Experts Debate the Future of AIDS Programs

On May 27, MSH and the African Medical and Research Foundation (AMREF) hosted “Strengthening Systems to Combat AIDS amid the Global Financial Crisis: What Got Us Here Won’t Get Us There,” a lively discussion among four experts at the Omni Shoreham Hotel in Washington, DC. 

Daraus Bukenya, MSH’s Global Technical Lead for HIV & AIDS/TB, grounded the discussion in an overview of the 30-year history of HIV & AIDS, particularly in Africa, which bears two-thirds of the burden of disease. Dr. Bukenya noted that the scale-up of treatment has exposed the weaknesses of health systems to deal with AIDS. “I think the challenge that came as a result of that emphasis was that we saw much less investment in prevention…. For every person now on treatment, we have five new infections…. We are trying to fight a battle that is almost unwinnable.” National health systems are fragmented, lacking integration, coordination, and leadership, Dr. Bukenya explained. “We need to reorganize… and ask, How do we build platforms on which effective, sustainable, cost-effective programs that can generate public health impact will be implemented?” 

Princeton N. Lyman, Adjunct Senior Fellow for Africa Policy Studies, Council on Foreign Relations, made the point that “The commitment to HIV/AIDS…is probably one of the greatest moral commitments in history…yet, when you look ahead at where this is taking us, it may not be sustainable.” He deplored the disproportionate impact of AIDS on women and girls, who are, according to Laurie Garrett, predicted to face the brunt of cutbacks amid the global financial crisis. 

Former Ambassador Lyman pointed out that many developing countries depend on donors to fund these programs. There has been a 40-fold increase in funding, yet, by 2025, if the trends in infection continue, 50 million people will be living with AIDS. “How are we going to treat 50 million people by 2025?... If you don’t get a handle on prevention, these figures will just keep rising,” he asserted. He went on to discuss three possible scenarios: that donors will decrease funding for HIV & AIDS, that they will increase funding for AIDS although other sectors such as education or the environment may be crowded out, or that there will be a backlash from donors, in particular for countries that do not control their infection rate. 

“What I find encouraging in all of this…is that…people are beginning to take seriously that this is a long-term issue.” He supported his point with the example of the AIDS 2031 project. 

Karen Cavanaugh, Health Systems Analyst in the Bureau for Global Health of the U.S. Agency for International Development (USAID), discussed the US government’s approach to strategically adjusting its approach to AIDS. She said “it’s important to highlight…that the US government has clearly stated its intention to maintain that commitment.” She noted that of the $63-billion six-year global health initiative recently announced by President Obama, $51 billion will be devoted to tackling AIDS, tuberculosis, and malaria. 

“We need to take a health systems approach to all of our efforts,” with a focus on strengthening countries’ capacity,” Cavanaugh continued. Based on its experience in the field, USAID is looking at three types of engagement through the US President’s Emergency Plan for AIDS Relief (PEPFAR): helping countries address weaknesses in their health systems; applying lessons learned from PEPFAR that could have broader benefits, creating “intentional spillover” into other areas of the health system; and “targeted leveraging,” that is, engaging with partners to take advantage of opportunities outside the area of AIDS, such as social health insurance.  

Alvaro Bermejo, Executive Director of the International HIV & AIDS Alliance, agreed with the other speakers that “the real failure of the health system…is the failure of prevention.” But he stressed that the World Health Organization model of health systems falls short of explaining the critical roles that the community and the family play—especially given the need for chronic care. According to Dr. Bermejo, “The scenario that presents the best results at the lowest cost is the one that addresses structural change,” by focusing on gender violence, sex workers, men who have sex with men, and other vulnerable groups. “It isn’t a health care services solution.” 

Dr. Bermejo also called for a change in the debate about money: “We can globally mobilize more money: the same as we can mobilize it for General Motors, we can mobilize it for the health response.” 

In response to a question from the audience about countries that have strengthened their health systems with donor funds, Ms. Cavanaugh gave examples from several countries: PEPFAR has helped Kenya change the way it recruits health care workers and assisted Haiti in supporting a performance-based financing scheme that helped the health system become more efficient and focused on results. She emphasized that the country has to drive the change. 

The panel was opened by Dr. Jonathan Quick, President and CEO of MSH. Dr. Joyce A. Sackey, Dean for Multicultural Affairs and Global Health at Tufts University School of Medicine and member of MSH’s board of directors, moderated the panel.