21 October 2011
Tim Siegenbeek van Heukelom

Bjørn Lomborg: The Five Best Ways to Fight AIDS

Bjørn Lomborg is the author of The Skeptical Environmentalist and Cool It, head of the Copenhagen Consensus Center, and adjunct professor at Copenhagen Business School. This article was originally published on Project Syndicate.

Making HIV/AIDS Investments Count

It is dangerous to believe that the end of AIDS is in sight. About 30 million people around the world live with HIV, and another 30 million are likely to become infected in the next decade if current trends persist. Funding from developed governments is dropping—a trend that must be reversed. But we also need to acknowledge that billions of dollars have been spent on well-meaning attempts to save lives, and there has been an alarming lack of high-quality evaluation of how these investments have performed.This is true not only of abstinence campaigns, for which there is no evidence of effectiveness, but also for many other mainstays of the AIDS response. On a systemic level, we do not know what works, where, and why—or how to replicate our successes.

In the project RethinkHIV, the Copenhagen Consensus Center and the Rush Foundation asked 30 of the world’s top HIV economists, supported by epidemiologists, demographers, and medical professionals to analyze the most promising responses to the epidemic in the world’s worst-hit region, sub-Saharan Africa. They were asked to examine what could be achieved with extra investments in six key areas: prevention of sexual transmission, reduction of nonsexual transmission, treatment of those who have the disease, initiatives to use social policy and health-system strengthening to fight HIV/AIDS, and vaccine research.

The resulting research papers offer the first-ever comprehensive attempt at cost-benefit analysis of AIDS priorities. Economics can offer a fresh perspective by showing us the overall value to society of competing spending options. Among worthwhile investments, some are very costly and achieve little good; others are remarkably cheap and incredibly effective. Whether on AIDS or other problems, additional funds should be spent first where we can achieve the highest return for our money.

To spark a dialogue about HIV/AIDS priorities based on the RethinkHIV research, the Copenhagen Consensus Center and the Rush Foundation asked five world-class economists—including three Nobel laureates—to form their own conclusions about how best to spend additional funding. The panel zeroed in on five investments that they believe should be at the top of policymakers’ lists.

Most important, they identified an urgent need for increased investment in developing an HIV vaccine. This is clearly a longer-term response to the epidemic: Research by Dean Jamison and Robert Hecht (PDF) for RethinkHIV suggests that we are about 20 years away from large-scale vaccination, and that increasing current funding by around 10 percent, or $100 million a year, would meaningfully shorten that projection. This would save millions of lives and potentially end the epidemic in the long run, while dramatically improving scientific understanding of the disease in the near term. For every dollar spent, it is likely that the benefits would run into the tens of dollars.

As a shorter-term response to the epidemic, the Nobel laureates were convinced by research by the economist Lori Bollinger (PDF) that we could practically wipe out mother-to-child transmission of HIV by 2015 with additional expenditures of just $140 million a year. About 350,000 infants became HIV positive in 2008, through pregnancy, labor, delivery, or breast-feeding, accounting for approximately 20 percent of all new infections. Since we have such cost-effective programs to halt this tragedy, the Nobel laureates concluded, this is a compelling investment.

So, too, is spending more to make blood transfusions safer. Bollinger calculates that annual investment of $2 million over five years would achieve 100 percent safe blood transfusions by 2015 and avert more than 131,000 HIV infections, while alleviating fears of infection for the almost half-billion people who would otherwise receive blood that was not comprehensively screened.

The Nobel laureates also found that male circumcision is an excellent use of funds. They focused particularly on the longer-term benefits of infant-male circumcision, arguing that there is massive untapped potential to introduce this very cheap practice across Africa. We know that adult-male circumcision reduces the odds of transmission from a woman to a man by up to 60 percent. Research by Jere Behrman and Hans-Peter Kohler (PDF) of the University of Pennsylvania makes clear that the real focus needs to be on working out the best ways to broaden adult circumcision efforts across the region, and to convince men that getting circumcised is a good idea. We also need to introduce counseling to ensure that men do not treat circumcision as a vaccine, and engage in riskier behavior as a result.

