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UN fails AIDS test

Philip Stevens
Medical Progress Today
August 18, 2006

This week at the biannual AIDS conference in Toronto Peter Piot, head of UNAIDS, announced that prevention is the key to defeating the AIDS pandemic. This is a huge volte–face from UNAIDS which has spent the last three years throwing money at treatment programmes for those already infected, while ignoring the less immediately rewarding—but vital—task of AIDS prevention.

This switch of strategy is welcome, but raises serious questions about the competence of UN high command. Under the UN's watch, the last few years have seen new infections soaring and money poured into grandiose but unrealistic treatment programmes that have not delivered the value anticipated by the amount of money that was spent. Risks have been taken with patient safety. And the legacy of the UN's treatment programmes will be a form of economic welfare dependency for the worst–afflicted countries that will entrench poverty without reducing AIDS.

To understand how we came to this sorry situation, it is necessary to rewind to the 2000 International AIDS conference in South Africa. Around this time, advances in medical science were making AIDS in the West a manageable condition, as opposed to the automatic death sentence it had been a few years previously. Health activists thought—not unreasonably—if American AIDS patients can get the miracle drugs, why shouldn't people in poor countries?

In 2003, the UN transformed the activists' demands into policy by creating the "3 by 5" programme, a plan to put three million AIDS sufferers in lower–income countries on ARV treatment by 2005.

Unfortunately, this well–intentioned goal ignored some hard truths. The most obvious is that countries with the worst AIDS problems also have the fewest doctors, nurses and clinics. In Nigeria, for example, there are only 28 doctors for every 100,000 people. How did the UN expect to massively "scale–up" treatment if the people were not there to administer the drugs?

The answer is that it couldn't: at the end of 2005 only 1.3 million people were receiving treatment. Of course, it is to be celebrated that these people have been given the chance to live longer. But why make such promises if they are totally unrealistic?

While the UN earned political kudos among the activists by doing something to advance AVR treatment, it neglected the only way to reverse the pandemic: prevention. This has been a betrayal of the 4.9 million people who were infected in 2005 alone.

These people all now need to be added to the tens of millions of patients already needing expensive and difficult treatment. In this way, the UN is responsible for creating a vicious and growing circle of suffering and death.

ARV medicines require clinical oversight and adherence to specified regimens if they are to be effective. In countries that don't have appropriate medical infrastructure, there is a risk that patients will miss doses, or even share drugs amongst their families. This is an invitation for the virus to mutate and develop resistance to those drugs.

Samples taken before 1996 showed about 5 per cent drug resistance to existing HIV strains, rising to at least 15 per cent between 1999 and 2003. This all implies significant extra costs as drug–resistant patients have to be moved onto expensive second—and third–line therapies.

Meanwhile, mismanagement of funds, inefficiency, waste, overpriced technical assistance and corruption within recipient governments has meant that the cost of treating a developing–country patient for two years ballooned to $12,538 by the end of 2005—nearly ten times the $1,633 that was initially estimated by UNAIDS.

Based on this past performance, the goal of sustaining many years of ARV treatment for 10 million people will be astronomical. At the very least, it will leave precious little aid available for the myriad other diseases which affect Africa.

Admittedly, the failure of the "3 by 5" programme taught the UN it needs to invest in infrastructure if it is to meet its 2010 treatment targets, so it now plans to spend $750m on building clinics between now and 2008. The UN has not explained, however, who is going to pay for maintenance of the clinics or salaries. This requires large quantities of hard foreign currency, something which is in desperately short supply in sub–Saharan Africa.

Either the new hospitals will slowly rot or OECD donors (mainly the US) will have to finance them in perpetuity. But the influx of the billions of dollars of foreign currency necessary to maintain them could wreak all kinds of macroeconomic damage, such as the rapid appreciation of local exchange rates, inflation and fiscal volatility. These hurt the poor the most.

In effect, the UN's failure to prioritise prevention earlier and get a grip on the pandemic is now forcing it to create OECD–financed welfare states in sub–Saharan Africa that are unsustainable for donors and bad for Africa.

Good intentions are no substitute for accountability when things go wrong. Toronto is an opportunity to hold the UN to account and demand answers from its leadership.

Philip Stevens is director of the health programme at International Policy Network in London. He is the author of numerous health policy publications, including Free Trade for Better Health (2006) & The real determinants of health (2005), and his writings on health policy have appeared in a wide range of international newspapers. He holds degrees from the London School of Economics and Durham University.
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