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Medicine, monopoly and malice: critically-acclaimed documentary on access to medicines ‘Fire in the Blood’ opens in UK and Irish cinemas

Fire in the BloodA new documentary film opening in UK and Irish cinemas this week tells the story of what its makers call “the Crime of the Century” – how available low-cost antiretroviral medicine was blocked from reaching Africa and other parts of the global south in the years after 1996. The film signals the dangers of the increasingly-perilous outlook for access to essential medicine in developing countries.

Fresh from its much-talked-about premiere at the Sundance Film Festival in Park City, Utah, last month, Fire in the Blood opens at the Irish Film Institute (IFI) in Dublin and the Prince Charles Cinema in London later this week. The film will be released in cinemas  across the UK on Monday 25th February.  The film tells a harrowing story of inhumanity and heroism, with a highly compelling cast of characters.  It details how it could come to pass that millions upon millions of people, primarily in Africa, were left to die horrible, painful deaths, while the drugs which could have saved them were being safely and cheaply produced and distributed just a short airplane ride away.

“I was curious to see what the reaction in the US would be”, says writer-director Dylan Mohan Gray.  “So much indoctrination about the necessity of high drug prices has gone on there that the Big Pharma Research & Development (R&D) defence is very much a sacred cow… even those with profound reservations about how the industry behaves tend to grudgingly accept its validity.  This is very easy for me to understand, since I was more or less that way myself when I began digging into all this.”  Gray was, however, gratified to discover that the American audiences who waited in line to attend six sold-out screenings at Sundance had much the same reaction after seeing the film that he had had when he began to work on the story.  “There is a very strong sense of betrayal when people find out what their governments have done in their name… and a very powerful conviction that the prevailing system of developing and commercialising medicine has to change”.

As the film points out, drug companies actually do very little basic research for drug discovery.  “84% of drug discovery research is funded by government and public sources”, says Gray, citing the landmark work of Professor Donald Light, “Pharmaceutical companies fund just 12% of such research, while the lion’s share of their spending goes into marketing and administration.”  These facts will come as little surprise to those familiar with the industry, but many have never really contemplated the repercussions of pricing essential medicines at levels only a tiny sliver of the world’s population can afford. 

While the film tells the story of how multinational drug companies and the Western governments collaborated to keep low-cost generic AIDS drugs out of the hardest-hit countries at the height of the HIV/AIDS pandemic – at a cost of ten million or more lives – it also tells the fascinating story of the unlikely group of people which came together in order to try and break this blockade.  Among this number were front-line doctors, HIV-positive activists, generic drugmakers, intellectual property specialists and individuals of global stature such as Desmond Tutu and Bill Clinton (both interviewed in the film).  “That’s what really set this story apart for me”, says Gray.  “It was a real-life David versus Goliath tale, full of incredibly interesting, daring, courageous mavericks who took on the world’s most powerful companies and governments to do what virtually everyone else at the time said was impossible (i.e. mass treatment of HIV/AIDS in Africa), and against all odds they won…” 

While the inspirational story of how low-cost generic AIDS drugs, first and foremost from India, came to save millions upon millions of lives in Africa (and beyond) is at the heart of FIRE IN THE BLOOD, the film concludes on a distinctly alarming note.  “The story this film tells was on the verge of being forgotten, something we can’t afford to let happen”, says Gray. The film details the tireless efforts of Western governments, working on behalf of industry, to impede and cut off supplies of affordable generic medicine from countries like India and Thailand to other parts of the global south, primarily by means of bi- and multilateral trade agreements which low- and middle-income countries are placed under enormous pressure to sign.

“The drug industry is stagnant, its pipeline is anemic and it has pinned all its future hopes on China and India”, notes Gray.  “Almost all these companies are publicly-traded, which means their bosses have to keep turning profits quarter-by-quarter if they want to try and keep their jobs… as they see it, they simply can’t afford to take a humanitarian view on issues of access.”  With the World Health Organisation having estimated that one-third of all deaths worldwide are attributable to treatable and preventable diseases, largely due to lack of access to medicine, the stakes could not be higher. 

Meanwhile, for all its insistence that high prices are the only practical trade-off for an industry that spends so much money on R&D to find new and innovative medicines, Gray noted with a wry smile that the who’s who of senior pharma executives will be gathering in London for the industry’s can’t-miss event, the Pharma Summit, just a few days after FIRE IN THE BLOOD opens theatrically in the UK.  “I was amused, but not surprised, to read that the theme of this year’s summit is Should pharma cut its losses and get out of R&D?”.

