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HIV fight hits cash
crunch
By Alan Boyd
SYDNEY -
A looming cash crisis threatens to unravel much of
Asia's recent success in stemming the spread of the AIDS
virus, with the biggest impact probably being felt by
the three most populous nations in the region.
Position papers presented at the 14th
International AIDS Conference in Barcelona, which ended
on the weekend, indicate that US$2.5 billion will be
needed annually by 2005 just to care for victims of the
disease in developing Asian countries. This is
equivalent to the entire global support budget for AIDS
in developing countries during 2001, and does not
include the additional costs of community education and
preventative strategies.
Asia currently meets
only 20 percent of its funding needs for about 7 million
carriers of the human immunodeficiency virus (HIV) that
causes AIDS, relying on international donors - primarily
development agencies such as the World Bank and the
Joint United Nations Program on HIV/AIDS (UNAIDS) - for
the rest.
But there are worrying signs that
compassion fatigue within the global community could
leave some nations short just as the virus is beginning
to take hold in populous China, India and Indonesia. A
global fund set up by the World Health Organization
(WHO) a year ago has managed to scrape together only $2
billion in pledges, well short of the target of $10
billion that will be needed to sustain existing
programs.
About $800 million will be disbursed
from the fund this year, but not all will go toward the
containment of AIDS. The appeal is also intended for use
against tuberculosis (TB) and malaria.
More
donations will be vital if Asia is to secure
anti-retroviral drugs that can help arrest the decline
in life expectancy induced by the AIDS crisis and check
the potential wider economic impact from the loss of
millions of productive adults.
The WHO
calculates that there are 6 million people with AIDS in
developing nations who could live a longer life if they
had access to affordable combinations of anti-retroviral
drugs. Only about 10,000 patients in Asia are believed
to be using the drugs, which cost $12,000-$15,000 a year
at US prices. Pharmaceutical companies have lowered the
retail price in developing countries to $500, but this
is still too expensive for most of Asia.
Some
countries - notably India and Thailand - have sought to
raise money offshore for direct investment in the
manufacture of generic versions of the drugs, but with
little success.
Without new pledges through the
global fund, the burden will shift back to individual
governments, that have often been half-hearted in their
funding commitments. China and India, both believed to
be on the verge of catastrophic increases in HIV cases,
came in for particular criticism in Barcelona, and
appear likely to be penalized when it comes to the cash
carve-up.
The fund director, Richard Feachem,
indicated that allocations would be closely tied to
domestic input, which in effect meant that governments
would only get as much back as they spent from their own
resources. In addition, funding will be subject to an
automatic review after the third year of allocations
according to the efficacy achieved during the first two
years in utilizing cash handouts.
Neither China
nor India was given any AIDS funding in the initial
round of allocations from the fund when they were
announced in April, though more disbursements are
pending.
A total of $15 million was granted to
China for the control of malaria and TB, while India got
$1.9 million for TB programs. Indonesia, another
frequent target of international criticism, received
$6.2 million for TB control.
India's per capita
expenditure on health care is a mere $2 a year, an
amount described as woefully inadequate by Feachem and
UNAIDS director Peter Piot, whose agency helps
administer the fund. AIDS programs collectively attract
funding of $55 million a year, and have not been greatly
affected by 1991 economic reforms that slashed other
health funding. Tuberculosis, one of the main infections
associated with AIDS, gets a further $18 million to $20
million annually. However, much of this cash is lost
because of poor targeting and corruption. European
governments complained in the early 1990s that as little
as one-third of AIDS funding was being put to use,
though the proportion is now higher.
Another
flaw in India's AIDS programs that may undermine its
access to international aid is an under-emphasis on
care, with most of the budget being used for education
programs rather than blood screening or treatment. The
government says it will switch the focus to treatment
once a vaccine becomes available. But speakers at the
Barcelona conference were generally skeptical that this
would happen much before the end of the decade.
By that time India is likely to be the frontline
of the global epidemic. UNAIDS believes there are
already 3.8 million Indians infected with HIV, and that
5 million will be infected within 2-3 years. In absolute
terms, India will probably have the biggest number of
victims worldwide, though less than 1 percent of the
total adult population is likely to be infected.
