Paying the price of HIV/AIDS-South Africa and beyond 

The long-awaited signing of an agreement to receive US$41 million from the Global Fund for AIDS, TB, and Malaria (GFATM) represents "a turning point for South Africa", declared GFATM head Richard Feachem on August 7.
The agreement, which includes increased access to antiretroviral and tuberculosis drugs, could not be more timely since, according to a recent World Bank report, failure to rapidly step up efforts to fight HIV/AIDS could result in the economic collapse of nations such as South Africa.
Previous economic models have underestimated how HIV/AIDS decimates human capital and "weakens the ability of today's generation to pass on its skills and knowledge to the next", says co-author and World Bank economist Shantayanan Devarajan.
"In countries facing an HIV/AIDS epidemic on the same scale as South Africa, for example, if nothing is done quickly to fight their epidemic, they could face economic collapse within several generations". Despite $15 billion pledged by the US government for the next 5 years, and increased funds promised by the EU and bilateral donors, funding still falls well short of the $10 billion that UNAIDS estimates is needed this year to tackle the global epidemic.
"There is no question that we need more money for the fight", says Keith Hansen of the World Bank's AIDS control programme in Africa. "It is hollow solace to say that finally, 20 years after the start of the HIV epidemic, we have decided to run the race." Critics point out that already, US monies have been substantially cut, and now amount to less than aid to Israel allowed in the same budget.
President Bush's explanation was that programmes cannot effectively absorb more funding, while distribution mechanisms for medications are lacking. "Sadly, the President's statements are misleading regarding the capacity of affected communities to use additional resources", says Paul Zeitz of the Global AIDS Alliance. These resources are needed precisely to strengthen health-care infrastructure and improve distribution channels, he states. In another blow, the USA has limited its GFATM contributions to one-third of overall contributions to the fund.
Thus, if the EU and others don't raise $2 billion, the US contribution falls. But some donors, such as the British government, remain convinced of the need to channel substantial funds through other mechanisms, while waiting to judge the success of the fund.
Such delaying tactics could be deadly, as could a lack of secure funding.
Gorik Ooms of Me?decins sans Frontie?res, Belgium, notes that, for example, "poor countries that want to start a national HIV treatment programme need a funding source that is reliable and guarantees some continuity; they cannot start treating people now and abandon treatment in 3 years if the donor has second thoughts about it".
Moreover, says Richard Tren of Africa Fighting Malaria, a South Africa-based advocacy group, "I think there is a danger that each agency wants to do its own thing and grab its own glory-it is certainly true of malaria control. This results in bitty projects that are not necessarily based on good science or medicine".
Better cooperation within and between sectors-eg, health, water and sanitation, education-is vital, says Vicky Blagbrough of WaterAid: "There are fundamental divisions that widen the higher up the hierarchy you go. By the time you reach multilateral donor level, the divisions are chasms. This means policy decisions, implementation, funding, and research are not coordinated and thus often not cost-effective".
Previously, different donors required countries to monitor need and assess use of funds in different ways. In response, UN agencies have formed the Global AIDS Monitoring and Evaluation Team to strengthen countries' capacity for monitoring epidemics and the performance of their programmes. In addition, the World Bank is keen that countries adopt the Joint Policy Review process recently used in Kenya, a complex but transparent process that involves all stakeholders down to the smallest groups.
Despite these moves, widespread disagreement remains over how to pay for the fight. Ooms criticises "IMF and World Bank macroeconomists who continue to impose public spending caps that exclude AIDS treatment programmes". Devarajan counters that "excessive spending that exceeds revenue leads to high fiscal deficits which, in turn, cause macroeconomic crises that often hurt the poor".
In less than 3 years, virtually all of the poorest African countries that have developed a national plan have been awarded grants under the World Bank's multi-country AIDS programme, which, like the GFATM, funds public, private, and civil-society initiatives. Tren concludes that "while support from the west is important, vital even, the buck stops with African governments". At last, even South Africa has a chance to prove its critics wrong.