Finally, the panel of Nobel laureates concluded based on research by Mead Over and Geoffrey Garnett (PDF) that additional resources for treatment should go first to patients who are the sickest and most infectious. Because treatment is very expensive, coverage rates remain woefully inadequate. But treatment is not only an ethical imperative; it also is important in preventing and reducing sexual transmission.

The expert panel did not just identify the top-priority uses for additional funds. It also highlighted promising areas where more research is needed. As Anna Vassall, Michelle Remme, and Charlotte Watts of the London School of Hygiene and Tropical Medicine point out (PDF), gender inequalities and domestic violence are both associated with a significant increase in risk of HIV infection. So, if gender training programs were to piggyback on current income-boosting microfinance and agricultural-support programs, we could undermine norms about gender roles that entrench women’s dependence on men or condone domestic violence. It’s a proposal that deserves further investigation, as is the proposition from William McGreevey of Georgetown University (PDF) to increase efforts to focus treatment of HIV-positive patients to reduce opportunistic infections of cryptococcal meningitis.

We need to arrest the recent drop in AIDS funding and secure additional resources in order to make further headway against the disease. By highlighting sound investments—including some that are not currently at the top of policymakers’ to-do lists—RethinkHIV makes the case in economic terms for doing just that.

10 October 2011
Tim Siegenbeek van Heukelom

“Australia should lead a global HIV prevention revolution”

Today Bill Whittaker had an opinion piece in the ABC’s DRUM, arguing that Australia should lead a global HIV prevention revolution.

The global fight against AIDS is at a crossroads. On the one hand we have exciting new scientific evidence which could dramatically reverse the pace of the HIV epidemic and prevent millions of new infections, sickness and deaths.

On the other hand, there is weariness and complacency after 30 years of the epidemic as well as a global financial crisis putting tremendous pressure on national budgets around the world and threatening funding essential to reverse the relentless spread of HIV.

Mind-numbing statistics speak for themselves about the scale of the HIV epidemic and the work to be done: 30 million lives lost; another 33 million people living with HIV; and 7000 new infections occurring every day, mostly among young people.

New HIV treatments are having a tremendous impact in reducing illness and AIDS-related deaths, but the sustainability of providing HIV treatment – especially in low to middle-income countries – is threatened by the reality that for every one person put on HIV treatment, another two people become infected.

Recently, the United Nations agreed to a bold new Declaration to fight AIDS which Australia played a leading role in getting all UN Member States to endorse. A centrepiece of the UN Declaration are bold new HIV prevention targets for the global community to reach by 2015.

These global targets include reducing sexual transmission of HIV by 50 per cent; reducing HIV transmissions through injecting drug use by 50 per cent; and eliminating mother-to-child HIV transmissions – all by 2015.

So how would these targets be achieved under the UN Declaration?  Firstly, by dramatically scaling up prevention programs; by freeing up access to HIV testing; by increasing HIV education alongside wide availability of condoms and sterile injecting equipment; by promoting male circumcision in certain contexts; and by fully exploiting the potential of new technologies for communication and connecting people – such as social media, mobile phones and the internet.

The UN Declaration also calls for global action to ensure prevention programs properly focus on the three populations which are universally at higher risk to HIV, specifically men who have sex with men, sex workers and their clients and people who inject drugs.

Finally, the Declaration calls for new scientific evidence about the additional prevention benefits that HIV treatment can deliver to be capitalised on. So just as HIV treatment was revolutionised 15 years ago by combining different drugs – termed “combination treatment” – the Declaration heralds an era of “combination prevention”, where proven prevention programs and communication innovation are combined with wide availability of HIV treatment to help drive down rates of new HIV infections.

