Drowning a single illness in cash will do more harm than good

THE 5,000 researchers and activists making their way home from last week's International AIDS Society meeting in Cape Town are in fighting mood. For the past 10 years, AIDS has been the single biggest beneficiary of the hundreds of billions of dollars spent by wealthy countries to help Africa. This river of money is now under threat as donor governments begin to suspect that drowning a single disease in cash could be doing more harm than good to fragile health systems .

For most AIDS activists, this shift of thinking is unconscionable. After years of campaigning, they had convinced the world that AIDS was an exceptional disease that posed an existential threat all over the world, and therefore demanded an exceptional response.

This campaign gave birth to one of the biggest political mobilisations of recent history. Governments sat up and took note. New nongovernmental organisations started up by the hundred. In 1996, the United Nations took the unprecedented step of creating a dedicated agency , UNAIDS. Since 2003, AIDS programmes have tripled their financial support.

Nevertheless, it is increasingly clear that the leaders of the AIDS industry have not been good custodians of this largesse.

An early strategic blunder was the prioritisation by the UN of treatment over prevention. With the lion's share of funding going to buying and distributing antiretroviral drugs for those already infected, not enough attention was paid to educating people about the behaviours that transmit HIV. This led to far more infections than otherwise would have been the case.

Much of this treatment money has been badly spent. One study presented in Cape Town showed that global spending on AIDS has climbed to about 60% of the level needed to cover everyone in the developing world who needs treatment, yet only about 30% of infected people are actually receiving it.

This inefficient spending was entirely predictable considering the parlous state of the health infrastructure of the worst affected countries, such as Malawi or Zambia.

More egregiously, the AIDS community has until recently systematically mischaracterised the true nature of the pandemic, causing much wasteful spending. First, it claimed that everyone everywhere ó young and old, straight or gay, man or woman ó was at equal risk. Prof Jim Chin, a leading expert on AIDS epidemiology, describes this as a 'politically correct myth' propagated to ensure no AIDS patient is stigmatised. This myth has resulted in billions being wasted on spreading AIDS prevention messages to people at negligible risk.

UNAIDS also exaggerated the numbers infected worldwide in order to keep the disease ó and the money ó high on the political agenda. In 2007, UNAIDS was embarrassingly forced to revise down its estimates for dozens of countries.

It is now clear AIDS is not the global 'emergency' claimed by the AIDS lobby. While still a serious problem in southern Africa, research shows that the rate of infection is declining and the global peak in new infections has been passed in the mid 1990s. Yet AIDS still receives a quarter of all health aid, despite accounting for less than 4% of developing country deaths .

Fortunately, donors are beginning to recognise that an AIDS-centric approach to spending is not an effective way of improving health in poor countries, which is better done by strengthening overall primary care .

Last year, the UN established the Taskforce on Innovative International Financing for Health Systems. In May, its report argued that strengthening health systems should henceforth be the priority. This change of thinking is long overdue.

Nevertheless, it is under attack from the AIDS lobby. Former UN envoy on AIDS Stephen Lewis accused critics of 'naked bureaucratic envy' and wanting to pit different diseases against each other. Donors should not let such vituperative rhetoric derail them as they strive to improve health for everyone, not just a few.

Stevens is research director at International Policy Network, a development think-tank based in London.