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After years of neglect, the UN is finally focused on Aids prevention

The Nation (Thailand) August 24, 2006

After three years of throwing money at Aids treatment programmes while ignoring the vital task of prevention, the head of UNAids announced last week that prevention is the key to defeating the Aids pandemic.

This switch of strategy by Peter Piot at the bi-annual Aids conference in Toronto is welcome but it raises serious questions about the competence of UN high command.

Under the UN's guidance, the last few years have seen new infections soaring and money going into grandiose but unrealistic treatment programmes that have delivered terrible value for money and endangered patients. And the legacy of the UN's treatment 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 South Africa. Around 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 had been 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 "3 by 5" programme, a plan to put three million Aids sufferers in lower-income countries on anti-retroviral (ARV) treatment by 2005.

Unfortunately, this well-intentioned goal ignored some home truths, apart from the fact that ARVs 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 100,000 people. How did the UN expect to massively "scale-up" treatment if the people were not there to administer the drugs?

The answer is that it couldn't: at the end of 2005 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 activists for 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 in 2005 alone.

These people all now need to be added to the tens of millions of patients already needing expensive and difficult treatment: the UN has created a vicious and growing circle of suffering and death.

ARV medicines require clinical supervision and adherence to a specified regimen.

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 a drug resistance to existing HIV strains of about 5-per cent, rising to at least 15 per cent between 1999 and 2003. This all implies significant extra costs, as drug-resistant patients have to be moved onto expensive second- and third-line therapies.

Meanwhile, mismanagement of funds, inefficiency, waste, overpriced technical assistance and corruption within recipient governments has meant that the cost of treating a developing-country patient for two years ballooned to US$12,538 (Bt471,669) by the end of 2005 - nearly 10 times the $1,633 that was initially estimated by UNAids.

Based on this past performance, the goal of sustaining many years of ARV 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, the failure of the "3 by 5" programme taught the UN it needs to invest in infrastructure if it is to meet its 2010 treatment targets, so it now plans to spend $750 million on building clinics between now and 2008.

The UN has not explained, however, who is going to pay for the maintenance of the clinics or salaries. This requires a large amount of hard foreign currency, something that is in desperately short supply in sub-Saharan Africa.

Either the new hospitals will slowly rot or 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 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.

Philip Stevens is director of the Campaign for Fighting Diseases, London, an international development think-tank.

Philip Stevens

Special to The Nation