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AIDS Funding Binds Longevity of Millions to U.S.
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Few experts think that the financial responsibilities, whatever their magnitude, will end in 2015. As patients live longer they will take drugs longer, and many will eventually need more expensive ones, too.
Studies suggest that after several years of treatment, about 5 percent of patients each year become resistant to one or more of their antiretrovirals. If 8 million people are on treatment by the end of this decade -- which many experts think is realistic -- about 800,000 will need "second-line" therapy, which now costs 10 times as much as the cheapest starting combination.
Although there is debate in the global health community about whether programs are obliged to switch all failing patients to second-line treatment, or even third-line "salvage" therapies, everyone agrees that first-line treatment can never be stopped.
"The train is out of the station. People who are on treatment -- we can't drop them, if for no other reasons than ethical ones," said Peter Piot, the Belgian physician who heads UNAIDS.
The Global Fund already recognizes that treatment, once started, is essentially an irrevocable entitlement. If the fund cancels a country's AIDS grant for reasons of graft or incompetence, it promises to find a way for patients already on antiretroviral therapy to stay on without interruption.
Nevertheless, some experts think AIDS-treatment programs are not so different from other forms of foreign aid. Their obligations are just more obvious.
Dean T. Jamison, a health economist at the University of California at San Francisco, recalled recently that when he worked at the World Bank in the 1970s, Robert S. McNamara, the bank's president, required that staff overseeing projects in Africa demonstrate in writing how the recipient countries would shoulder the responsibility after five years.
Jamison said he and his colleagues dutifully complied, making up rosy economic scenarios that none of them believed. Privately, they all knew that whenever they drew up an assistance project, "we were putting together a set of implicit financial commitments that were likely to last for decades," he said.
And they have.
