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HIV and AIDS have swept across the world over the past two decades, killing millions and bringing about untold suffering. Although much has been done to stem the tide of AIDS, the disease continues to kill increasing numbers of people and shows no sign of slowing. The world is finally coming to realise the extent to which HIV devastates families, communities and countries, and now, at last, political will is building to tackle the epidemic. Governments, organisations and individuals have promised large sums, and more funding than ever before is being directed at the fight against AIDS. The HIV epidemic is most severe in some of the poorest countries in the world, those who lack adequate healthcare and education for their populations. These countries have been paying huge amounts of foreign debt to developed-world creditors, and have lacked infrastructure and resources to address the epidemic. The countries which are most in need pay back much larger amounts in interest than they receive in aid from the big funders detailed on this page. In 1996, available AIDS funding in low- and middle-income countries totalled US$300 million. By 2002, this amount had jumped to US$1.7 billion. By 2003, an estimated US$4.7 billion was available for the AIDS response that year. The latter figure also includes the steadily increasing funding that comes from country governments, and from the 'out-of-pocket' spending by directly affected individuals and families. In spite of this, 8000 people with AIDS are dying every day, and despite the fact that the disease can be treated cheaply. So is the money not enough? Is it being misspent? Or is the money not really there at all? This page provides an overview of the main players involved in the provision of AIDS medicines to the people around the world who need them the most. President Bush and the United StatesOne of the main providers of global funding in the fight against AIDS is the United States, under President George Bush. In his State of the Union address in January 2003, President Bush promised the world the President's Emergency Plan For AIDS Relief (PEPFAR), a commitment to significantly increase US spending on HIV around the world. Planned to run for five years, the plan was intended to direct $15 billion to places where it was most needed. PEPFAR became an umbrella for all the existing work being done by the United States, and for the funding which was already going out through USAID. While this is a huge sum, only $10 billion of this total was new money, $1 billion of which is to be provided to the Global Fund (more on the Global Fund later); $5 billion was money that had been previously allocated, meaning that it would have to come from existing programs. The President's plan has a goal of having 2 million people on antiretroviral AIDS medicines (ARVs) by 2008, preventing seven million new infections, and caring for 10 million people infected with HIV or children who have been orphaned by AIDS. The money is intended for several main purposes :
The money was to be spent primarily in twelve countries, later amended to fourteen, then to fifteen in June 2004 when Vietnam was added to the list. The choice of Vietnam surprised AIDS activists, some of whom criticised the decision, saying that China or India had considerably more severe HIV epidemics and much greater need. The choice appears to have partly been influenced by the fact that HIV in Vietnam is only now beginning to spread into the general population, something which could perhaps be averted by timely intervention.
There are indications that selection is based on the strategic importance or politics of the countries involved, and possibly on their possessing oil resources. One surprise choice for the list is Nigeria. The HIV epidemic in Nigeria, which is on the PEPFAR list, is not nearly as severe as that in Lesotho, for example. Nigeria had an estimated 5.4% prevalence at the end of 2003, and Lesotho an estimated 28.9%. Nigeria is the fifth largest supplier of US oil imports. The White House says that selection is based on HIV infection rates and institutional capacity to deliver care. Whatever the motives behind the money, it is already starting to make a difference, and lives are being saved. Additionally, whilst these fifteen countries are the focus of the President's initiative, they are not the only countries who will benefit - to a lesser extent, US spending targets 100 countries around the world. When the President's Plan was first introduced, there was concern that the funding allocated for the first financial year was much less than one fifth of the total, and that this was an indication that the full amount promised might not materialize. Spending such large sums of cash, however, is not as easy as it might seem - especially in countries which have only limited health-care infrastructure and capacity to absorb funding. PEPFAR funding has increased year on year, initially strengthening institutional capacity to absorb spending. The President's FY2005 budget is 16 percent above FY2004 and 78 percent more than FY2003. President Bush is now spending more than has ever been spent before on addressing the global AIDS epidemic, and, whatever his reasons, if this helps people it is surely a positive thing. The first round of funding totaled US$350 million and became available in February 2004. The second round of funding - US$500 million - was announced in June 2004. USAIDUSAID is a large organisation, engaged in many projects globally. When PEPFAR began, much of the US funding for the global fight against AIDS was going out through USAID, and this remains the case - PEPFAR now incorporates the USAID spending within its US$15 billion total. USAID does not exclusively spend money fighting AIDS - it assists countries which are recovering from disasters or are suffering from poverty, have non-democratic governments or are experiencing epidemics. It is an organisation which primarily promotes economic and democratic reforms. One consideration in USAID's decision-making process is the US national interest, and USAID has occasionally been criticised for being too bureaucratic, slow and inefficient. This year, with a budget of $795 million, USAID will assist more than 50 countries with HIV/AIDS programs, with 23 of these countries considered high priority. The criteria for determining the amount, level, and types of assistance countries receive include:
