HIV/AIDS Control May be Crowding Out Other Health Initiatives

HIV/AIDS control is now receiving enormous attention in global health circles. This is reason both for celebration and concern. It is reason for celebration because the disease has been neglected in the past and the tide may be turning against this humanitarian crisis. It is reason for concern because there is growing evidence that the extensive focus on this one disease is crowding-out resources and policy-maker attention for the many other causes of death and illness of the poor in the developing world.In an editorial that appeared in the Bulletin of the World Health Organization on December 1, World AIDS Day, I provide evidence (pdf) of possible crowding-out effects.For instance, over the years 1998 to 2003, as funding for HIV/AIDS grew from 9 percent to 43 percent of overall U.S. foreign assistance for health and population, funding in the health sector strengthening category nearly vanished, declining from 20 percent to just 1 percent. Aggregate funding for all other major causes stagnated, save for infectious disease control. We see similar trends among other donors and within developing countries.Given its high burden HIV/AIDS clearly deserves special attention. I argue that this attention should not come at the expense of other health initiatives, however. Deaths due to HIV/AIDS, after all, comprised around 5 percent of total mortality in low and middle-income countries as of 2001 according to a recent study in the Lancet (subscription required), and the 2006 UNAIDS report indicates that this figure has not likely increased since. This is a high but not overwhelming figure, and on epidemiological grounds cannot justify HIV/AIDS' large command of the limited resources wealthy and developing countries provide for health.A core problem is the insularity of many HIV/AIDS advocacy campaigns and programs. I note that:

Some organizations that work on HIV/AIDS - including UNAIDS and the Global Fund - are aware of these problems and issue warnings of possible displacement and call for support of health sector strengthening. However, most HIV/AIDS champions have been so impassioned about their own fight that they have lost sight of possible adverse effects on other health initiatives.

• First, health sector strengthening should become a central rather than peripheral element of the HIV/AIDS agenda, a change that will benefit the control of this disease and many other conditions.
• Second, HIV/AIDS advocates need to avoid insularity, be sensitive to the effects of their rapidly growing political power on other politically weaker health initiatives, and build bridges to other initiatives.
• Third, it is worth considering the greater good. Presumably health advocates share a commitment to reducing death and illness of the world's poor, whatever may be the cause. This principle may provide the underpinning for moving HIV/AIDS away from its insularity and toward linkages with other health initiatives, a shift that would benefit the poor of the developing world immensely.