Araddhya Mehtta is a global heath campaigner for Oxfam GB.

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An AIDS-free generation is in sight but action is needed now

Protesters campaigning against Novartis in India.In 2001, I stood in front of a huge picture in the UN building in New York. It showed an African woman on her death bed with another woman hold her hand. It said: “You must not die alone”. I screamed: “You must not die full stop! There is treatment!”

My friends in the UK were living and working thanks to treatment provided free through the public health system, so why not this lady?

Today, interviewers ask me: “What are the major challenges for HIV in country X?” My response is that there are four challenges facing all countries dealing with HIV: funding, health systems, medicines and prejudice.

AIDS has uncovered many ills in the world: donors’ lack of long term commitment, weak health systems and flawed drug research and pricing. Not to mention deep-rooted stigma, prejudice and discrimination against marginalised including women, men who have sex with men, drug users, and sex workers.

Achieving the goal of an AIDS-free generation and the control of HIV is in sight but action is needed now.

1. Donors dragging their feet

Firstly, donors are dragging their feet from supporting the Global Fund which provides grants to countries to finance effective prevention, treatment and care programmes. Clearly donors need to re-think their reluctance. The more people we treat now and the more infections we prevent, the less costly the AIDS response will be in the near future and the more lives will be saved. The opposite is also true: ignore scaling up of prevention and treatment now and pay later not only in terms of lives lost but also in terms of money needed to contain an escalating epidemic.

2. Drug companies – part of the problem as well as the solution

Second, drug companies! They are a big part of both the problem and the solution. Thanks to Indian generic companies’ competition, the price of first line antiretrovirals dropped from £10,000 per patient per year to under $100. But now patients need more effective medicines and some need new ones which are still under patent. To avoid the patent block, civil society organisations and others supported UNITAID, the international drug purchasing facility, to establish the Medicine Patent Pool (MPP).  MPP acts as a one stop shop where the big international pharmaceutical companies license their medicines to the pool and then generic medicine manufacturers can make the needed combinations – paying royalties on sales in countries that have patent on those drugs.

Yet so far, the big companies are dragging their feet or refusing to join. Only Gilead issued a license, which represents a good start but still needs to be improved. ViiV Healthcare (created by GSK and Pfizer), Boehringer Ingelheim, Bristol-Myers Squibb, Roche and Bristol Myers Squib are taking a long, long time to negotiate with MPP. I am not sure when they will conclude these negotiations with decent licenses. We cannot wait forever!

Other companies – notably Johnson & Johnson, Merck and Abbott – refused to join. Instead, they are trying hard to polish their public image by cutting separate deals with generic medicine manufacturers but the terms of the licenses are not transparent  and they exclude patients in many countries. For example, the latest J&J deal on the drug “darunavir” excludes the West Bank and Gaza where the drug is sold at USD 5900 per patient per year!

When will drug companies put patients’ lives before making huge profits?

3. A critical need to invest in public health systems

The need for treatment programmes highlights once again the fact that investing in public health systems must be a priority for all governments and donors. Without qualified health workers (including managers, planners, pharmacists, etc) infrastructure, health information systems, and medical supplies, we will not be able to scale up treatment to reach all who need it. Yet some government donors still see investing in public health system as a remote goal to dream about rather than an urgent action to be performed now. A decade of increased funding for HIV response and most countries still face bottle necks in the drug supply chain – because of a lack of investment.

4. Addressing discrimination

Last but not least, all governments, community and societal leaders must address the deep-rooted discrimination in their societies. Countries cannot continue to ignore the rights of women, girls and marginalised groups under the cover of culture, religion or any other banner. In this age where young people across the world are communicating and sharing views and ideas about rights, it is not possible to continue with discriminatory laws and rules.

For a start, access to prevention, treatment and care is a right for all.

Mohga Kamal-Yanni is a Senior Health and HIV Policy Adviser at Oxfam GB.

This blog was originally posted on  Oxfam Policy and Practice website on the 1st December 2012.

