Funding HIV and AIDS in South Africa Professor Alan Whiteside Slides borrowed from Teresa Guthrie AIDS 2031 Zapiro; Harris 20th October 2009

Demographic and Health Survey HIV Prevalence: Swaziland From DHS – can see sharp rise in infections once become sexually active and gendered aspect. This suggests that upon becoming sexually active the chances of a women becoming infected at a young age are extremely high. Thus, her children have a high probability of being orphaned at a very young age. These results also present the worrying indication that half of all women aged 25-29 are HIV positive. Rates among men do not seem to rise substantially until the 30-34 year age group where around 45% of men are HIV positive. Life time risk - This examines the likelihood of an individual becoming infected with HIV throughout their lifetimes, as prevalence rates for older age groups are not only the ageing of younger infections, but also include a percentage of new infections, therefore the chances therefore of becoming infected while in each age group are cumulative throughout an individuals lifetime. UNAIDS (2000) suggest that in countries such as South Africa and Zimbabwe where a quarter of the adult population is infected, AIDS will claim the lives of around half of all 15 year olds. This increases to two thirds of all 15 year olds in countries with higher prevelance, such as Swaziland and Botswana.

Funding questions How much? And it is expensive! Where from? typical health funding mix private/public/out of pocket Donor/government but we are not Malawi What are choices and priorities? For the hospital The province The national government The world Who chooses and how? Democratic Donor Stalinist In the medium to long term, there exists potential sources of risk that may disrupt funding for health and expenditure on health. Domestic and external sources of funding will be affected by different types of risks. Treatment, prevention, care and support strategies will be affected depending on the source of funds, as well as the frequency and depth of such risks

Global funding for HIV and AIDS: the current picture Source: UNAIDS. ‘What Countries Need, Investments Needed for 2010 Targets’ 2009

What we know is predictable Future demand for health services and the requisite supply of health services (treatment, care, support, prevention) is predictable. The ‘waves’ of the HIV and AIDS epidemic in S.Africa can be modelled with good accuracy Source: Dorrington et al. The Demographic Impact of HIV/AIDS in South Africa. Center for Actuarial Research, 2006.

What we know is predictable: ‘deaths’ Projected number of AIDS deaths in South Africa by level of ART coverage Source: Dorrington et al. The Demographic Impact of HIV/AIDS in South Africa. Center for Actuarial Research, 2006.

Prevention: cholera to swine flu 10

AIDS: Mopping the Floor while the tap is running

Global Responsibilities: treatment rights and funding Funds can dissapear and funding can dry-up. Zambia’s main aid donors suspended aid in May 2009 after confirmations of corruption by senior government officials Funding crisis in August 2009 severaly affected ARV treatment clinics in the Free State province of S.Africa. Donor disorders: accountability standards that are applied to developing country recipients; industry The people that suffer are those who are denied treatment after previously being on drugs and who are denied treatment altogether. Interruptions to treatment leads to drug resistance, and therefore greater costs.

Global Responsibilities: long term commitments Donor funding has 3-5 year time horizons It is critical to shift away from short-term emergency health aid, towards long-term health development that is sustainable But donors will not fund chronic conditions which are seen as life style: eg obesity, smoking The consequences of climate change will be long wave event, and the world recognises that resources will be needed for very long term Global health responsibilities needs global commitment: - the global response to SARS and swine-flu was quick and comprehensive - the UK will pay close to a billion pounds for flu vaccinations

Funding (un)predictability Long-term global financing is unpredictable Donor funding is time bound Domestic (South African) is predictable but not sufficient Ways forward DART Trial More for our money Move to an AIDS economy – sea changes in the way we do things and see things PREVENTION PREVENTION PREVENTION In the medium to long term, there exists potential sources of risk that may disrupt funding for health and expenditure on health. Domestic and external sources of funding will be affected by different types of risks. Treatment, prevention, care and support strategies will be affected depending on the source of funds, as well as the frequency and depth of such risks