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Making AIDS History

January 16, 2012

By Fiorenzo Conte

In the last decade the expansion of people with access to ART (antiretroviral therapy) has been dramatic: from 100,000 in 2003 to more 6 million at the end of 2010. This in itself it is a success to be celebrated insofar as human lives have been saved. However, it poses the question: as new people get infected with the virus and as those currently enrolled on first line ARV are forced to move to more expensive second line ARV, who can bear such an economic burden? The dramatic expansion of ARV has been achieved through aid money and it is unlikely that any donor (US included) is willing or able to sustain the ballooning economic burden associated with expanded access to ARV. The reason behind the growing need for treatment  is that efforts to prevent new infections has fallen short of its target. A new book by Mead Over, researcher at the Center for Global Development, makes a very basic yet often ignored point about infections and treatment:  to make the latter sustainable one needs to prevent the former. Over has the merit to explain in very clear terms that the goal should be to stabilize the number of people infected so that the costs for treatment does not increase over time. To do so policies should aim to drop the number of new infections below that of AIDS deaths: this is what the book calls an AIDS transition.

So if the ultimate goal is to hold down AIDS mortality and at the same time to bring down new infections, what are the policies which could incentivize government to pursue such goal? Mead proposes a policy instrument called cash-on-delivery. The principle behind it is very simple: donor and recipient country agree on a specific target; if the recipient achieve such a target it will receive an economic reward. The novelty of such an approach is that the target needs to be an outcome, for example number of infections prevented or number of new people who accessed ART. Such focus on outcome is a necessary step away from current approaches stuck on inputs: for far too long the focus had been narrowed to how many people attended prevention events (inputs) rather than on how many people changed their behavior and therefore prevented infections.

Such cash-on-delivery address in my view another pitfall of HIV/AIDS policies: the lack of economic incentives to engage with HIV/AIDS project. A comparative study of AIDS policies in Uganda and Botswana by Allen and Health revealed how the presence or lack of financial incentives played a role in tipping government into investing time and efforts into AIDS policies. In Botswana, the international aid community had largely withdrawn by the mid 1990s on the assumption that Botswana has enough resources to deal with the new epidemic. Yet, the three main sources of income for Botswana i.e. cattle, diamond and tourism were never directly affected by the epidemic and as a result the political class showed very little interest in tackling the growing AIDS epidemic. On the other hand, Uganda could count on a  donor involvement and continuous cash flow which created institutionalized economic incentives to engage with HIV/AIDS policies on a day-to-day basis.

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