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From Vol. XLIV, No. 4, "The MDGs: Are We on Track?",? December 2007

Each year, 2.5 million people become infected with HIV, 8 million contract tuberculosis (TB), and between 300 million and 500 million fall ill from malaria. Together, these diseases kill more than 5 million people per year, the equivalent of a full 747 airplane crashing every 44 minutes1. They are diseases of poverty and inequality, but all are treatable and preventable. The vast majority of those affected live in countries that have only a few dollars to spend on health care each year and are least prepared to respond to pressing needs.

The fight against these diseases can be won. AIDS, TB and malaria can be prevented. The lives of those living with HIV can be successfully extended for many years; malaria and TB can be cured. In southern Africa's Lubombo Spatial Development Initiative, for example, a multi-pronged approach to prevent and treat malaria led to nearly a 90-per-cent drop in transmission of the disease1. To fight TB, China's use of the DOTS treatment strategy allowed the country to prevent 30,000 deaths from the disease per year2. Thailand has been able to stem the spread of AIDS and guarantee universal access to AIDS treatment for all who need it. Its aggressive prevention efforts are estimated to have averted over 7 million new HIV infections3. In addition, data on the global prevalence of HIV/AIDS is also improving through better collection methods and widespread surveillance systems.
Even in the poorest African countries, major progress has been made. HIV prevalence rates have declined in several highly affected countries, including Kenya and Zimbabwe4. Nearly 90 per cent of TB cases across Africa, with the exception of war-torn countries, are being treated with DOTS5; many are re-energizing national programmes to combat malaria. Zambia, for example, has achieved notable early success against the disease through a combination of hut spraying, insecticide-treated bed nets and drug treatment. Malaria deaths have already begun to decline6.

Progress in fighting these diseases has been facilitated by the dramatic increase in resources provided by international donors, including the United States President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. About 70 per cent of all global AIDS funding comes from international donors, and roughly half of the money contributed directly by donor Governments comes from PEPFAR7, which has succeeded in moving money quickly. PEPFAR has vastly expanded treatment programmes while investing significantly in prevention and care activities. Its funds have supported treatment for over 1.4 million people infected with HIV8.

The Global Fund is another significant funder for AIDS programmes, providing over one fifth of the world's financing, and is the leading funder for malaria and TB programmes, providing over two thirds of global resources for both diseases9. The Global Fund has pioneered an innovative financing model that focuses on a country-driven process and aims to build the capacity of each country to respond to AIDS, malaria and TB. Through this approach, its supported programmes have provided treatment for more than 1.4 million people with HIV and 3.3 million with TB, and have distributed 46 million insecticide-treated bed nets to prevent malaria10.

Building on the momentum of recent years' accomplishments, the international community should act quickly towards even greater gains. Several of the most urgent priorities are described below: New sources of financing are needed to fight AIDS, malaria and TB. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that the $10 billion provided in 2007 is $6 billion less than the amount needed to provide universal access to AIDS treatment, prevention and care. Funding requirements for AIDS alone will continue to rise rapidly in the future, reaching more than $50 billion by 201511. Our investments now will not bring immediate returns, but will prevent the AIDS pandemic from spreading for decades to come. Large sums are also needed to fight TB and malaria.

New funding sources for AIDS must be sustainable. Predictable revenue flows are critical for maintaining life-saving antiretroviral treatments for AIDS patients and for curbing potential emergence of drug-resistant strains of the virus. The need for new and creative approaches to generate predictable revenue in low-income countries has inspired the development of innovative financing mechanisms (IFMs), including a tax on airline tickets, which has been adopted by more than a dozen countries and has already raised hundreds of millions of dollars for drugs and diagnostics for AIDS, malaria and TB. The airline tax will serve as a long-term predictable source of financing12.

More IFMs are needed to raise the sums necessary to effectively tackle these diseases. One idea is for some highly affected middle-income countries, such as Botswana and South Africa, to adopt a special health tax. Raising additional funds in these countries could free up international resources for use in other nations. The international community should make the development of IFMs an urgent priority.

Increasing the commitment of political leaders. Money is only part of the solution. Another urgent priority is to increase the commitment and support of political leaders, especially the Heads of State, particularly in Africa, who can be uniquely influential in convincing people to protect themselves and others against these diseases. The impressive progress in Uganda in reducing the incidence and prevalence of HIV in the early 1990s is often attributed in part to the active engagement of President Yoweri Museveni and other political leaders, although progress in the country has since slowed down13.

Governing bodies have tremendous leverage in affecting change. For example, in China, the Ministry of Health has produced and broadcast 900 TB programmes in more than 1,000 counties to increase public awareness of TB, as well as availability of free diagnostic and treatment services14. Despite a devastating civil war, several rival authorities in Somalia have made efforts to allow TB patients to cross roadblocks of warring factions in order to travel to treatment centres15. The Tanzanian Government not only distributes thousands of bed nets to fight malaria in Zanzibar, but works closely with local mosque leaders to raise awareness of the disease16.

High-level political engagement could also cut through the bureaucratic challenges that have hampered the effectiveness of prevention and treatment efforts. Among the challenges, Governments have often been slow to approve funding to health providers and have struggled to find staff that can monitor programmes17. Progress was slow in many early malaria programmes due to deficiencies in health systems and their inability to administer care after years of neglect; but as infrastructure and health systems are strengthened, treatments have rapidly increased18. Political leaders, working with other stakeholders, should take active steps to fix these inefficiencies by ensuring that Governments can effectively oversee and coordinate national responses.

