Financing the global response to the epidemic will cost $9.2 billion a year, according to one estimate

Graham McKerrow, HIV i-Base

Delegates’ clothes and bags and the conference buildings were littered with little orange stickers demanding “Cheap drugs for all! Where is the $10 billion?” and during the week this figure gained currency as the amount required to respond meaningfully to the epidemic.

Two years ago, at Durban, the big issue had been to find the political leadership to tackle the epidemic in developing countries. At Barcelona the big issue was how to pay the costs, so there was a good turnout for a session on Tuesday morning entitled Financing the Global Epidemic.

Various academics have estimated what it would cost to mount an effective response to an epidemic that has resulted in 40 million people living with the virus, and one that is now accepted as being in an early stage of its development.

One is Professor Stefano Bertozzi of the National Institute of Public Health in Mexico and the University of California at San Francisco and he was the first speaker of the session.

Bertozzi estimates it would cost $9.2 billion a year with just over half of that ($4.8 billion) being spent on prevention, and slightly less than half of it ($4.4 billion) being spent on care, which would include antiretroviral treatment for 3.2 million people by 2005.

Bertozzi and colleagues prepared their work for the United Nations General Assembly Special Session on AIDS (UNGASS) in June last year when it was decided to launch the Global Fund to Fight AIDS, TB and Malaria. Other estimates have been higher and the Global Fund has yet to announce its target, but many speakers and groups at the conference seemed to accept a figure of $10 billion was needed annually. Others said this figure was far too small and up to $25 billion was needed.

A different exercise by the World Health Organisation’s Commission on Macroeconomics and Health estimated that $13.6 billion to $15.4 billion would be needed annually on top of what is already spent if the response to HIV included upgrading infrastructure.

Bertozzi explained that his task had been to estimate the resource needs up to 2005 without significantly extending the health infrastructure: with no new clinics and little extra training.

“These are obviously crystal ball kind of estimates,” Bertozzi admitted, “taking small scale costs rashly scaled up across the globe, but nevertheless they play a role.”

The money would cover the costs of palliative care, treatment for opportunistic infections, blood tests, prophylaxis for OIs and antiretrovirals. It would also pay for prevention initiatives and for the support of orphans.

Bertozzi insisted his estimate would “not take us to where we would like to be” in 2005 but, accepting a country’s existing infrastructure, where it could be in 2005 with extra resources.

And he emphasised: “It does not pretend to be an estimate of the resources needed to care for all people living with HIV/AIDS or to prevent all new infections by 2005.”

Bertozzi said of his estimate: “We couldn’t know how much would be saved with better ARV deals. The model has an idealised view in which the poor pay less than the rich. Our estimate is that poor countries pay less than the current lowest deal, which is for South Africa.

“But negotiating capacity more than need predicts better deals in many parts of the world,” he said.

The Bertozzi model did not take into account how much money might be wasted in inefficiency and corruption. “In the real world it will not be as efficient as we modelled it. In all ways we underestimated the figures,” he said. And he summed up: “The resources needed by 2005 are not there yet but they are more than reasonable, they are needed and they are feasible.”

Dr Crispus Kiyonga, Chair of the Global Fund, and former minister of health in Uganda, said the fund has raised $2.1 billion in promises but only $300 million has been received. They have already approved grants of $616 million over two years.

Hans Binswanger spoke movingly about other ways of financing the response to the epidemic. An economist and advisor to the World Bank, and himself positive, he has launched an organisation called AIDS Empowerment and Treatment International (AIDSETI), a network of 23 national organisations of PLWHA.

He said that 10% of people can afford to pay for their treatment but he asked “Who is going to pay for the 90% unable to pay?”

Binswanger, from Washington, said he was asked last year if he couldn’t save a single life: “Of course I could, on my salary from the World Bank. Then I had the humbling realisation that I was simply not willing to pay.”

So he volunteered to pay for the treatment of an orphan in Uganda. He was given the names of two children, Ronaldo, aged 8, and James, aged 6, and left to choose which would get treatment at his expense. On medical advice he chose Ronaldo. “Tears came to my eyes for James,” he told the 500 delegates at the session.

Binswanger criticised people for being unwilling to pay and highlighted governments “like those being sued by activists in Brazil and South Africa”, HIV activists in the north, donor governments and pharmaceutical companies.

Then he asked his audience: “What can you do? Become willing to pay – for at least one child, one woman or one man.”

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