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Prevention better than cure, UN realises
Philip Stevens
August 22, 2006

http://www.businessday.co.za/articles/topstories.aspx?ID=BD4A254240

AFTER three years of throwing money at AIDS treatment programmes while ignoring the vital task of prevention, the head of UNAIDS said this week that prevention was the key to defeating the AIDS pandemic. This switch of strategy by Peter Piot at the biannual AIDS conference in Toronto is welcome, but raises serious questions about the competence of the United Nations high command. Under the UN’s guidance, the past few years have seen infections soar and money go to grandiose but unrealistic treatment programmes that have delivered terrible value for money and endangered patients. The legacy of these programmes will be a form of economic welfare dependency for the worst afflicted countries that will entrench poverty without reducing AIDS.

This all started at the 2000 International AIDS conference in SA. At about this time, advances in medical science were making AIDS in the west a manageable (but not curable) condition, as opposed to the automatic death sentence it was a few years previously. Health activists thought — not unreasonably — that if American AIDS patients could get the miracle drugs, why shouldn’t people in poor countries?

In 2003, the UN transformed the activists’ demands into policy by creating the "three by five" programme, a plan to put 3-million AIDS sufferers in lower-income countries on antiretroviral treatment by last year. Unfortunately, this well-intentioned goal ignored some home truths, apart from the fact that antiretrovirals are only palliatives, not cures.

The most obvious is that countries with the worst AIDS problems also have the fewest doctors, nurses and clinics.

In Nigeria, for example, there are only 28 doctors for every 100000 people. How did the UN expect to "scale up" treatment massively, if the people were not there to administer the drugs?

The answer is that it could not: at the end of last year only 1,3-million people were receiving treatment.

Of course, it is to be celebrated that these people have been given the chance to live longer, but these wild promises gave false hopes. While the UN earned political kudos among the activists by being seen to do something about treatment, it neglected the one and only way to reverse the pandemic: prevention.

This has been a betrayal of the 4,9-million people who were infected last year alone. These people now need to be added to the tens of millions of patients who already need expensive and difficult treatment: the UN has created a vicious and growing circle of suffering and death.

Antiretroviral medicines require clinical supervision and adherence to specified standards. In countries without appropriate medical infrastructure, there is a risk that patients will miss doses, or even share drugs among their families — an invitation for the virus to mutate and develop resistance to those drugs.

Samples taken before 1996 showed about 5% drug resistance to existing HIV strains, rising to at least 15% between 1999 and 2003. This all implies significant extra costs as drug-resistant patients have to be moved onto expensive second-line and third-line therapies.

Meanwhile, mismanagement of funds, inefficiency, waste, overpriced technical assistance and corruption within recipient governments has meant the cost of treating a developing-country patient for two years ballooned to $12538 by the end of last year — nearly 10 times the $1633 initially estimated by UNAIDS.

Based on this past performance, the goal of sustaining many years of antiretroviral treatment for 10-million people will be astronomical. At the very least, it will leave precious little aid available for the myriad other diseases that affect Africa.

Admittedly, failure of the "three by five" programme taught the UN it needs to invest in infrastructure to meet its 2010 treatment targets, so it now plans to spend $750m on building clinics between now and 2008.

The UN has not explained, however, who is going to pay for maintenance of the clinics or salaries. This requires large quantities of hard foreign currency — something that is in desperately short supply in sub- Saharan Africa. Either the new hospitals will slowly rot, or donors from the Organisation for Economic Co-operation and Development (OECD) donors, mainly the US, will have to finance them in perpetuity.

But the influx of the billions of dollars of foreign currency necessary to maintain them could wreak all kinds of macroeconomic damage, such as the rapid appreciation of local exchange rates, inflation and fiscal volatility. These hurt the poor the most.

In effect, the UN’s failure to prioritise prevention earlier and to get a grip on the pandemic, is now forcing it to create OECD-financed welfare states in sub-Saharan Africa that are unsustainable for donors and bad for Africa.

Good intentions are no substitute for accountability when things go wrong.

UNAIDS needs more than just a new slogan: it needs leaders capable of spreading the loud and practical message that treatment cannot cure AIDS and that prevention is the only way to save millions more from pain, poverty and death.

*Stevens is director of the Campaign for International Development think-tank Fighting Diseases, in London.

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