Addressing the vulnerabilities of adolescents to HIV. National responses to HIV/AIDS must give priority to the special vulnerabilities faced by adolescents. Young people are at particularly high risk of contracting the disease -- half of all people with HIV/AIDS acquire it between the ages of 15 and 2419. An important part of any effective strategy is widespread education campaigns, inside and outside schools, as well as increased access to health services, including condoms20.

Among adolescents, girls are particularly vulnerable to HIV infection. In Africa, three out of four 15- to 24-year-olds with HIV are females. This is largely due to girls' relative powerlessness in sexual relationships and the prevalence of such relationships between young girls and older men. Girls who engage in these types of relationships have less control over negotiating safe sex and are at higher risk of HIV infection21. Protecting young girls from the risk of HIV will require changing the social norms and practices that breed gender inequality and power imbalances between genders20.

Adopting universal testing as part of a comprehensive approach to prevention. All countries highly affected by HIV should adopt universal testing as part of a broader prevention strategy. Most HIV-infected people -- up to 80 per cent in some countries -- do not know that they are infected22. Provider-initiated testing can ensure that HIV-infected people receive treatment early enough to ensure that medication can extend their lives23. This treatment can have a positive effect on prevention, because people receiving antiretroviral drugs are also less infectious.

In Botswana, patients are routinely tested unless they decline, and special efforts have been made to test those in rural areas, including through the use of mobile-testing facilities. Using this approach, Botswana increased testing by 134 per cent between 2004 and 2005; 41 per cent of those tested were HIV-positive. Based on this achievement, efforts are now underway to replicate this approach in Kenya, Lesotho, Malawi, Rwanda and Uganda24.

Universal testing must be adopted as one part of a more comprehensive prevention approach, including treatment of sexually transmitted infections, condom promotion, adult male circumcision, prevention of mother-to-child transmission, and targeted efforts to prevent infections among vulnerable groups, such as sex workers. By using an appropriate mix of these strategies, comprehensive prevention efforts could avert half of all infections that are projected to occur by 201525.

Time for action. Despite the gains made in recent years, millions of people continue to die from AIDS, TB and malaria. This need not be the case. The world possesses the know-how to combat these diseases, and many countries have already demonstrated progress in tackling these killers. By taking the steps proposed above, we can control AIDS, malaria and tuberculosis to the same extent as has been achieved in the developed world. Equity and social justice demand that we commit ourselves to doing this.


Notes

1. UNAIDS, AIDS Epidemic Update 2007 . Friends of the Global Fight, Fact Sheet on Malaria and Fact Sheet on Tuberculosis .
2. Ruth Levine and the What Works Working Group, Millions Saved (Center for Global Development, 2004).
3. Mead Over et al., The Economics of Effective AIDS Treatment in Thailand (2007).
4. UNAIDS, Report on the Global AIDS Epidemic (2006).
5. WHO, Report on Global TB Control (2007). This figure is calculated for countries where data are available, but does not include all African countries.
6. Presentation delivered by Zambian Minister of Health Brian Chituwo at the Bill and Melinda Gates Foundation's Malaria Forum (16 October 2007).
7. UNAIDS, Report on the Global AIDS Epidemic (2006); Kates et al., Financing the Response to AIDS in Low- and Middle-Income Countries (Kaiser Family Foundation and UNAIDS, 2007).
8. PEPFAR, World AIDS Day 2007: The Power of Partnerships- Latest PEPFAR Results (December 2007).
9. Global Fund, Partners in Impact: Results Report (2007).
10. Global Fund, Global Fund Investments Deliver AIDS Treatment to 1.4 Million People (29 November 2007).
11. UNAIDS, Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support (2007). These estimates were made prior to the revised epidemiological numbers released by UNAIDS on 20 November 2007. As a result, total funding needs may decline slightly but will still be much higher than the current amounts being provided.
12. UNITAID Website .
13. "HIV/AIDS in Uganda". Avert Website .
14. The Global Fund, Stopping Tuberculosis in China (2007).
15. The Global Fund, Somalia and Tuberculosis (2007).
16. The Global Fund, Fighting Malaria in Zanzibar (2007).
17. Oomman et al., Following the Funding. Center for Global Development (2007).
18. Testimony of Dr. Stefano Lazzari, Global Fund Senior Health Advisor, to the House Committee on Foreign Affairs (April 2007).
19. Robert Blum, Trends in Adolescent Health (2006).
20. The Alan Guttmacher Institute, Risk and Protection: Youth and HIV/AIDS in Sub-Saharan Africa (2004).
21. International Center for Research on Women, Girls and HIV: Vulnerability, Risk and Burden (2007).
22. AIDSmap, WHO/UNAIDS endorse opt-out HIV Testing .
23. Mead Over, Opportunities for Presidential Leadership on AIDS. (Center for Global Development, forthcoming).
24. Keith Alcom, "Routine or opt-out counselling and testing: findings from the 2006 PEPFAR meeting" (HIVinSite, 2006).
25. Global HIV Prevention Working Group, "Bringing HIV Prevention to Scale" (June 2007).

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