argued - Center for Global Development

183 Pages·2011·1.29 MB·English

by  Lawrence Converse

CGD_Aids_Transition_cover-FINAL.pdf 1 6/28/2011 2:49:15 PM
“Mead Over proposes a canny model for marshaling and coordinating O Achieving an
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donor contributions to AIDS prevention and treatment in developing
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countries. Achieving an AIDS Transition includes prudent and detailed

plans that promise to bring us all closer to a transition long overdue.”
— Paul Farmer, co-founder of Partners in Health
AIDS Transition

“Living with AIDS is clearly better than dying with AIDS. But the best
outcome is to return to an AIDS-free world. Mead Over's book provides

the essential foundation for understanding the transition.”
— Paul Collier, author of The Bottom Billion
Preventing Infections to Sustain Treatment

“There is an urgent need to take a long-term view on AIDS. Achieving an

AIDS Transition is thought-provoking and provides an important

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contribution to this vital debate.” c
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— Peter Piot, former executive director of UNAIDS i
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Mead Over, a senior fellow at the Center for Global Development,
is one of the world’s leading experts on the economics and

cost-effectiveness of HIV/AIDS prevention and treatment.
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Achieving an
AIDS Transition
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PRAISE FOR
Achieving an AIDS Transition
“Mead Over proposes a canny model for marshaling and coordinating
donor contributions to AIDS prevention and treatment in developing
countries. Achieving an AIDS Transitionincludes prudent and detailed
plans that promise to bring us all closer to a transition long overdue.”
PAULFARMER,Kolokotrones University Professor of Global Health and Social Medicine,
Harvard University, and co-founder of Partners in Health
“Living with AIDS is clearly better than dying with AIDS. But the best
outcome is to return to an AIDS-free world. Achieving an AIDS Transition
provides the essential foundation for understanding the transition.”
PAULCOLLIER, director of the Centre for the Study of African Economies, University of Oxford,
and author of The Bottom Billion
“There is an urgent need to take a long-term view on AIDS. Achieving an
AIDS Transitionis thought-provoking and provides an important
contribution to this vital debate.”
PETERPIOT,director of the London School of Hygiene & Tropical Medicine and
former executive director of UNAIDS
“By examining the worldwide AIDS epidemic through the lens of
economics, this book shows how donors and governments can look
forward to the day when the burdens of AIDS and its treatment costs will
be greatly reduced and increasingly affordable by national governments. I
recommend this book to all who are looking for hard-headed analysis and
a possible solution to the long-term sustainability of AIDS funding in
severely affected countries.”
PROFESSORSIRRICHARDFEACHEM,founding executive director of the Global Fund to Fight AIDS,
Tuberculosis and Malaria, and executive director of Global Health Sciences, University of California–San Francisco
“I highly recommend this book to those particularly concerned with a
shared responsibility of tackling the AIDS epidemic in Africa. As sufficient
donor funds are going to be increasingly harder to come by in these
challenging global financial times, this book seeks a fresh set of ideas on
how realignment of incentives between donors and our African
governments and citizens can move us closer to self-sufficiency.”
DAVIDSERWADDA, former dean of the Makerere School of Public Health, Uganda
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“At last, an innovative approach to stemming the flow of new HIV
infections. Mead Over brings to our attention the importance of the AIDS
transition and offers a hard-hitting, incentive-driven approach to HIV
prevention.”
MICHAELMERSON,director of the Duke Global Health Institute and
former director of the WHO Global Program on AIDS
“Mead Over is constructively provocative and someone whose thoughts
deserve wide distribution and discussion.”
JIMMYKOLKER, chief of HIV/AIDS, UNICEF, and former deputy global AIDS coordinator, PEPFAR
“Mead Over has proposed several ways that incentives can be used, at the
national, local and individual levels, to improve the effectiveness of HIV
prevention. His ideas are an important part of the global discussion as we
search for innovative ways to sustain AIDS financing and slow the growth
of the AIDS burden.”
DAVIDWILSON, global AIDS program director, World Bank
“Achieving an AIDS Transition gives hope to millions. This book is
required reading for policymakers, researchers, students, and anyone
interested in learning how the transition to a world free of AIDS
can happen.”
GERMANOMWABU, professor of economics, University of Nairobi
