Raising money for fighting AIDS is the easy part. Spending such sums effectively is harder, writes James Chin* in Geneva As health ministers gather for the World Health Assembly in Geneva this week (19-24 May), there is one organisation that can justifiably feel smug. UNAIDS, the United Nations' specialist AIDS advocacy body, has raised some $110 billion for the next five years: thanks to its efforts and $50 billion from United States taxpayers, AIDS will shortly become the biggest single item in foreign aid. Good managers know that good policy cannot exist without accurate data but UNAIDS has systematically exaggerated the size and trend of the pandemic, in addition to hyping the potential for HIV epidemics in "general" populations. While this distortion of HIV epidemiology has been useful for raising money, it has resulted in billions of dollars of unnecessary and misdirected spending. Part of UNAIDS's fundraising success has been its ability to convince donors that the pandemic is getting worse and is also a potential threat to all people everywhere. But UNAIDS's claims are not supported by the epidemiologic data. This data tells us that those at greatest risk of HIV infection are: heterosexuals and gay men who have unprotected sex with concurrent and multiple partners, within open or overlapping sex networks; regular sex partners of HIV infected persons; and people exposed to HIV infected blood, such as injecting drug users. In framing the global response to AIDS, UNAIDS has ignored this in order to promote a range of myths that have more to do with political correctness than science. For instance, UNAIDS claims that poverty and discrimination are major determinants of high HIV prevalence. In 1987, John Mann, the first head of AIDS at the World Health Organisation, claimed that being "excluded from the mainstream of society or being discriminated on grounds of race, religion or sexual preference, led to an increase of HIV infection," a litany that has been uncritically accepted by UNAIDS. All available data suggests the opposite. In Africa, AIDS is a disease associated with wealth. The richest people in Kenya, Tanzania and Ethiopia have HIV infection rates several times higher than the poorest, probably because wealthy men and women in these countries have a greater number of sex partners. Poverty and discrimination present barriers to gaining access to prevention and treatment services but are not primary determinants of sexual behaviour -- the real determinant of sexual HIV transmission. The US response to global AIDS -- $50 billion over the next five years -- is based on the poverty principle. This mistake could lead to all kinds of mis-spending down the line. In a similar vein, UNAIDS has consistently claimed that the world is on the brink of generalised heterosexual HIV epidemics. In 1997, UNAIDS chief Peter Piot gloomily foretold that, "AIDS will cut through Asian populations like a hot knife through cold butter". Aside from a few explosive heterosexual epidemics within large commercial sex networks in Thailand, Myanmar, Cambodia, and several states in India in the late 1980s to early 1990s, Piot's dire and colorful prediction never occurred. A recent report by an independent Commission on AIDS in Asia has acknowledged that epidemic sexual HIV transmission has not spread in Asia beyond the highest HIV-risk groups, such as gay men, injecting drug users, and sex workers, into any general population. However, UNAIDS's perpetuation of the myth that everyone is at risk of AIDS has led to billions wasted on HIV prevention programmes directed at general populations and especially youth, who, outside of sub-Saharan Africa, are at minimal risk of any exposure to HIV. UNAIDS's proposed budget for 2008 includes $1.9 billion for prevention programmes aimed at young people and the workplace. While some of this will be usefully spent in sub- Saharan Africa, the rest is effectively wasted. At least $5 billion has been wasted in this way in the last five years. Meanwhile, to the shame of the global health community, a handful of diseases that are relatively inexpensive to prevent or treat -- several vaccine-preventable diseases, diarrhoeal diseases, malaria and some acute respiratory infections -- continue to account for about four million annual child deaths globally. UNAIDS is apparently concerned that support to AIDS programmes might be reduced if most regional HIV rates are stable or decreasing and HIV remains concentrated in the highest HIV-risk populations. These are realistic concerns but global and regional HIV rates have remained stable or have been decreasing during the past decade; HIV continues to be concentrated in populations with the highest levels of HIV risk behaviours; and HIV is incapable of epidemic spread in the vast majority of heterosexual populations. Continued denial of these realities will further erode whatever credibility UNAIDS and other mainstream AIDS agencies and experts may still have, and will seriously damage the future fight against this disease: let's face the data and put the money where the real problems really are. * The writer is a clinical professor of epidemiology at the School of Public Health, University of California at Berkeley and former chief of the surveillance, forecasting, and impact assessment unit of the Global Programmme on AIDS of the World Health Organisation.
