Where AIDS Funding Should Go
Last month public health experts from around the world gathered in Beijing to celebrate the launch of a comprehensive international study of health interventions and strategies for the 21st century. The book that resulted is known as Disease Control Priorities in Developing Countries, second edition (DCP2). In over 1,400 pages of research by more than 300 authors, it presents the scientific community's cutting-edge understanding of the most and least effective ways of meeting the health challenges the developing world faces. It includes the cost and effectiveness of 319 preventive and curative interventions, ranging from immunization to bypass surgery.
The global epidemic of HIV-AIDS remains the most critical health challenge in much of the developing world. DCP2 presents a set of proven, affordable, effective strategies that developing countries can use to bring AIDS under control, as well as those now known to be less effective or ineffective. These conclusions represent the consensus of scientific opinion from around the world.
The United States has pledged more money to fight AIDS than any other country, a fact exemplified most dramatically by the unprecedented $15 billion for the President's Emergency Plan for AIDS Relief. In addition, the U.S. government provides the bulk of financing for AIDS vaccine development. But the program allocated only 28 percent of its funds to prevention in 2005. And even this amount belies the fact that the government's policies for using much of this money fly in the face of scientific evidence on the effectiveness and cost of prevention strategies it is being spent on.
DCP2 reaches five conclusions that are either opposed by the U.S. government or that recommend strategies the United States is not using:
· More than half of the funds allocated for prevention of sexual transmission are designated for programs to support "abstinence and be faithful" programs. But evidence to date indicates that such programs are neither effective nor cost-effective. If there is any reason to continue them, they need to be undertaken in combination with rigorous evaluations to monitor their effects and to learn which aspects work and which do not.
· Condom distribution is known to prevent HIV transmission. It is inexpensive and should be a vital part of all prevention programs. But as a recent Government Accountability Office report noted, the Bush administration insists that condoms be promoted only for "high risk" sexual encounters and rarely for adolescents. Furthermore, government-sponsored literature perpetuates a myth of condom failure that undermines the repeated evidence of international and domestic studies. We urge free distribution of condoms worldwide, especially in countries with a high incidence of HIV-AIDS.
· Societies need to reduce the social stigma and discrimination against individuals who have HIV or who are at risk of infection. This end to discrimination must include sex workers, who are highly vulnerable and play a significant role in spreading the epidemic in many countries. Yet U.S. policy, set forth in the Trafficking Victims Protection Reauthorization Act of 2003 (the "litmus test" for sex workers) requires that foreign organizations receiving funds for AIDS relief demonstrate that they are opposed to prostitution, thus making it next to impossible for sex workers themselves or any organization supportive of sex workers to engage in activities related to care or prevention. As a result, a $48 million AIDS prevention grant for Brazil was recently suspended because the intended recipients were unwilling to sign the pledge.
· Needle exchanges have proved highly effective in interrupting the spread of infection among users of injection drugs. These people often play a key role in igniting and sustaining epidemics. There is no evidence for the claim that needle exchanges "encourage" the use of illegal drugs. But U.S. policies prohibiting possession of drug paraphernalia, combined with prescription laws for purchasing needles, limit federal funding for this inexpensive and effective method.
· Any public health intervention must be tested by empirical evaluations of its actual effectiveness. Funding for such rigorous evaluations is extremely limited.
Ignoring evidence costs lives. Our government's policies should be informed by science. Billions of dollars can be poorly spent, and thousands of deaths incurred, from failure to consider the existing evidence and failure to gather evidence of effectiveness from existing interventions. The government owes this leadership not only to American taxpayers and our international partners but, most important, to all the people around the world affected by the specter of HIV-AIDS.
Dean Jamison, an economist, was lead editor for DCP2. Nancy Padian, an epidemiologist, was co-lead author of DCP2's chapter on AIDS. Jamison is a visiting professor and Padian is director for research in global health sciences at the University of California at San Francisco.