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Reflections on the AIDS Conference 2012: reasons for hope but the battle continues

An HIV/AIDS activist in a ‘Keep the promise’ march at the XIX International AIDS Conference (AIDS 2012) Washington D.C. As the 19th AIDS conference drew to a close last week, I left Washington DC with mixed feelings of hope and despair. Advances in science gave me hope for the day we can cure HIV, yet pharmaceutical companies’ fierce fight for control over existing and emerging technologies remind me of the battles ahead. I was optimistic about the commitments made by Jim Kim, the new president of the World Bank, to invest in health systems that work for the poor, but worried that declines in donor funding will slow down progress. Above all, I was energised by the activists in the North and South who have for decades demanded action. Yet I felt frustrated at the lack of high-level commitment to address prejudice, stigma and discrimination. Here I reflect on my three greatest hopes and the three battles in the struggle to end AIDS.

REASONS FOR HOPE

1.   THE SCIENCE IS MOVING TOWARDS ENDING AIDS
Great strides have been made by the scientific community and the goalposts have clearly shifted – instead of “fighting AIDS” we now talk about “ending AIDS”. Scientific advances in prevention and treatment have saved lives and turned the deadly disease into a chronic condition. Medicines for those who develop resistance or side effects are more effective than ever before and scientists are on track to find a cure. There are new lab techniques to test and closely monitor people living with HIV in order to improve treatment. The evidence is clear that treatment is an effective method of prevention and new studies show that early treatment results in far better health outcomes. Therefore, there is a strong recommendation to start treatment as soon as a person is diagnosed.

2.   BOLD COMMITMENT FROM THE WORLD BANK
In his opening remarks, the new World Bank President Jim Yong Kim stated that the World Bank would play a pivotal role in ending AIDS by focusing on what it does best: building health systems. I strongly believe that investing in health systems (including infrastructure, health workers, drug supply chains, and health information systems) is a critical prerequisite to ending AIDS.  To achieve Jim Kim’s vision I hope that the World Bank will increase its support to developing countries (with help from other donors) to invest in free public health care and support community-based care. Access to free treatment has been critical in the struggle against HIV and we must learn from this lesson.

3.    THE POWER OF ADVOCATES
In his speech Jim Kim reminded delegates that at every point in the history of the epidemic, it was the HIV activists who have led the way – putting pressure on politicians and drug companies to act. The 2012 conference brought together the veteran fighters who broke the silence on HIV decades ago and the young activists who are driving the movement today, demanding their rights and creating new societal norms in difficult contexts, such as the Middle East.

THE THREE BATTLES

1.   PHARMA: THE DE JA VU PHENOMENON
As new medicines come on stream, there are signs that pharmaceutical companies are taking the same path they took decades ago when the first ARVs became available and advocates fought tirelessly to demand access to new treatment. Now as then, the pharmaceutical companies want to control of the Intellectual Property for these medicines in order to maintain absolute control of the market.  For example, companies such as Johnson & Johnson and Merck are refusing to license their medicines to mechanisms like the Medicine Patent Pool (MPP), an initiative which would enable widespread generic competition and hence expand access to medicines. Some companies have cynically claimed that they are refusing to work with the MPP because they want to ensure patient adherence – as if a patent monopoly would allow them to monitor every patient! Others claim that the market for their products is so small that it cannot bear more than 2 to 3 producers: the company itself and those it decides to provide voluntary licenses.  Such licenses tend to have very limited geographical coverage and their standards are not open for public scrutiny (unlike the MPP license which has transparent policy and is mandated to negotiate wide geographical coverage).  Besides, generics companies, which understand the dynamics of the generics market, are best placed to determine whether it is worth producing a generic version after the entry of 2 or 3 generics producers.

2. DECREASED FUNDING
There is no doubt that donor funding for HIV and health is decreasing. The global financial crisis has been blamed for this decrease. Yet it is not possible to end AIDS without investment in massive scale-up of prevention and treatment efforts, especially via the Global Fund. Last year, the Global Fund cancelled Round 11 causing difficulties in programmes in a number of countries such as Malawi and the Democratic Republic of Congo.

This year the Global Fund is discussing a new funding model to replace the Round system.  We activists are concerned that the “financial crisis” will dictate a model that dampens country demand.  Allocating budgets to countries, as has been proposed at the Global Fund, will induce “self-censorship” whereby countries go for what they can buy with their allocated funds rather than what they actually need. I hope that the Global Fund board rejects such top-down approaches and maintains the principle that it prides itself on: country ownership. To enable the serious work to end AIDS to continue donors will also need to fulfil their funding commitments.

3.   WOMEN AND VULNERABLE GROUPS
The initiative to have a HIV free generation via stopping mother-to-child transmission is to be applauded. Yet the lack of commitment of donors and governments to treating women before and after birth is appalling. Also, the lack of high-level political commitment from country leaders to tackle prejudice, stigma and discrimination threatens to undermine the goal of ending AIDS.