“Mead Over is one of the clearest thinkers in global health. He is also one
of the few who has maintained an objective long-term view of the AIDS
epidemic and, in stark contrast to many in the field, not shied away from
articulating the consequences of inappropriate action.”
RIFATATUN, professor of international health management, Imperial College London, and director
of the Strategy, Performance, and Evaluation Cluster, Global Fund to Fight AIDS, Tuberculosis and Malaria
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Achieving an
AIDS Transition
Preventing Infections
to Sustain Treatment
Mead Over
center for global development
Washington, D.C.
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Copyright © 2011
Center for Global Development
1800 Massachusetts Avenue, N.W.
Washington, DC 20036
www.cgdev.org
Achieving an AIDS Transition: Preventing Infections to Sustain Treatment
may be ordered from:
BROOKINGS INSTITUTION PRESS
c/o HFS, P.O. Box 50370, Baltimore, MD 21211-4370
Tel.: [phone]; Fax: [phone]; Internet: www.brookings.edu
All rights reserved. No part of this publication may be reproduced or transmitted
in any form or by any means without permission in writing from the Center for
Global Development.
CGD is grateful for contributions from The Bill & Melinda Gates Foundation
in support of this work.
Library of Congress Cataloging-in-Publication data
Over, A. Mead.
Achieving an AIDS transition : preventing infections to sustain treatment /
Mead Over.
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-933286-38-9 (pbk. : alk. paper)—ISBN 978-1-933286-62-4 (e-book)
1. AIDS (Disease)—Prevention. I. Title.
[DNLM: 1. HIV Infections—prevention & control. 2. Acquired
Immunodeficiency Syndrome—prevention & control. WC 503.6]
RC607.A26O93 2011
616.97’92—dc22 2011000619
9 8 7 6 5 4 3 2 1
Printed on acid-free paper
Typeset in Sabon and Myriad
Composition by R. Lynn Rivenbark
Macon, Georgia
Printed by R. R. Donnelley
Harrisonburg, Virginia
Cover photo: AIDS orphans in the Biwi/Mchesi area of Lilongwe, Malawi. Some rights
reserved by Flickr user khym54 under the Creative Commons Attribution 2.0 license.
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1
Contents
Preface ix
Acknowledgments xi
1 The Global AIDS Transition:
A Feasible Objective for AIDS Policy 1
Defining an “AIDS Transition” 2
Harbingers of an AIDS Transition 12
Timing and Costs of an AIDS Transition in Africa 17
Rethinking AIDS Assistance to Facilitate
an AIDS Transition 28
2 Using Incentives to Prevent HIV Infections 33
With Appropriate Incentives, HIV Prevention Can Work 34
Using Performance-Based Incentives for HIV Prevention 39
Counting the Saved: A “Cash-on-Delivery” Approach
to HIV/AIDS Assistance 58
Potential Fiscal Savings from Better Prevention 77
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viii CONTENTS
3 Sustaining and Leveraging AIDS Treatment 80
Donor-Supported AIDS Treatment:
The First International Entitlement 80
AIDS Treatment Successes and Failures 85
The Future Fiscal Burden of Treatment 99
The Rationing Dilemma: Who Gets a Seat in the Lifeboat? 108
Indirect Effects of AIDS Treatment 111
Ensuring HIV Prevention through Better Treatment 115
Appendixes
A Alternative Approaches to Estimating the Average Cost
of Antiretroviral Treatment 123
B A Meta-Analysis of the Health Benefits of Early
Initiation of Antiretroviral Therapy 126
C A Model for Projecting Future AIDS Treatment Costs 130
Notes 135
References 147
Index 159
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Preface
C
an an economist’s perspective help to justify greater expendi-
ture on controlling the AIDS epidemic? When the late Dr. Jonathan Mann,
the first head of the Global Program on AIDS, approached me at the World
Bank in 1987 with that question, I had only an inkling of how big a prob-
lem AIDS would become for the developing world in general and for Africa
in particular. Nor could I imagine that donors would spend so many bil-
lions of dollars on AIDS—only to see the need for money grow even faster.
At a 2005 summit conference in Gleneagles, Scotland, the G-8 leaders,
perhaps encouraged by the billions of dollars newly authorized by the
United States to fund the President’s Emergency Plan for AIDS Relief
(PEPFAR), pledged to assure universal access to AIDS treatment by 2010.
But after years of double-digit increases reaching a high of $7.7 billion
dollars in 2008, donor disbursements for AIDS stabilized in 2009 at
$7.6billion and are unlikely to increase in the next few years. This scaling
back in donor ambitions is happening despite the continued increase of
the number of people living with HIV/AIDS, which in 2010 surpassed
33million.
One possible future is that donors will turn away from AIDS, reducing
their budget allocations and expenditures year-by-year. Under this scenario,
the grand humanitarian commitments to vanquish AIDS in poor countries
will be gradually and quietly abandoned—just as the goal of malaria eradi-
cation was abandoned a few decades ago.
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