RETHINKING THE GLOBAL AIDS RESPONSE

Author:

Alan Whiteside

Article Type:

Article Number: 3

Significant global events mean we need to revisit ‘business as usual’

ABSTRACT Alan Whiteside muses on how global events are not only interrelated but have a multiplier effect, and what this means for how we move forwards with a global AIDS response that reflects these realities.

This issue’s opinion piece looks at the big picture. There is a proverb, first recorded in the 13th century, that reminds us of the interconnectedness of everything. It describes how a horseshoe is lost because there is no nail: this means that a crucial message does not get through and as a result first a battle, and then the kingdom, is lost. There are currently big global events that will have a significant impact on the response to HIV/AIDS and hence the number of new infections and deaths. Some of the major ones, and their consequences, are described below.

For people living in the United Kingdom the last 10 days, between 8 and 19 September, passed in a blur. On Thursday the 8th it was announced that the Queen had died. The State Funeral was on Monday 19th, and for the 10 days between the announcement and the funeral normal life and activities were on hold. Political paroxysms meant that just a few days before Boris Johnson had visited the Queen, at her home Balmoral, in Scotland, to formally resign. The new Prime Minister Liz Truss was there, a few hours later, to obtain the Queen’s blessing on forming a new government. I open with these events as they dominated British government and resulted in a hiatus in decision-making that went beyond the UK. Furthermore, they meant global media attention was focused on the events in London. I confess to having dipped into the coverage. No one does pageantry quite like the British and the immaculate uniforms and precision marching were indeed spectacular.

It was not the only global event to attract the eyes of the media. The war in Ukraine, which began with Russia’s invasion on 24 February 2022, continues. Initially it seemed inevitable Russia would win. At the time of writing, (the end of September 2022) the tide has turned, and Ukrainian forces are gaining ground. The cost of this war is immense and Ukraine could not have managed without huge financial and material support from its western allies. According to Statista, between 24 January and 3 August 2022 the United States committed €10.32 billion in financial aid, €9.21 billion in humanitarian aid and €25 billion in military aid, a total of €44.53. European Union institutions gave €16.24 billion in the same period and categories. Although these above dwarf all other contributions by order of magnitude, 36 countries have provided bilateral support. A reminder, the Global Fund was seeking $18 billion for its Seventh Replenishment. No one, except perhaps Russia, budgeted for a war and so the tap is running dry.

In Pakistan the flooding that began at the end of August has continued. Vast swathes of the country remain under water. To date, while the death toll has been mercifully small, more than 1.14 million houses have been damaged and many destroyed. It is estimated 7.6 million people have been displaced and 575,000 are in relief camps. This has had a huge impact on agricultural production, the price of which has risen by nearly 80% since January 2022. In September Japan and Puerto Rico were devastated by tropical storms. The pace of climate change is picking up.

Globally we are seeing significant inflation. In the US the rate is estimated at 8.3%, in the UK 9.9% and in the Netherlands 12%. South Africa, the country with the largest number of people living with HIV in the world has a rate of 7.8%. Inflation has the dual effect of putting prices up and reducing the value of money given or spent and putting pressure on the Ministries of Finance and/or Treasuries. There is a global cost of living crisis. One of Bill Clinton’s campaign slogans in 1992 was, “It’s the economy, stupid”. This could be tweaked to ‘it’s the domestic economy, stupid’.

And the UK’s latest financial package announced last week has left the country with a budget that places even more pressure on external borrowing and as a result the pound sterling is almost at parity with the US dollar for the first time in fiscal history.

The catalogue of events may, on first sight, not have much to do with HIV and AIDS. Let us remind ourselves that government budgets are under pressure everywhere and we have already seen significant declines in overseas development assistance (ODA)

The World Food Programme (WFP) describes 2022 as a year of unprecedented hunger. The number of people facing acute food insecurity rose from 135 million to 345 million since 2019. At the same time ‘While needs are sky-high, resources have hit rock bottom. The WFP requires $24 billion to reach 153 million people in 2022. However, with the global economy reeling from the COVID-19 pandemic, the gap between needs and funding is bigger than ever before.’ The Pakistan flood have destroyed hundreds of square kilometres of crops. The Ukrainian war has reduced grain harvests and made moving them increasingly difficult.

And then, of course there is the other pandemic, COVID-19. Bizarrely, according to a Reuters report on 14 September 2022 the head of the World Health Organization (WHO) is quoted as saying, ‘the end is in sight’, referring to the pandemic when talking to reporters at a virtual press conference. Perhaps the immediate medical emergency is ending but the consequences of lost years of education and production, the trauma of lockdowns and the increase in gender-based violence will last for years.

This then is the context in which the last replenishment of the Global Fund for AIDS, TB and Malaria took place last week. It is hard to be optimistic when we see that the Fund’s third biggest donor, the United Kingdom, failed to pledge with a vague promise to do so at a later date. What we need is to move beyond the grating, but false, optimism of the agencies we rely on to lead the response to the HIV and AIDS pandemic to a new realism. While we need new commitments, we must look at ways to better utilise resources we have. This was addressed in a recent BMJ article on approaches to improving the efficiency of HIV program investments.

In the next article in this series, I will look at what these events mean for the key players in the field, among them the Global Fund, the US President’s Emergency Fund for AIDS Relief (PEPFAR) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). There is however one glimmer of a silver lining. The largest share of ODA for health comes from the USA, both bilateral and multilateral. The US dollar is the strongest it has been for many years and so this assistance goes further.