FINALLY..
In a nutshell, the science, the advocates, and the new World Bank give me reason for hope. It’s now time for pharma, donors, and governments to play their part. Activists will not wait for long to act!

Mohga M Kamal-Yanni works for Oxfam as a Senior Health & HIV Policy Advisor

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Debating the World Bank Report on Fiscal Constraints – A return of the 90′s?

A recent World Bank report on the fiscal dimensions of HIV and AIDS in a selection of sub-Saharan African countries has stirred significant debate. Here, Professor Brook Baker argues the report is ‘seriously out-of-date’ and ignores important new evidence on treatment-as-prevention.  Dr Markus Haacker, co-author of the report, responds…

Professor Brook K. Baker (professor of Law at Northeastern University School of Law and Policy Analyst for Health GAP (Global Access Project).

The World Bank has just recently issued a “new” report: “The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda.”  The Report doesn’t really feel “new” because it represents a recurrent theme in the World Bank approach from the earliest days of the global AIDS pandemic – it’s not fiscally sustainable to treat people living with HIV in high impact, low-resource countries – instead the world must focus on “prevention.”  The World Bank is seriously out-of-date, or conversely, perversely pig-headed, for four main reasons:

First, it’s report now issued in March of 2012 is already seriously out of date since it relies almost exclusively on pre-2009 data.  Despite opportunities to do so in the editing process and in its media work, the World Bank has chosen to totally ignore the exciting new science concerning treatment-as-prevention – research that shows that suppressive anti-retroviral therapy reduces the risk of onward transmission of HIV by at least 96%!  This gold-standard research is now being confirmed by ecological data showing actual declines of new infections in places where anti-retroviral scale-up has reached a “tipping point.”  Some of the most exciting findings come from KwaZulu Natal province in South Africa, the epicentre of the pandemic, where community infections are dropping precipitously now that a deadly delay in treatment rollout has been reversed.

The Report is also seriously out of date because it fails to take into account recent evidence of greatly enhanced efficiencies in AIDS programming.  The US PEPFAR program has evidence that its treatment costs have decreased by over 2/3 in just the past few years.  Doctors without Borders is achieving stunning efficiencies by task-shifting treatment initiation and monitoring to nurses and community health workers respectively, by moving services to the community level, and by involving patients in groups support and adherence activities.  Both of these dramatic developments call most of the World Bank’s calculations into question.

Second, there is growing evidence, again ignored by the World Bank, that even a moderate expansion of investments now in treatment scale-up and in diffusion of scaleable prevention methods like male circumcision, condoms, and needle-exchange can have significant impacts on new infections and thus future treatment costs.  One would think that a premiere economic think-tank like the World Bank could more strongly champion the idea that spend-a-dime-today instead of a dollar-tomorrow makes good economic sense.  The Bank has certainly strengthened its understanding of the fiscal impacts of HIV/AIDS by taking into account the predictable future costs of continuing and new infections, but it has failed to appreciate the Big Bang benefits of early investments.

Third, the World Bank uses magical thinking rather than evidence to rally support for unspecified “prevention” activities.  The Bank was one of the main proponents of prevention-only throughout the 1990s.  Treatment was too expensive, it wasn’t cost effective to treat poor people living with HIV, expenditures couldn’t exceed revenues, donors are fickle so don’t count on them, etc. Although the Bank’s language has become less coarse and callous, many of the same “truisms” are repeated in the current report.  Using the neutral language of quasi-liability (instead of what other pundits call a treatment mortgage), the Bank argues that the costs of treating people infected now and of those newly infected (discounted to present value) show that treatment expansion is “unsustainable.”  The Bank treats each and every country in its study solely within the context of its own economic resources showing severe domestic fiscal constraints, when it could in fact call for innovative global financing – like a financial transaction tax – and more predictable and long-lasting pooled global resources – like at the Global Fund.  It emphasizes – indeed almost excuses – donor defunding because of a global financial crisis that is too precipitous to permit a ramp-up in global health spending, but apparently a crisis that is not so serious so as to preclude a multi-trillion dollar bailout for banks and to continue numerous military follies.  The truth of the matter is that principles of global solidarity for global health should be promoted by the Bank as the real solution to short– and mid–term fiscal pessimism.

