The International AIDS Economics Network (IAEN) held a two-day pre-conference in Amsterdam on 20th and 21st July, ahead of the 22nd International AIDS Conference. The theme was ‘Sustainable AIDS Response Results in the Era of Shrinking Donor Funding’. This was timely given the context of shrinking international funding for development assistance for health (DAH), and specifically, the HIV and AIDS epidemic. The meeting would not have been possible without support from a number of donors and the very hard work of the steering group, ably led by Dr Steven Forsythe of Avenir Health.
The topics included funding trends, costing, costs and cost-effectiveness, sustainability, and the economics of HIV testing. This meeting is important as it assumes that AIDS funding needs advocacy, and one way to obtain it is to show that it makes sense to spend resources here. At the same time, participants recognized these resources are finite and so looked at economic tools to get the ‘best bang for the buck’. They include modelling and cost-benefit and cost-effectiveness analyses.
The importance of the topic was indicated by the keynote speakers the meeting was able to draw for the opening. Ambassador Deborah Birx, U.S. Global AIDS Coordinator and U.S. Special Representative for Global Health Diplomacy, and Mark Dybul, Georgetown University Medical Center, and former head of the Global Fund, spoke on the first day.
All the presentations were interesting and had varying levels of technicality. Some big questions were raised. Health economist Charles Birungi asked, “Long-term liabilities of HIV financing = debt sentence? The fiscal impact of HIV in Uganda”. As we saw in the rest of the AIDS 2018 conference, the current best practice is to treat people as early as possible once they have tested HIV-positive and ensure they adhere to antiretroviral treatment. Barring significant scientific advances, an 18-year- old in Malawi could require drugs for 40 years or more. This has a cost, and the person receiving the treatment may not be able to afford it.
A deeply interesting presentation by Gavin George of the Health Economics and HIV/AIDS Research Division of the University of KwaZulu-Natal entitled “An examination of men’s wealth- and age-disparate partnerships in South Africa: A nationally representative cross-sectional survey” addressed the ‘sugar daddy’ syndrome. George used data from the National HIV Communication Survey of South Africa to assess this. He concluded:
- Comparatively wealthier men in both urban and rural areas are no more likely to engage in age-disparate partnering than poor men.
- Whiles age-disparate relationships are characterized by transactional sex, the relationships are not the sole domain of wealthier men.
- HIV prevention messaging highlighting the risk posed by the economically advantaged ‘sugar daddy’ may not be accurately representing the risk posed by older men across the economic spectrum.
This is not to say ‘transactional sex’ is not a driver of HIV, but rather that sugar daddy/sugar baby relationships may be over-emphasized. It feeds into another question that, to my mind, has never been properly answered. Where in poverty-stricken communities does the money for the ‘sugar’ come from?
Annie Haakenstad of Harvard’s TH Chan School of Public Health illustrated the dependence of many countries on DAH. She concluded, “Some countries may be able to spend substantially more of their domestic resources on HIV/AIDS relative to current spending. Some of the countries with the highest burden of HIV/AIDS and the most dependence on DAH may not be able to spend much more, however.” The question that arises from this is: which can, which can’t, and what should the global response be? As suggested elsewhere in the GFO, in an article discussing the ‘Risky Middle’ category of countries, this is both a political economy issue and a human rights issue.
Writing in the International Health Policies Newsletter on the meeting, Mit Phillips of Médecins Sans Frontières noted “Excellent presentations on political economy … However, the difficult choices that would be in real life the consequence of such theoretic modelling and investment comparisons were rarely touched upon, and nobody questioned the shrinking international and overall funding as a given. Some people were perhaps happy that sustainability was finally taking centre stage again, after 20 years of ignoring the reality of poor countries and weak health systems” (click here for more on this).
Economists are going to be increasingly important in the response to HIV and AIDS. Decisions made on a technical basis may not be popular. The reality is that as international funding decreases, this will evermore be how the world operates.
PowerPoint presentations from this pre-conference will soon be available on the International AIDS Economics Network website at www.iaen.org.