Infection rates in Africa, by contrast, are as high as
37 percent.
China, with an estimated 1 million
to 1.5 million HIV carriers, has also been accused by
UNAIDS of not doing enough to contain the virus, and of
failing to educate its population on preventive
measures. A study released by the agency in late June
reported that public awareness of the disease was low
because of a lack of resources, weak government
commitments, faltering health-care systems and
bureaucratic inefficiency.
Nearly 20 percent of
Chinese have never heard of AIDS, and there is little
pressure to moderate risky behavior patterns. HIV
infection levels are expected by the WHO to reach 10
million in 2010. Yet government data consistently
under-state the threat. As recently as two years ago,
Beijing contended that only 30,736 people were
HIV-positive, and its tally is still 40-60 percent below
foreign estimates.
Chinese authorities are only
now accepting the wider social risks. A national
response was drawn up two years ago and funding sharply
boosted. A total of $12.4 million was set aside for AIDS
programs last year, up from $1.7 million in the previous
12 months. But this amount is still viewed as wildly
unrealistic in terms of the sheer scale of the threat
posed by China's huge population of migrant workers and
the inadequacy of village-level health services.
Indonesia and Myanmar, both hamstrung by limited
domestic resources, are the other two countries that
particularly concern health workers, partly because
neither has yet acknowledged the full extent of the
problem.
With a relatively low infection rate of
120,000, Indonesia has not faced the same funding
challenges as some of its neighbors: Thailand, with half
Indonesia's population, has 670,000 HIV carriers.
However, the toll is expected to rise rapidly as
detection systems are improved in outlying provinces
such as West Papua, where infection rates are soaring.
Some estimates put the likely number of Indonesian
victims at 500,000 within 2-3 years.
Public
health chiefs in Indonesia admitted last year that too
little had been done to confront the problem, but blamed
the political and economic turmoil that erupted after
the regional financial crisis of 1997-98. Overseas
observers point to an official policy of self-denial,
noting that the government persists in playing down the
threat. The National AIDS Commission has reported only
3,856 AIDS deaths since 1987.
Like the Thai
scheme that it emulates, Indonesia's AIDS program
directs most resources toward prevention, in the hope of
achieving 100 percent use of condoms - a formidable
challenge in Asia's biggest Muslim community. Little
money is left to buy drugs for treatment, though the
government hopes to secure donations from abroad as part
of a national campaign that was launched in late March
to mobilize more resources. Few donors have come
forward.
Myanmar's military junta puts an even
lower priority on the care of AIDS victims. Health
Minister Major-General Ket Sein told a WHO seminar last
year: "Contrary to the gloomy picture presented in some
reports in the Western media, HIV/Aids is not rampant in
Myanmar."
The WHO's own figures present a
different picture of Myanmar, with at least half a
million HIV carriers; some independent agencies believe
there could be a million. As many as 4 percent of the
adult population are believed to be infected, the
highest proportion in Asia. Poor health services have
hidden the full extent of the threat. The WHO ranks
Myanmar 190th out of 191 countries worldwide in the
level of its health care, while the AIDS program also
ranks somewhere near the bottom.
Nevertheless,
there are tentative signs of a breakthrough in
prevention, with condom use becoming common in some
border areas where the infection is rampant. And the
Yangon government is waking up. Recently it allowed a
soap opera with an anti-AIDS message to be screened
nationwide on TV, even while funding for treatment was
being held back.
But cash is not likely to roll
in until the authorities start putting the TV slogans
into practice and take a bigger responsibility for their
own health problems. Pointedly, Myanmar was omitted from
the initial list of recipients for aid from the global
fund, and gets little attention from individual donors.
Myanmar spent $3 million on health care in 1999,
a per capita outlay of only 60 US cents, which is 20
times below the minimum level recommended by the World
Bank. Because of economic sanctions over its
human-rights record, Yangon does not get any official
international aid and has little support from foreign
governments. Development assistance amounts to about $1
per capita, compared with $35 for Cambodia and $68 for
Laos.
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