Are we spending too much on HIV?

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Abstract
An exceptional disease? Why has this happened? One factor surely has been the success of HIV lobbies and activists in promoting HIV as exceptional.12 In rich countries, HIV has become the crusade of the famous, fashionable, and influential. In high prevalence countries, HIV affects the middle classes more than the poor13 and is of more concern to them: middle class children do not die from pneumonia or malaria and middle class women do not die in childbirth.The exceptional status accorded HIV, and its excessive relative funding, has produced the biggest vertical programme in history, with its own staff, systems, and structure. This is having deleterious effects apart from underfunding of other diseases. These include separating HIV from sexual and reproductive health and creating parallel structures that constrain the development of health services. National AIDS commissions, country coordinating mechanisms, UN agencies, etc are tripping over each other for funds and influence. HIV is also affecting adversely the organisation of health services. Funding for prevention of mother to child transmission, for example, is producing separate structures rather than strengthening everyday antenatal care and maternal child health by making testing and prevention part of the routine work of nurses and midwives. Also, well funded HIV programmes attract staff from other health services, aggravating chronic shortages.Because HIV interventions are not integrated into health services, this excessive spending is not effective. Nevirapine or other prophylaxis is given for only 9% of pregnancies in women with HIV, and only 1.5 million people are receiving antiretroviral drugs.8What is all this money being spent on? Much of it goes on “multisectoral” activities and “mainstreaming” HIV into just about every social activity. These have become the emperor's new clothes of public health. The World Bank's evaluation notes: “projects are complex with many participants engaged in activities for which they have little capacity, technical expertise, or comparative advantage.”14 Much money is wasted in areas that reflect the interests of those on the AIDS industry payroll more than evidence. It could be more effective if used to strengthen public health, which already provides preventive interventions in other sectors, cooperating with local authorities and ministries. Moreover, claiming HIV as exceptional may have increased stigmatisation.15