Activists invaded the platform at the International AIDS conference in Vienna last week to demand more money — but for what? With drugs now less than $100 per person per year, treating the five million people now on therapy should cost $500 million, say $1 billion including logistics and support. Yet the world spends $16 billion annually on HIV. Where's it going? “In too many countries, too much money pays for too many people to go to too many meetings and get on too many airplanes to do too much technical assistance," former US President Bill Clinton told the conference. His diagnosis that the HIV industry has become fat on aid is spot on: those activists depend on this aid, mostly through the army of NGOs it has created. A good start to cutting waste could be made by closing down UNAIDS, the UN's lobbying organisation that costs tax payers the best part of half a billion dollars a year. It was set up in 1996 by UN agencies persuaded that HIV was so special that it should be removed from the purview of the World Health Organization. From the start, UNAIDS has been self-serving, providing the UN with data and arguments for massively expanding HIV funding regardless of other global health priorities. Much of its data and arguments have been proved wrong (in 2007 it had to halve its estimates for India and slash others) and much of its lobbying has been based on alarmist projections (like the pandemic long-predicted for East Asia that did not and will not happen). Data from a few hard-hit southern African countries was used to make global policy, and to secure for AIDS an excessive 40% share of health aid to Africa, depriving other more important areas including family planning and reproductive health. In addition to unscientific claims of impending disaster, UNAIDS was slow to accept inconvenient scientific evidence. Its mantra that HIV is a “disease of poverty” willfully ignores the evidence that prevalence is higher in the middle classes of Africa than the poorer. On prevention, UNAIDS has been dismal. It was slow to grasp the key role of concurrent sexual partners in driving transmission, instead promoting broad prevention aimed at the general population, most of whom are at minimal risk. It was slow to support clinical circumcision in prevention despite mounting evidence in favor. UNAIDS has not hesitated to take credit for recent declines in HIV but, in fact, HIV has been falling in Africa since the late 1990s, before UNAIDS was working and before the big HIV funding started. The decline is more a result of the natural course of the disease. How important is HIV? Globally it is insignificant, accounting for 3% of deaths. Even in Africa HIV is not significant for the vast majority of the continent's 53 countries. Excluding just five countries (South Africa, Zimbabwe, Nigeria, Kenya and Uganda) with the highest number of HIV deaths relegates HIV for the rest of Africa to around 6% of deaths — below deaths from diarrhoea, childhood diseases, malaria, respiratory infections, cardiovascular diseases, maternal and perinatal conditions, and accidents and injuries. Yet last week in Vienna UNAIDS continued its sleight-of-hand propaganda that, globally, AIDS is the biggest killer of women of reproductive age, when this is true in only a handful of southern African countries. The cost of putting five million people on HIV treatment could prevent 10 million child deaths every year from pneumonia and diarrhoea that are simpler and cheaper to treat. It is a tough choice — but not one AIDS activists are concerned with. President Obama is right to shift new aid to support underlying health delivery systems that will be there for all health needs not just one disease. The self-serving lobbying of UNAIDS, by contrast, illustrates vividly the folly of a single-disease UN agency. Time to put half a billion dollars to better use. Roger England is Chair of the Health Systems Workshop, an independent think-tank promoting health systems reform in poor countries. He has worked for several international agencies including secondments to the World Bank and the World Health Organization.