Criticisms
Results so farBy September 2004, PEPFAR had helped to put at least 25,000 people on ARV therapy. The next target will be to have 200,000 people receiving ARV medication by June 2005. While the results to date are disappointing, it is acknowledged that the process of providing antiretrovirals to the population of a resource-poor country is initially a slow one. After a while, it begins to accelerate and more rapid progress towards targets should be seen. AVERT.org has a page devoted to discussion of PEPFAR. The Global Fund to Fight AIDS, Tuberculosis and MalariaOften simply referred to as 'the Global Fund' for short, this organisation was created at the urging of UN Secretary General Kofi Annan and many national leaders. The concept of a Global Fund was unanimously endorsed in June 2001 at the first UN General Assembly Special Session to focus on HIV/AIDS. In July 2001 at its meeting in Genoa , G8 leaders committed US$1.3 billion to the Fund, and it was formally set up in January 2003. The purpose of the Global Fund is primarily to dramatically increase resources to fight three of the world's most devastating diseases, and to direct those resources to areas of greatest need . It is a partnership between governments, civil society, the private sector and affected communities. The Global Fund attaches no conditions to any of its grants, and there are no political eligibility criteria. The Global Fund financially supports the work of new and existing projects around the world, mostly in developing countries. It does not implement programs directly, relying instead on the knowledge of local experts. The Global Fund only finances programs when it is assured that its assistance does not replace or reduce other sources of funding. The funding process takes place through an ongoing series of rounds. It begins with a call for proposals at the start of a new round and ends with a performance evaluation of a funded program two years after funding has been disbursed. Since it was created the Global Fund has approved proposals worth US$3 billion over two years to 314 grants in 128 countries. It has thus far disbursed funding totalling US$672 million, and signed grants for $US 1.8 billion. Of the US$3 billion which has been approved :
The Global Fund's main problem is that its ability to disburse funds depends on its receiving donations. If funding can buy AIDS medication and prevent a HIV+ person's death, then that funding must be continued, or the person will die. Global Fund money which is spent on treatment needs to remain on at least the same level as the previous year, as treatment programs which have been set up must be continued. The Global Fund is finding that donations are lagging behind its spending plans and applications from countries. The Global Fund announced in November 2004 that it will begin accepting applications for a fifth round of project grants in March 2005 and will approve grants in September 2005. It had intended the fifth round to take place in December 2004, but is currently unable to do this due to funding shortfalls. By January 2004 almost US$5 billion had been pledged to the Global Fund up to 2008 and beyond. US$2.1 billion had actually been paid to the Global Fund, and it was due to receive another US$1.2 billion - leaving a shortfall of about US$400 million for 2004. America is by far the largest donor to the Global Fund, and f or 2004, the United States pledged up to US$547 million for the Global Fund, provided that every US$1 was matched by US$2 from other donors by September 30, 2004. Because the rest of the world failed to come up with enough cash to release the entire US$547 million of American money, US$88 million could not be spent by the Global Fund, and will be carried over to the financial year 2005. The Global Fund feels that contributions from countries should be based on their GDP and expects 80% - 90% to come from the 47 most developed countries, and that foundations, corporations and individuals should contribute the remaining 10% - 20%. Contributions from the corporate sector, however, have so far been very limited, making up only 2% of total pledges. The largest commitment from the private sector has been US$100 million from the Bill and Melinda Gates Foundation. The Global Fund is finding that money from all sources is coming more slowly than promises, and it has begun to actively lobby for additional cash. The American government has been criticized for spending much time and money in setting up the PEPFAR cash-disbursal system when one already existed in the Global Fund. It is understandable, however, that the Americans would want to retain some control over how the vast sums that they are providing are spent. In turn, the US has criticized the Global Fund for acting too slowly - for wasting time while donated money is sitting in its bank accounts. A positive aspect of the Global Fund is that, unlike other sources of funding, donations are not conditional on the recipient countries using the money to buy goods or services from donor countries. Between them, the Global Fund and PEPFAR are, in terms of funds disbursed, the largest organizations funding the fight against AIDS. They are not, however, by any means the only organizations involved in the fight against AIDS. AVERT.org has a page devoted to discussion of the Global Fund. The World BankThe World Bank is the largest long-term investor in prevention and mitigation of HIV/AIDS in developing countries. A key function of the Global