There is no doubt that the United States has shown tremendous leadership and brought about remarkable results in the global fight against AIDS over the past decade. U.S. investments through the Presidents Emergency Plan for AIDS Relief (PEPFAR) have strengthened overall health systems, built and sustained capacity to address HIV and a host of other diseases, and helped scale up treatment to save millions of lives. While innovative prevention efforts are still needed to achieve an AIDS transition (e.g. a sustained decline in the total number of people living with HIV/AIDS), it seems we have reached a “tipping point” where the science, technology and know-how are available to realistically talk about creating an AIDS free generation, as Secretary of State Clinton did a few weeks ago. With continued political support and sustained financing, two things that PEPFAR has enjoyed since its creation in 2003 (including bi-partisan support, full funding in annual appropriations and re-authorization in 2008,) we may be able to capitalize on this tipping point and finally turn the tide of the pandemic.
But in the current U.S. political and fiscal environment, it’s becoming increasingly clear that this kind of support for AIDS funding may have also reached a “tipping point” and will be increasingly difficult to maintain in coming years. Congress and the Administration face a tough election in 2012, and there isn’t much appetite to put HIV/AIDS on the political agenda. As the budget debate slogs forward on Capitol Hill, funding for global health could face cuts up to 9% in FY2012 and much more in 2013 if sequestration is triggered. It’s unclear what percentage of those cuts will come directly from PEPFAR's budget but it would be naive to assume AIDS funding will remain untouched regardless of its necessity and merit.
Unfortunately, capitalizing on the AIDS tipping point is precariously dependent on continued U.S. support. In 2010, 54% of publically donated funds for HIV/AIDS worldwide came from the United States, and continued support is necessary to sustain the progress that has been made thus far. If political and financial support tips away from HIV/AIDs right now, it could offset the gains that have been made and once again place an AIDS free generation out of reach.
This dynamic is setting the scene for a showdown next summer when the International AIDS Conference (IAC) returns to the United Stated for the first time in 22 years. For one week in July, AIDS advocates, researchers and practitioners from around the world will convene in Washington, DC to discuss how to tip the balance of the AIDS epidemic in their favor. Meanwhile, 15 blocks away, U.S. policy makers will be discussing how to tip the balance of the budget back towards the green, and HIV/AIDS funding (dollars that sustain many of those researchers and practitioners up the road) will be in their crosshairs.
As a sheer numbers game, reconciling these two sides should not be difficult. A recent analysis from the American Foundation for AIDS Research on the human impact of sequestration in FY2013 shows that reductions in U.S. global health funding would have a minimal impact on the deficit, representing only 0.42 percent of the $1.2 trillion in mandated reductions. But the human impact of these cuts would be devastating: 403,000 people would not receive life-saving treatment, 92,000 more people will die from HIV/AIDs related illnesses and 181,000 more children will become orphans. The bottom line –global health spending is such a small percentage of the total U.S. budget that across the board cuts will not tip the balance of the deficit reduction, but they will cost thousands of lives, reverse years of gains against HIV/AIDS, and instantly thrust the AIDS tipping point in the wrong direction.
But the case for ending the AIDS pandemic is more complicated than a numbers game. It will require fresh approaches and bi-partisan political will in both the Administration and Congress – with the later likely to be even scarcer than usual in 2012.
So is there a middle ground? Maybe. Taking a cue from the new CGD/Center for American Progress working group, a period of austerity may present opportunities to improve the global response to AIDS and give rise to discussions on how to make structural and procedural changes to programming that would make it more effective and efficient moving forward.
In turn, sustained (if not expanded) financial support from the U.S. at this critical time could help turn the tide of the HIV/AIDS pandemic enough that the need for total investment in the future would drop significantly. This may necessitate realigning the donor/recipient relationship through innovative approaches in aid financing and delivery (cue Cash on Delivery Aid for HIV/AIDS) as my colleague Mead Over explains in his new book, Achieving an AIDS Transition. These changes would make funding more sustainable and predictable over the long-term, and help prevent tax payers from concluding that foreign assistance doesn’t deliver and never ends.
On this World AIDS Day, as we contemplate these two tipping points and look forward to a promising but uncertain 2012, I have two wishes. For Congress, as they continue to address the budget deficit, I hope they consider how close the AIDS pandemic is to a tipping point – one that the U.S. can be proud of helping achieve and one that is worth seeing through. Seeing that the Global Fund will not expand its treatment roll for the next two years, U.S. leadership is more important than ever. Neglecting to act would discount billions of dollars in investments already made, and leave millions of lives hanging in the balance.
For members of the AIDS community, I hope they can recognize that the days of perpetually increasing resources are gone and they may soon have to work towards an AIDS free generation with a smaller piece of the pie. Getting the most out of a shrinking pie means reducing the number of slices to go around. Likewise, turning the tide of the AIDS pandemic amidst constrained resources means getting serious about trying new strategies to incentivize effective prevention and reducing the number of new infections. Doing so will help mitigate the reality of today’s fiscal environment and lead us down a more sustainable path. And perhaps, come this time next year, everyone will find a way to tip the balance in their favor.