Once, no one wanted to talk about Aids. Now the global pandemic commands $14bn a year, roughly half of all spending on health worldwide. The single most important contributor to Aids funding is the US President's Emergency Plan for Aids Relief, or Pepfar for short.
Launched by George W Bush in 2003, Pepfar is the largest financial commitment ever made by any nation to combat a single disease. It wields a budget of $6.7bn for 2010 alone, and claims to have succeeded in putting more than 2.4 million people on antiretroviral therapy, particularly in its "focus" countries (primarily in sub-Saharan Africa). This includes some double-counting with the other major provider of antiretrovirals, the Global Fund to Fight Aids, Tuberculosis and Malaria, but the scope is impressive nonetheless.
The tentative optimism needs to be put in context. There are still 33.4 million people with HIV, and, as access to antiretrovirals improves, the number living with the virus continues to climb. Moreover, Aids-related illnesses remain a major cause of death globally, claiming two million lives a year. Initiatives such as Pepfar may have provided life-saving drugs to many, but some global health advocates feel that such organisations are at times more accountable to themselves than to the people enrolled on their programmes. And their sheer scale can disrupt the local health systems of small African countries.
Under Bush, Pepfar faced more criticism than most. Its initial refusal to purchase and disperse cheaper, generic antiretrovirals, in preference for only drugs approved by the US Food and Drug Administration, delayed the roll-out of life-saving medicines and demonstrated an unseemly interest in extending the market for overpriced (and usually US-manufactured) drugs. Equally controversial was the Bush-era insistence that a third of the money slated for reducing HIV infection be spent on promoting social values, including abstinence, delay of sexual debut and partner reduction. Such policies are straight out of the Republican book of morals. A focus on monogamy has little value as a preventive tool in countries such as Thailand, where the main mode of transmission is now between married partners.
With the election of Barack Obama a year ago, hopes were high that much of this would change for the better and that Pepfar might become a more positive standard-bearer in the global fight against HIV and Aids.
The new president was quick to repeal the most controversial of Bush's global health policies: the "global gag rule" - an outright refusal to fund any organisation that offered (or even provided information about) abortion. And with the appointment of the new US global Aids co-ordinator, Eric Goosby, the emphasis at Pepfar soon began to fall less on the "emergency" response and more on sustaining existing programmes. Sustainability is important to avoid the emergence of drug resistance, which can render antiretrovirals ineffective.
However, some activists argue that such talk merely disguises the harsh reality of funding cuts. As early as May last year (when his budget plans for 2010 exposed a $1.5bn shortfall in Pepfar funding), they were arguing that the new president had reneged on his campaign promises on Aids.
Since then, Obama has not responded convincingly to their concerns. His new five-year Aids plan, released at the end of 2009, is silent on the extent to which Pepfar intends to address concerns about the ongoing lack of transparency in its funding. This worries global health advocates, who wonder if the strategic interests of the US, rather than the health needs of people in its programmes, may be determining Pepfar's choice of which Aids programmes to fund and where. Addressing these problems will be difficult, but it is essential that Obama should do so sooner rather than later. For all the importance of treatment, it remains the case that, for every two people being put on antiretrovirals, a further five are being infected.
There are, however, systemic as well as political problems to overcome. Pepfar allocates a great deal of funding on the basis of evidence it receives from Aids programmes already in operation. But according to Vinh-Kim Nguyen, a doctor and social scientist with the University of Montreal's department of social and preventive medicine, such evidence of the efficacy of particular interventions can be self-selecting. Organisations promoting treatment interventions (rather than, say, simple prevention or safe sex) find it much easier to get hold of supporting data, because much of the data is taken from individuals already enrolled on programmes being evaluated. Anyone else is excluded, so there is little countervailing evidence (it's hard to provide data on a person not yet infected). But that also makes it difficult to know whether treatment-only approaches to HIV and Aids are always the most effective.
This should not be taken as an argument for scaling back antiretroviral provision, but it makes it much trickier to gauge how, when and where treatment would be more effective than a less costly alternative.
The underlying problem with Obama's Pepfar is that - for all the lip-service Goosby has paid in recent months - it is not fully engaging with the constellation of problems associated with HIV and Aids: vulnerability to infection, impoverishment, disempowerment of women, stigmatisation and a persistent Aids denialism, to name a few. These are social issues that are not always easily quantified, and are often the consequence of relative inequality as much as outright poverty.
In sub-Saharan Africa, women aged between 15 and 24 are more than three times as likely as their male counterparts to be HIV-positive; in the United States, the prevalence of HIV among African-American males in the District of Columbia ranks alongside that of some of the worst-affected countries. The only consistent feature linking sub-epidemics among injecting drug users in the former Soviet republics, men who have sex with men in Asia and heterosexual women in sub-Saharan Africa is the way that HIV can be seen, in each case, to cut along and reinforce pre-existing socio-economic divides.
With funding for many global health initiatives likely to decline in the current economic climate, there is concern that these underlying causes of vulnerability will be pushed further to the margins in a drive for greater statistical accountability and savings in initiatives such as Pepfar. Pledges to the Global Fund are down. The lives of those who have already been enrolled on antiretroviral programmes in settings where there continues to be a lack of development in local health systems will be put at risk. So, too, will the lives of many more people as yet uninfected.
Simon Reid-Henry is director of the Centre for Global Security and Development at Queen Mary, University of London
DC doubles up as infection capital
A report published in March 2009 revealed that more than 3 per cent of the population of the District of Columbia - Washington, DC - is infected with Aids or HIV. This makes the area the most severely affected in the United States. According to Shannon Hader, director of the district's HIV/Aids administration, such rates are "on a par with Uganda and some parts of Kenya . . . higher than in West Africa".
Following another report - issued in 2007 - that aimed to emphasise the unsettling reality of what was called a modern epidemic, the 2009 document showed a 22 per cent increase in the number of cases of the illness (currently estimated at roughly 15,120).
Worse still, health professionals observed, the latest figures are based on those who agreed to be tested; as such, the actual number is likely to be far higher than the report suggests. And the rate is "on the rise", claims Hader, due to the widening scope of the condition. Once mainly affecting men who have sex with men, HIV/Aids is now a health risk for people of every age, race and sex.
The US government has been criticised for failing to confront the crisis effectively. Critics note how policies that prevent the use of public funds for social programmes such as needle exchanges have led to an increase in the rate at which drug users are being infected by the virus.
Others suggest that the key to tackling the crisis is open discussion, to break down the taboos surrounding HIV and Aids.