As the biennial international AIDS industry conference gathers 25,000 delegates in Mexico, a wind of change is blowing. UNAIDS, the United Nations’s AIDS advocacy body, stands accused of exaggerating the threat of AIDS, wasting billions on “preventing” epidemics that were never going to happen and undermining basic health care in Africa by diverting ever-larger funds to HIV/AIDS.
Illustration: Malay Karmakar / Mint
The impending change of leadership of UNAIDS provides an opportunity for fresh thinking. That is why I am a candidate for the position. My platform is to dismantle the organization constructively to help ensure that HIV spending is balanced with that on other equally pressing diseases through stronger primary health care.
No one is denying HIV/AIDS is a serious problem: It has hit some sub-Saharan African countries hard, particularly South Africa. Globally, however, its impact is less severe. The annual two million HIV deaths are about the same as the number of children under five years of age who die in India from easily preventable diseases such as pneumonia.
But while HIV causes only 3.7% of global mortality, it receives 25% of all health aid, plus a big chunk of domestic expenditure. In sub-Saharan Africa, HIV/AIDS constitutes less than 20% of the disease burden, a figure that is skewed upwards by South Africa. Yet HIV/AIDS receives 40% of health aid — $4.6 billion in 2006, and rising. HIV/AIDS aid now often exceeds total domestic health budgets.
For years, activists have justified this disproportionate spending by claiming that HIV/AIDS is exceptional: a disease of poverty, a developmental catastrophe and an emergency demanding wide-ranging UN intervention.
These claims have now been demolished. New data from Africa show that prevalence is highest among the middle classes and more educated. Although HIV can tip households into poverty and constrain national development, so can all serious diseases and accidents. Prevalence in Africa has peaked and rates in Asia are far lower than projected by UNAIDS. India was declared in 2005 as having the biggest numbers of people with HIV in the world, at 5.7 million. When India did its own, better, research, the figure fell to 2.5 million and UNAIDS had to acknowledge the correct new estimate.
The UNAIDS claim that HIV is a “potential threat to the survival and well-being of people worldwide” is sensationalist. As the World Health Organization’s (WHO) head of HIV stated last month, “It is very unlikely there will be a heterosexual epidemic” outside sub-Saharan Africa. The success of UNAIDS advocacy is constraining improvement in basic health services in the poorest countries. Excessive HIV funding has created two-tier health systems, a kind of medical apartheid in which HIV patients receive treatment free, while non-HIV patients pay for sub-standard services.
HIV funding also bypasses countries’ institutions, creating parallel financing, employment and systems, thus entrenching bad management and creating duplication and waste.
The US in particular is at fault: Its HIV programme, or PEPFAR, the President’s Emergency Plan for AIDS Relief, has flooded 15 countries with dedicated resources, taking staff and skills away from other needs. And the Global Fund to Fight AIDS, TB and Malaria is not far behind.
Although UNAIDS has now reduced world HIV estimates from 39.5 million to 33.2 million, it is still calling for huge increases in annual spending — from $9 billion today to $42 billion by 2010 and $54 billion by 2015.
Flooding the world’s poorest countries with foreign currency on this scale would cause inflation and push up interest rates — a de facto tax on the poor. As an advocacy body, it is hardly surprising that UNAIDS wants more money but its demands look increasingly absurd. While the AIDS industry grows fatter, primary health care in the poorest countries is in crisis. As Mozambique’s health minister, Paulo Ivo Garrido, wrote last year, “The reality in many countries is that funds are not needed specifically for AIDS, tuberculosis or malaria. Funds are firstly and mostly needed to strengthen national health systems so that a range of diseases and health conditions can be managed effectively.”
Time is up for UNAIDS. Why do we have a UN agency for HIV, and not for pneumonia or diabetes, each of which kills more people? UNAIDS should be dismantled rapidly, because its single-issue campaigning is distorting global health spending and betraying the world’s poor. Its useful monitoring function can be transferred to the WHO.
This will be resisted strongly. The worldwide HIV industry has become a monster with too many vested interests and reputations at stake, too many single-issue NGOs and too many rock stars with AIDS support as a fashion accessory. In Mozambique, there are 100 times more NGOs devoted to HIV/AIDS than to maternal and child health.
With UNAIDS dismantled, international donors can concentrate on strengthening health systems by providing sustained and predictable funding.
Roger England is chairman of the Health Systems Workshop, an independent think tank promoting health systems reform and strengthening in poor and middle-income countries. Comment at firstname.lastname@example.org