The Public Health Approach Makes Sense for the Global Fund
When the Global Fund to Fight AIDS, TB and malaria was created in 2002, its aim was to provide financial support to developing countries in their battle against the three border-crossing communicable diseases for which treatment and prevention options were available.
In the decade since the Fund has been providing grants to 150 countries around the world, it has evolved its financial model to respond to the unmet needs in the countries with the highest burden of disease and the lowest ability to pay for it. The Global Fund has decided to streamline eligibility for Global Fund grants along these lines, using prevalence data to assess burden of disease and per capita gross national income to assess a country's finances.
But as a longtime AIDS activist with a background in medicine and public health I would like to make the case that these markers of GNI and prevalence may leave some countries that have acute unmet needs out of the net of Fund financing, which could have serious consequences for their populations. Instead, the Global Fund should take a public health approach to financing, casting as wide a net as possible to help control the global spread disease.
There is a conventional wisdom about the three diseases that suggests they are afflictions of poverty -- that once a country surpasses a threshold of development, they tend to disappear. While that may be true for some communicable diseases, and while sub-Saharan Africa does have the highest regional prevalence of HIV in the world, it is a mistake to attribute infection and the spread of this epidemic to poverty as the main reason.
The reality about HIV is that high infection rates are correlated with sexual behaviours and practices -- not necessarily with poverty. So to my mind, basing eligibility for HIV funding by the Fund on financial benchmarks would deliberately neglect some countries where there is a real risk of a rising AIDS epidemic.
That risk is unacceptable, particularly since there have been so many advances in the understanding of the disease and how it is transmitted. In May 2011, the Fund board of directors called on the secretariat to work more closely with countries to re-program (this is the key word that was approved) existent grants to achieve the best possible impact. A day later, a first report of a major scientific study of people on anti-retroviral treatment concluded that those who are able to achieve an undetectable viral load reduce by 96% the chance of transmitting the virus to their sexual partners.
Taking these two events together shows how providing medical treatment can not only save a life but can protect the health of the population: demonstrating a clear public health benefit. Of the 35 million people estimated by UNAIDS to be living with HIV, only 10 million are taking ART. This means, globally, that 71% of people who have a highly infectious virus are not taking medication to control it, raising the risk that they will transmit it, even unknowingly, and furthering the spread of this global epidemic.
To get a sense of what this risk is, we should turn to six G-20 countries. Turkey, India, Saudi Arabia, China, Russia, Indonesia: in 2012, none of these countries had ART coverage above 20% of their total infected population. Not surprisingly, according to the 2013 ‘AIDS By The Numbers’ report released by UNAIDS, the two regions of the world where the HIV epidemic is still surging ahead disproportionately are the two with the lowest average ART coverage rates: Eastern Europe/Central Asia and the Middle East/North Africa.
Compare that to a country like Uganda, where nearly 40% of people living with HIV are taking ART every day, or Haiti, at above 20% or Cambodia, which has gone above 60%. That a Russian citizen living with HIV would have a greater chance at prolonging his life by moving to Uganda seems unfathomable to me and underscores the need for a re-thinking of the eligibility parameters established by the Fund.
Taking a public health approach to controlling epidemics means not just measuring prevalence to assess disease burden; it means incorporating incidence rates as well as yearly volumes of new infections.
We welcome the move at the November 2013 Global Fund board meeting to approve support for ambitious regional initiatives for the eradication of malaria, irrespective of borders with countries with a different eligibility status, such as Nicaragua with Costa Rica, Haiti with Dominican Republic or Guatemala with Belize and Mexico. This shows that there is scope within the Global Fund to apply the public health approach to respond to cross-border and regional issues. Why can't this same support be applied to the HIV response?
The public health approach is not about providing financial resources to countries that do not need them; it's about using public health as the benchmark for decision-making.
At AIDS Healthcare Foundation, we acknowledge that there might be additional costs in applying the public health approach, but this is not an insurmountable obstacle. We are highly confident that the Fund's Fourth Replenishment will be fully funded for the $15 billion sought for the next three years. Equally, there are unspent resources within countries that need reprogramming to be more effective and we call on countries to work together with the Fund to do this without delay.
Finally, by establishing a more permanent and predictable replenishment model, which considers quotas to countries based on the example of other global financing mechanisms such as the IMF and the World Bank, we believe that investing fully in the Global Fund now will ensure that the need for resources in the future will decline alongside the rates of infection as we bring these diseases under control and towards elimination.
Dr Jorge Saavedra is a global ambassador for the AIDS Healthcare Foundation