So what should this mean for Australia? Our rate of new HIV infections is running at around 1,000 new infections per year, mostly among gay men. But should we be satisfied with this level of new infections – the personal and community impact of this – and the something like $1 billion plus price-tag that comes with each 1,000 new infections? Of course not.

Australia’s current National HIV strategy and most state and territory strategies continue a lamentable drift away from setting bold, time-bound HIV prevention targets so essential to generate momentum and monitor progress.

Now is the opportunity for us to embrace “combination prevention”, re-double our efforts and set bold HIV prevention targets aligned with the 2011 UN Declaration to really drive down Australia’s HIV infection rates.  These targets should include:

  • Reducing sexual transmission of HIV among men who have sex with men by 80 per cent by 2015.
  • Eliminating HIV transmission from injecting drug use by 2015.
  • Eliminating HIV transmission among sex workers and clients by 2015.

These prevention targets should be complemented by a treatment target of having 90 per cent of people with HIV in Australia on HIV antiviral treatment by 2013.

These are the kind of bold actions that the 2011 UN Declaration calls for and that all countries, including Australia, have pledged to implement.

Australia has shown great leadership and innovation in HIV prevention. One of the best things Australia can do to support a global HIV prevention revolution is to lead by example and champion what we are doing.  We must not miss this opportunity to re-vitalise our HIV prevention strategies and to help lead global efforts to stop the spread of HIV and its devastating impact on so millions of people around the world.

Bill Whittaker is one of the architects of Australia’s response to AIDS and has worked in HIV policy and strategy for more than 25 years. Bill is a member of Pacific Friends of the Global Fund’s Coordinating Committee.

7 October 2011
Tim Siegenbeek van Heukelom

Michael Kirby: Summing up the UNAIDS meeting on the criminalisation of HIV

In Geneva, from the 31 August to the 2 September, UNAIDS organised an expert meeting to review the scientific, medical, legal and human rights issues related to the criminalization of HIV exposure and transmission. Justice Michael Kirby, a retired judge of the High Court of Australia and member of Pacific Friends’ Coordinating Committee, was one of the experts to review the application of the criminal law to HIV.

Here an excerpt from an interview with Michael Kirby at the UNAIDS expert meeting in Geneva:

There are some exceptional cases where the criminal law has a role to play. However, the criminal law has been pushed into a whole range of other activities which are counter-productive from the point of view of a public health response to HIV. The use of criminal law is also likely to lead to disproportionate and highly punitive measures which are not helpful in responding to the epidemic in a way that prevents the spread of HIV.

After the meeting Michael Kirby did a wonderful job in summing up the key points and views from the high-level meeting in this report.

29 September 2011
Tim Siegenbeek van Heukelom

“HIV/AIDS, TB and Malaria are still Emergencies”

23 Septebmer 2011. A statement from the Communities Living with HIV, Tuberculosis and affected by Malaria Delegation of the Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria

The Communities Living with HIV, Tuberculosis and affected by Malaria Delegation (Communities Delegation) of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) welcomes the report of the High-Level Independent Review Panel (HLP) and acknowledges the recommendations put forth in strengthening fiduciary controls and oversight mechanisms at all levels of the Global Fund, which are consistent with its values of transparency and accountability.

The comprehensive findings of the HLP is a result of six months of intensive work, and includes the review of 40 existing grants with a conclusion that all current weaknesses are opportunities that can be strengthened and improved.  The Board of the Global Fund will meet on the 26th September 2011, in Geneva, Switzerland to review and discuss the findings and recommendations, act on the most urgent issues and agree on a process to address and action the recommendations.

The Communities Delegation is deeply concerned, however, on how some of the findings of the HLP can be misconstrued.  The Global Fund has committed US$ 22.4 billion in over 150 countries to support large-scale prevention, treatment, care and support programmes against the three diseases.  This in practical terms translates to putting 3.2 million people on HIV treatment, treating 8.2 million people infected with Tuberculosis (TB), and 190 million bed-nets distributed to avert malaria infections.  Millions of lives have been saved, because of the work of the Global Fund and its partners, and this needs to be put into perspective.

