a simple method for allowing people in advanced countries to exchange anonymous confidential health information - see www.hivprevention.co.uk. This proposal was usually ignored by the medical profession and very occasionally ridiculed. Since then, things have marginally improved and doctors now accept that the exchange of such information is not such a bad thing after all. Today, in much of Africa and India, many people have access to mobile phones and SMS and this proposal now has validity there as well as in advanced countries. Considering the amounts being spent on HIV in the world, there must be something odd going on when no one looks carefully at this proposal. I allowed my patent to lapse many years ago and so have no vested interest in the matter. Alfred Nassim Software and Civil Engineer Ryde PO33 2UW Competing interests: None declared
Are we spending too much on HIV? 21 February 2007
John Lwanda, medical practitioner 5c Greystone Avenue, Rutherglen G73 3SN Send response to journal: Re: Are we spending too much on HIV?	Are we spending too much on HIV? As one who has lost 5 out of 11 sibs to HIV, I cannot but be aware of the magnitude of HIV. Indeed HIV has been described, in the African context, as ‘bigger than colonialism'. Roger England’s article notes that HIV contributes 17.6% of the burden of disease while receiving 40% of all health aid in 2004 [BMJ, 344]. De Lay et al on the other hand state that 20% of all deaths globally in people aged between 15-49 were due to AIDS and 31% of communicable, maternal, perinatal, and nutritional conditions were attributable to HIV in 2002. Though the figures differ, the element of relative ‘overspending’ compared to other health and social developmental sectors is obvious. But while England makes the point that this is due to an excess of spending on a disease that carries less morbidity than others and De Lay et al. argue for more spending both sides miss the crucial point that, at present HIV is the only tropical disease receiving anywhere near Western levels of health funding. The reasons for this are many and varied but include: the global nature of HIV; the wages and expenses of expatriate health workers and the many groups involved in HIV work in the tropics. England could have maximised his argument that the money channelled into HIV should be spent through local national health departments. Some African NGOs and Delay et al. may argue for the present status quo, which has created, in some cases to the detriment of health and governance institutions, parallel institutions as it benefits their causes. England on the other hand should have presented a breakdown of exactly how the HIV funding is being used. He may find that only a small fraction of that trickles down to the African HIV patient and that a significant chunk of it rubber bounces back to the West. Although HIV funded expatriates do subsidise some national health systems as they treat all patients, this only masks the deficiencies in those countries. If and when the HIV money dries up it will be too late to correct the deficiencies. Ref: 1. England, R. Are we spending too much on HIV? BMJ 2007; 334: 344 2. Lwanda, J. 2005. Politics, Culture and Medicine in Malawi: Historical continuities and ruptures with special reference to HIV/AIDS. Zomba: Kachere Competing interests: None declared
It is how we spend on HIV in Africa,, not how much we spend that counts. 21 February 2007
Joseph A Sonnabend, physician 30 Hamilton Terrace NW8 9UG Send response to journal: Re: It is how we spend on HIV in Africa,, not how much we spend that counts.	Specifically targeted approaches against HIV without consideration of other factors, particularly other infectious causes of morbidity in Africa, may not ensure the most effective use of funds. Many endemic infections in parts of Africa, which are frequently associated with poverty, may enhance the replication of HIV and promote its spread by several demonstrated mechanisms. Some may even impair the efficacy of antiretroviral therapy. The allocation of a portion of AIDS designated funds towards traditional - and relatively inexpensive, public health interventions would be appropriate and independently improve the health of people. Approaching the treatment of AIDS as part of an integrated program to improve public health, rather than as an isolated endeavour may prove to be a more effective use of AIDS designated funds. Treating HIV is obviously important, but it is not necessarily the same as improving the health of populations.Indeed, dealing with the former in isolation may sometimes not even be a step towards the latter goal. Competing interests: None declared
The world should increase Total health budgets, NOT cutting HIV budget 23 February 2007
Joseph Ana, Commisioner for Health Ministry of Health, Cross River state, Nigeria Send response to journal: Re: The world should increase Total health budgets, NOT cutting HIV budget	Roger England might have a point in his article in alerting the world to the 'disproportionate spending on HIV' when compared to other conditions such as malaria, etc. But that is not the main problem, going by our experience in cross river state of Nigeria where we are told that we have achieved the greatest ever reduction in sero-prevalence of the disease. HIV is about 25 years old, a very young disease, therefore needs more seed money to be understood and for prevention and effective treatments to be found. Malaria and Tuberculosis ( most recent TB increase are due to HIV anyway) are relatively 'ancient' conditions, better understood even though suffering from perenial underfunding because most countries will not put their money where their mouth is when it comes to Health. A few years ago, the United Nations and African Union agreed that every nation should devote at least 15% of their GDP to the health subsector. How many countries have come near to achieving such a decision?. Very few, if at all. My main worry about Roger England's alarm is that the success achieved so far in stemming the disastrous upsurge of HIV in the last few years will be eroded, very quickly,if the funders believe his article and cut down on funding,which will inevitably lead to closure of proven and effective anti-HIV interventions. We say in cross river state of Nigeria that, 'that we have cut our sero-prevalence rate from 12% in 2003 to 6.1% in 2005 does not mean that we should be complacent. On the contrary we should work harder to push it down to 1% in 2007 . That means we have embraced the stepping up of activities in all Thematic areas from prevention to treatment,to home and palliative support, and plugging legal loopholes', etc. We are establishing more VCT centres, more comprehensive ARV therapy centres and passing the Law against stigma and discrimination of people with HIV. We are taking the intervention nearer where people live and work and thereby enhancing the possibility of 'access for all by the end of 2007'. We have strenghtened monitoring, evaluation and money for value measurements across our response to the pandemic. It will be disastrous to cut funding to HIV just because we are beginning to see the green shoots of progress against the pandemic. Rather, all countries should implement the agreed minimum allocation to the whole health subsector which is what the real problem is. It should not be HIV versus malaria or TB or immunisation. It should be adequate funding for Health against all diseases. Competing interests: None declared