Fourth, the World Bank appears to neglect the economic and social benefits of a healthier population and to ignore some of the costs of premature deaths.  Focusing on fiscal costs of treatment, while ignoring the huge social and economic benefits of the survival of the vital age 25-45 cohort is just plain strange.  Young and middle age adults are economically productive, they raise and help education children, and they care for elders.  In a pure economic sense, they build economies, promote economic development, pay taxes, provide care labour, and innovate.  Earlier deaths decrease the value of investments in education and impede social reproduction.   Likewise, the Report makes some reference to macroeconomic impacts of HIV on macroeconomic growth, but it seems to discount the long-wave impacts of successive losses of the middle-generation.  Focusing primarily on fiscal costs while forgetting economic benefits is an unbalanced way to inform policy choices.

Countries need advice on future costs, but they need it based on current facts.  They need advice not just about how selfishly the world economy and governance is currently constructed, but how they might be revised to make the right to health and Universal Access real.  The failure of the Report is not a failure of the collective researchers or the individual authors, but rather of the rigid and dogmatic ideology of the World Bank that consider “fiscal space” a law of nature, while ignoring newly discovered evidence that treatment is now one of the most promising tools for prevention.  Let’s hope the Bank issues a new, more hopeful report, responsive to recent development and cognizant of the power of new investments to end AIDS.


Response from Dr.  Markus Haacker (co-author “The fiscal dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda”)

Dear Prof. Baker,

I have read your comments on the recent book on the “The Fiscal Dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda.” As one of the authors, let me offer you a few notes on your comments.

The sustainability of HIV/AIDS programs is a matter of serious concern to governments and the leadership of national HIV/AIDS programs across sub-Saharan Africa and beyond. The book is a contribution to address these concerns, by providing an analysis of HIV programs from a fiscal perspective, to inform policymakers and donors on the extent of the challenge of financing the current HIV/AIDS program, and a springboard for addressing the dialogue about the funding of the programs as well as thinking about new approaches to improve the effectiveness of HIV program, including many of the approaches that you are describing.

The following comments are broadly aligned with the three points you make.

(1) The drafting of the report was completed in late 2010, and incorporates a large number of references published in 2010. Additonally, I have incorporated  during the editing process the data which were released in end-2010 by UNAIDS in the context of the Report on the Global AIDS Epidemic. Your comment that the report “relies almost exclusively on pre-2009 data” is clearly wrong, and I am puzzled as to what might have given rise to this misconception. I also disagree on your claim that the report disregards “greatly enhanced efficiencies in AIDS programming.” For example, the unit cost of treatment in South Africa were based on a very elaborate analysis of providing ART through the public health system as of 2010 conducted on behalf of the Department of Health.
Two more points on your comments regarding the latest evidence in the analysis:
(a) One of the challenges in incorporating the latest evidence from empirical research is the fact that costs differ substantially across countries – superimposing empirical findings from recent research, which are to some extent country-specific, over current or recent national data is a source of great errors. Using the best available data shared by the national HIV/AIDS programs therefore is legitimate and useful, and helps anchoring the analysis with the ongoing policy dialogue.
(b) At this time (and especially a year ago when the book was written), the evidence on “treatment-as-prevention” is not advanced enough to support the epidemiological modeling the fiscal analysis in the book is based on. I know of substantial current efforts to take this further, to translate the evidence into population-level modeling, but expecting that this fiscal analysis should outsmart and upstage the very complex epidemiological modeling efforts that are going on now specifically in this direction is unfair and inappropriate.

(2) I largely agree with your comments regarding “investments now in treatment scale-up and in diffusion of scaleable prevention methods.” This is exactly the reason why the book places so much emphasis on the costs of meeting the demand for HIV/AIDS-related services caused by new infections. Quantifying these costs is a tool for motivating investments in prevention methods such as the one you mention – to convince a Minster of Finance or donor to provide funding, e.g. for “male circumcision, condoms, and needle-exchange,” it is useful to have estimates of the resulting financial savings (and, of course, of the obvious health benefits) at hand.

(3) The four reports combined in this book take a country-specific perspective, and was written to inform specific governments. Irrespectively of donor commitments, these governments are accountable to their citizens to meet the demand for public services. Assuming that “innovative global financing” or the Global Fund (which itself is in a financial crisis) would pick up the bill would be irresponsible from the perspective of the national HIV/AIDS program. However, I would hope that the analysis of the situation in countries like Swaziland and Uganda (where the estimated costs of the response to HIV/AIDS exceed any debt relief received) will help securing global HIV/AIDS funding.
The report does not argue “that the costs of treating people infected now and of those newly infected (discounted to present value) show that treatment expansion is ‘unsustainable.’” It uses a comparison with debt sustainability analyses conducted by the IMF and the World Bank to highlight the financial burden countries like Swaziland and Uganda are facing. But this burden needs to be interpreted against the extraordinary health challenges facing these countries, which means that simply looking at the costs of the HIV program would be grossly inappropriate. Moreover, by linking the scale of the financial costs to criteria which have been used in the past for allocating debt relief, the analysis offers concrete tools for soliciting external funding that can be used for negotiating external support.