HIV/AIDS Program is to lead the monitoring and evaluation efforts of UNAIDS at country level. The World Bank is one of eight co-sponsors of UNAIDS. The World Bank tends to look at the economic aspects of the epidemic, as well as the human ones. It says that 'HIV/AIDS can have a devastating economic impact on countries with severe infection rates. Estimates suggest when the prevalence of HIV/AIDS reaches 8 percent - about where it is today for 13 African countries - the cost in terms of economic growth is estimated at about 1 percent a year.' The World Bank's Multi-country AIDS Programme - which amounts to US$1 billion for Africa and US$155 million for the Caribbean - serves as a major funder for a number of initiatives, including condom procurement and promotion, something which seen a decline in international funding over recent years. In the past six years, the World Bank has committed about US$1.7 billion through grants, loans and credits for programs to fight HIV/AIDS. Historically, the World Bank's HIV work has mainly focused primarily on HIV prevention and education. More recently, however, the Bank now works to expand access to antiretroviral medication and in building and strengthening national health care delivery systems. In addition to providing grants, the World Bank can provide interest-free loans to low-income countries to set up HIV related projects or to provide AIDS treatment. Sometimes, as in the cases of Brazil or India, the loans can be considerable, but countries are expected to repay them. For the poorest nations, World Bank support for HIV/AIDS projects can be up to 100% grant financed. In allocating both its loans and its grants, the World Bank tries to emphasise the support of community-level projects and to avoid bureaucracy as much as possible. DFIDDFID stands for the Department of International Development, and is the UK government's department for managing Britain's distribution of foreign aid. Like USAID in America , it covers more aspects than only HIV, although addressing the problems of HIV and AIDS are among its principal goals. DFID is a major donor to the Global Fund, and is the world's second biggest bilateral donor on HIV and AIDS - spending more than £270 million in 2002/03. In 2004, DFID said that over the next 3 years the UK would spend at least £1.5 billion on AIDS-related work. The UK also funds UNAIDS, saying in 2004 that it will provide £36 million to support the organisation. The William J. Clinton FoundationThe Clinton HIV/AIDS Initiative is actively working in more than twenty countries in Africa, Asia and the Caribbean to support governments' efforts to combat the AIDS epidemic. The Initiative is not actively a treatment provider, but works to provide the necessary skills, contacts and advice to allow national governments to provide treatment more effectively and affordable than they might be able to do alone. One of the most important achievements of the initiative to date has been the negotiation of the reduction in price of brand-named pharmaceutical antiretroviral AIDS medication. In 2003, the Clinton HIV/AIDS Initiative announced an agreement with five suppliers of generic ARV medications that dramatically cut the price of the most commonly used drug therapy combinations to less than $140 per person per year. The agreement will also cut the cost of testing equipment by 80%. AVERT.org has a page explaining the issues surrounding generic and branded antiretroviral AIDS drugs . At the moment, the Bush money is not being used to buy any generic antiretrovirals because the FDA has not evaluated these generics because they are patented in the U.S. and could not legally sold in the US. Other projects funded by the Global fund and national governments, however, are taking advantage of the Clinton pricing deal, and purchasing medicines at greatly reduced prices. The Bill and Melinda Gates FoundationWhilst small by comparison to other organisations, the Bill and Melinda Gates Foundation has nonetheless given very large sums of money and support to the global fight against AIDS. Bill Gates is reportedly worth around US$43billion, and has promised to give it all away during his lifetime. He is the world's biggest single philanthropist and his Foundation gives money to a variety of projects, notably assisting the fight against HIV / AIDS . Bill Gates has a high media profile as the founder of Microsoft and his Foundation's philanthropy in the AIDS field generally attracts media attention, which also helps to highlight the problem area in which he works. The Foundation has projects in Botswana - where, alongside the Merck Pharmaceuticals Company Foundation and the Ministry of Health, they formed an antiretroviral treatment program which now supports over 14,000 people. The Foundation has also pledged US$150 million to the Global Fund. One criticism which has been made of the Bill and Melinda Gates Foundation is that the software company Microsoft, which makes the money given to the Foundation by Mr Gates, favors the Trade-Related Aspects of Intellectual Property Rights agreement, the World Trade Organization's international agreement protecting patents and intellectual property. This same agreement has been responsible in the past for preventing drugs manufacturers to produce cheaper copies of patented AIDS drugs - something which could have saved a vast number of lives. More recently, large patent-holding companies have announced that they will not enforce patent rights in middle- and low-income countries, and the TRIPS agreement has become much more flexible. Certainly in the past, however, it would be fair to have said that TRIPS has killed more people than philanthropy has saved. The Bill and Melinda Gates Foundation is the world's second largest philanthropic organisation after the Wellcome Trust, but there are many other organizations which give money to help in the fight against HIV and AIDS. The table below shows funds committed by top 15 US grantmakers in 2002.
