Establishing Priorities and Budgets First Step in Global Response to AIDS, JAMA Reports

Setting priorities and budgets are some of the most "challeng[ing]" steps in combatting global AIDS, according to participants at a recent conference on worldwide resource allocation for HIV/AIDS and other infectious diseases sponsored by the Chicago-based International Association of Physicians in AIDS Care. JAMA reports, "What began several years ago as a trickle of patients with HIV/AIDS has become a deluge" in South Africa and many other African nations, bringing the "resource-strapped nations to their fiscal knees." The provision of basic health services for those infected with HIV has depleted the countries' health ministry resources, despite assistance from nongovernmental organizations, church groups and community organizations. JAMA notes, "The ongoing challenges are not only finding the resources for disease prevention and treatment, but setting often difficult priorities for how those resources should be used in the midst of intersecting epidemics." World Health Organization Commission on Macroeconomics and Health Chair Jeffrey Sachs is "spearheading an effort to determine how to obtain the highest returns from international public health funding as well as realistic estimates of the sums needed to produce those returns." Currently, wealthy countries contribute $500 million per year to fight HIV/AIDS in poorer nations, but to "effectively control the pandemic" they would have to increase their contributions to between $5 billion and $10 billion each year, he said. However, Sachs noted that "money alone won't solve the problem," as there is not yet a "cohesive strategic plan" to fight AIDS. He indicated that such a plan must include prevention, treatment, community support and research on and development of recommendations for breast feeding, salvage therapy (treatment for patients who have failed one drug regimen) and an HIV vaccine.

Affordability Important Factor in Prioritizing Interventions
Health economist Steven Forsythe of the Liverpool School of Tropical Medicine concurred with Sachs, saying that developing nations must begin to devise and apply criteria to prioritize interventions so that those receiving funds "will actually change the course of the epidemic in their regions." Forsythe noted, however, that many countries often "just take a wish list approach," citing an example of Kenyan health officials who recently identified 156 interventions for which they would spend $31 million in six years. Their highest spending priorities concentrated on drugs to treat STDs, female condoms and care for children orphaned by AIDS. Forsythe said that these interventions "would not necessarily control the epidemic." He added that the criteria of affordability needed to be used when prioritizing interventions. Forsythe examined the affordability of antiretroviral therapy in light of countries' health budgets, calculating that in Zambia, the cost of providing the drugs to 25% of the HIV-positive population would consume half of the health budget. In Botswana, the cost would be twice the health budget and in Mozambique, the cost of providing antiretroviral therapy would be 57 times the country's total health budget. Although Sachs "maintained" that drug therapy could be made available to developing countries through "increased foreign aid and discounted drug prices," Dr. Dorothy Ochola, a UNAIDS program coordinator in Uganda, concluded, "[T]he cost of the drugs is still a barrier" (Voelker, JAMA, 12/6).