Are Country Reputations for Good or Bad AIDS Leadership Deserved? An Exploratory Quantitative Analysis Nicoli Nattrass AIDS & Society Research Unit Centre for Social Science Research University of Cape Town

Testing the Conventional Wisdom Some countries (e.g. Brazil, Thailand, Uganda) are seen as demonstrating ‘good’ leadership on AIDS, whereas others (notably South Africa) are infamous for poor leadership. But are these reputations deserved, or do they just reflect different challenges, constraints and opportunities? This paper uses regression analysis of HAART coverage to explore which countries performed above expectation, as expected or below expectations.

Botswana Costa Rica Thailand Brazil Cuba Chile Mexico Cambodia Rwanda Namibia Venezuela South Africa Trinidad & Tobago Russia Latvia Kazakhstan Iran Uruguay

Highly Active Antiretroviral Therapy (HAART) coverage is positively associated with per capita income and HIV prevalence – but substantial variation remains.

level of development (GDP per capita) external support (being a PEPFAR country or in receipt of Global Fund 1 st round funding), scale of the epidemic (HIV prevalence, the absolute size of the HIV+ population and its distribution between urban and rural areas) other heath-related demands (non-AIDS DALY’s per capita) politico-institutional context (political stability and established democracy, % of births with skilled personnel). Sensitivity analysis also conducted controlling for language fractionalisation and region Explanatory variables – to account for factors governments cannot change in the short-term

Model 1 predicts: Being a PEPFAR focus country raises HAART coverage by 67%; For every 1% increase in HIV prevalence, HAART coverage rises by 0.2%; For every 1 percentage point increase in the share of the HIV- positive population in urban areas, HAART coverage rises by 2.5%; and Being an established democracy raises HAART coverage by 55%. Y = HAART coverage (Log) GDP per capita (PPP) (2005) PEPFAR focus country0.556**0.581***0.512** Global Fund 1st round recipient * (Log) adult HIV prevalence (2005)0.202**0.222***0.176* (Log) HIV+ population (2005) Proportion of HIV + people in urban areas0.881**0.793**0.522* Political stability (2005) Established democracy0.483**0.438**0.062 % of births with skilled health professionals (Log) non AIDS DALYs per capita (2002) Language fractionalisation *** Latin America & the Caribbean 0.982*** Southern Africa West Africa 0.561*** East Africa N8278 Adjusted R Selected Country Residuals Brazil Uganda South Africa

A regression residual of 0 means the country has precisely the predicted/expected level. Those countries with regression residuals ranging from -15 to +15 were classed as performing ‘as expected’. Those with residuals greater than 15 were classed as performing better than expected, and those with a negative residual below -15 were classed as performing below expectations. The figure displays the results from regression 1 for those countries whose regression residuals fell into the same category for all three specifications.

“I have been to every country in East and southern Africa, many of them two, three and four times. I can say confidently and categorically that every single country …. is working harder at treatment than is South Africa, with fewer relative resources, and in most cases nowhere near the infrastructure or human capacity of South Africa. It is a situation which is absolutely mystifying” Steven Lewis, 2005 (UN Special Envoy on AIDS) This supports the conventional wisdom about SA….

Further research is needed into those countries which performed significantly better than expected, but which do not have established reputations for good AIDS leadership (notably Mali, Burkina-Faso and Suriname). It is possible that in the general discourse about AIDS leadeship, insufficient attention has been paid to the role that governments can play in facilitating the importation and distribution of generic antiretrovirals (as occurs in Burkina-Faso) and in ensuring that the health system is well organised and efficient (as is the case in Suriname, but not in Trinidad and Tobago.