During times of a massive financial crisis and instability in the biggest world economies, major Global Fund contributors could translate the outcomes of the report into excuses not to meet funding commitments.  The Global Fund needs the current and new donors to increase their contributions and pledges expressed at the Third Voluntary Replenishment Conference from US$ 11 billion to more than US$20 billion to ensure that efforts and gains made in the last decade can be effectively sustained.  The Global Fund is thus far, the only mechanism in existence that could invest these resources needed in life-saving interventions.  The report states, “the failure of the Global Fund would be a global health catastrophe”.

Currently, 15 million people living with HIV are in dire need to be on life-saving drugs; the case detection for TB globally is at 65%, with drug resistant TB spiralling faster; and malaria cases though contained might be at a risk of exploding if efforts are not preventive efforts are not sustained.  These are all emergencies that require immediate attention and extraordinary actions so as to benefit the very communities that we stand up for.

The Communities Delegation does not support the HLP suggestions to re-evaluate the Board decision on Round 11 funding, and proposals for new eligibility criteria.  The Board of the Global Fund needs to be able to discuss the impact, consequences and recommendations responsibly bearing in mind the tremendous ramifications these decision(s) will have on achieving MDGs 4, 5, and 6, and ultimately on the lives of communities.

Shared responsibility is at the core of partnerships, and the Global Fund is a unique funding mechanism andpartnership with an oversight and governance structure that includes multi-stakeholder participation at both global and national level.  The report provides a timely opportunity for both implementers and donors to not only make the money work, but also to demonstrate how it works.

We are dismayed with some disparaging and opportunistic public statements related to the leadership at the Global Fund Secretariat after the release of the HLP report, and would like to point out that the recent reappointment of the Executive Director proves the trust and confidence of the Board in his work.  The Communities Delegation has confidence in the leadership of the Executive Director, and would like to express our most sincere gratitude to staff at the Global Fund Secretariat for their tireless commitment and dedication to ensuring that lives are being saved across the three diseases.

The Communities Delegation reiterates its position of zero tolerance to corruption and the commitment to transparency and accountability.  We bring to the Global Fund Board the voices and needs of millions of people living with and affected by the three diseases, and together with the CivilSociety Constituencies on the Board of the Global Fund, we will remain vigilant to ensure that the most urgent changes in the structures, policies and processes of the Global Fund are implemented in order to continue saving lives.

We call for the responsible use of the public information released in the HLP report by media and governments and other partners, with a reminder that the challenges related to the three disease is an on-going emergency in many parts of the world.  We need to ensure that the recommendations of the Board, and its responses to these recommendations constantly place the lives of people at the centre of our discussions.

On behalf of the Communities Delegation,

Shaun Mellors
Board Member,
Communities Delegation

Lucy Chesire
Interim Alternate Board Member,
Communities Delegation

Rachel Ong
Communications Focal Point,
Communities Delegation

28 September 2011
Tim Siegenbeek van Heukelom

“Australia must do better on HIV”

The National Association of People Living with HIV (NAPWA) called on the Australian government and health bodies to reorient National HIV Strategies to better align with those set by the United Nations at the High Level Meeting held in New York in June this year.

Australia [has] to up its game and reduce transmissions of HIV amongst men who have sex with men, by 80 per cent by 2015.

http://www.napwa.org.au/media/2011/09/26/australia-must-do-better-on-hiv

Pacific Friends operates as a program within the Kirby Institute at the University of New South Wales.

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Pacific Friends of the Global Fund to Fight AIDS, Tuberculosis and Malaria is a high-level advocacy organisation which seeks to mobilise regional awareness of the serious threat posed by HIV & AIDS, tuberculosis and malaria to societies and economies in the Pacific. In pursuing its goals Pacific Friends has a specific interest in highlighting the need to protect the rights of women and children in the Pacific.

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