AusAIDAusAID manages the Australian Government's official overseas aid program. The objective of the aid program is to advance Australia's national interest by helping developing countries reduce poverty and achieve sustainable development. AUSAID operates mainly in the Asia-pacific region and focuses on a number of developmental issues, of which HIV is only one. In 2003 - 4, AusAID spent 21% of its budget on controlling STD infection, including the spread of HIV. AusAID is implementing a $A 200 million, six-year HIV/AIDS initiative in the Asia-Pacific region, which was announced in June 2000. At the Second Asia-Pacific Meeting on HIV/AIDS in Bangkok in 2004, Australia's Foreign Minister announced a significant funding boost of $A350 million over six-years to combat the disease - more than doubling their commitment to a total of $A600 million by 2010. AusAID concerns itself primarily with the Asia-Pacific region, and following the Global Fund's decision to put additional resources into this area, announced that it was contributing $A25 million over three years to The Fund. In addition to this, Australia is the largest bilateral donor working on HIV/AIDS programs in the Pacific and South East Asia. The majority of the $A200 million initiative is spent through bilateral country programs. The way forwardImportant progress has been made in raising additional funds to respond to the global AIDS epidemic. In 2003, the Global Fund to Fight AIDS, Tuberculosis and Malaria committed US$2.1 billion through 227 grants in 124 countries. Pledges to the Global Fund through 2008 more than doubled in 2003, and the number of countries giving financial support continues to grow. The world's richer countries are also generally those who have not been hit so hard by the impact of AIDS and, in recent years, they have begun to acknowledge that they have a moral obligation to support those countries who have been more grievously affected. HIV has become more of a priority. The deficit between current spending and need reflects that national governments and other grant-making organisations need to show greater willingness to place the global AIDS epidemic at the top of their agendas. Wealthier countries continue to take from poorer ones huge sums in annual interest on old and developmentally-crippling debts. With the other hand, they give back smaller sums in the form of funding to fight AIDS. If more debt were to be cancelled then the debtor countries, very often those with the highest HIV prevalence rates in the world, would have the opportunity to fight their HIV epidemics with their own resources, rather than becoming increasingly dependant on cash and drugs from the West. Huge global inequalities still remain : Spending per person living with HIV in the United States exceeds that in the Latin America and Caribbean region by a factor of 35, and it is 1000 times higher than in Africa Although much is being done, in June 2004, 5.5 million people in developing countries needed immediate antiretroviral treatment, and of these, only 8% were receiving it. The work that has been done thus far to provide medication s only the beginning of the task ahead - much more must be done. Not only must money and drugs be provided, but they must either be continually provided or a sustainable drug-provision system must be built. Once a HIV+ person has been provided with antiretroviral medication, this provision must continue for their lifetime - if it is stopped, they are likely to die within weeks. The PEPFAR plan, for example, runs until 2008 - but when 2008 arrives then either it must continue, or the institutions providing medication must be able to access their own supplies. It is time for the richer countries of the world to make a heartfelt and significant contribution, in terms of financial commitment and political leadership, and millions of lives might yet be saved. It is already too late for millions more. Page written by Steve Berry Main sources:
Last updated March 30, 2005 |