Finally, I am – as you hope – confident that “the Bank (will issue) a more hopeful report, responsive to recent development and cognizant of the power of new investments to end AIDS.” However, I am not so optimistic regarding the immediate gains from the innovations you are describing. In the countries the report looks at, about one-half of the estimated burden of financing the HIV/AIDS program addresses the needs of people already living with HIV/AIDS (and the other half the costs of projected infections), and even a steep decline in HIV incidence would have very little impact on the funding needs of the HIV/AIDS program over the next decade. With all the “exciting new science” you quote, it would nevertheless be irresponsible to lose sight of the need to secure the funding of the existing HIV/AIDS programs.

 

Response from Professor Brook K. Baker to Dr. Markus Haacker

Thanks for your public response.

I agree with your point 1 that there are some references to 2010 publications, but the bulk  are earlier.  Adding 2010 UNAIDS data is certainly useful, but from the vantage point of 2012, 2011 was a very big year.

I don’t agree with your point 1(b) that it was unfair or inappropriate to suggest that the paper could have at least mentioned the emerging evidence on treatment as prevention.  Although it may not have been possible to redo the analysis in light of the complicated recalculations you describe, the idea that treatment as prevention might impact the fiscal analysis you offer is something that paper must address, especially since the paper seems to place treatment and prevention in opposition, once again.

With respect to your point 3, it’s a little hard to interpret your report, the World Bank press release, and all the mainstream press about the paper as not suggesting that treatment scale-up is unsustainable.  That conclusion is stated in summary terms, although I agree that there is also much more detailed and sophisticated analysis in the four country studies.

I certainly understand the importance of the Report’s focus on HIV prevention – it is something that AIDS activists have fought for for generations.  The problem is that “prevention” has often been presented as an oppositional concept to treatment – very directly during the 1990s and even thereafter.  Likewise, the Report’s discussion of treatment scale-up really presented treatment, now in March 2012 when published, as a separate category from prevention.  Given stunning developments in the scientific validation of treatment-as-prevention over the past two years (Haiti study and then HPTN 052 and frankly observationally even earlier than that), it certainly would have been appropriate to mention treatment as now being even more synergistic and intertwined with prevention.  That is not to say that the paper couldn’t have urged countries to know their pandemic (as it did) nor that it shouldn’t have urged countries to be alert for further developments on the prevention front (something that could have been clearer).  However, by leaving your recommendation for prevention open-ended – without any real specification of evidence-based prevention successes like male circumcision, treatment-as-prevention, etc. – the paper risked being interpreted according to the old behavior-change prevention/treatment binary.

Admittedly, the Report did encourage both more investments – by donors and by countries – and greater efficiencies.  But the headline conclusion of the Report, as I said above, was fiscal unsustainability.  It may have been your intention to ensure country self-reliance on domestic resources (after all you say below that countries shouldn’t count on innovative financing or the Global Fund), but cautious ministries of finance, already acculturated to an ideology of macroeconomic fundamentalism, will read the Report very pessimistically.  In my estimation, they are likely therefore to encourage less rather than more scale-up, especially since treatment will be understood according to the Report as being oppositional to prevention in terms of resources.  Anything the authors and the Bank could do to clarify and prevent this kind of interpretation would be helpful.

Professor Brook K. Baker is a professor of Law at Northeastern University School of Law.  He is also a policy analyst for Health GAP (Global Access Project).

Dr. Markus Haacker is co-author of  ”The Fiscal Dimension of HIV/AIDS in Botswana, South Africa, Swaziland, and Uganda”. Dr Haacker is a growth and development economist,  and  currently an Honorary Lecturer at the London School of Hygiene and Tropical Medicine. He also works as a consultant to the World Bank and UNAIDS.

This article was originally posted on the European Aids Treatment Group website (posted on 22/03/2012).  It has been adapted and reproduced here with permission from Professor Brook K. Baker and Dr. Markus Haacker.

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.