US international aid programs are funded annually by Congress, which means they are by necessity subject to political unpredictability. US assistance for, say, immunications, student exchanges, or well-building programs routinely are ramped up, only to be quickly scaled back. Fortunately, many efforts are "sustained" even if funding is undercut: immunizations have long term benefits, exchange students have new skills, and new wells can last for years.

Providing antiretroviral therapy (ART) is different. A patient receiving ART needs medicine for the rest of their lives. If you stop the medicine, they die. There is no current prospect of a "cure" for AIDS, just long-term management.

Current US policy calls for providing millions of people with ART in coming years (two million through PEPFAR, plus additional numbers via the Global Fund and World Bank). This means that potentially millions of people in the relatively near future will have their lives directly dependent on the congressional appropriations process -- forever. I don't know of any other program in the history of US assistance where this degree of direct dependence has been true. It's quite easy to visualize troubling future scenarios.

Two ideas might help with funding unpredictability or burnout. First, a continued drop in drug prices will ease the dilemma. Perhaps some fraction of US funding could be steered immediately into research efforts targeted at "price bottlenecks". Second, US (and international) funders could take a multi-year view by establishing an endowed "AIDS Treatment Foundation". There are many examples of Congress endowing efforts in order to sidestep the short-horizon nature of US budgets. Such an initiative would assure at least some prospect of longer term commitment to patients throughout the world receiving ART.

In May 2003 President Bush signed the "Global AIDS Bill" which, among other things, established the "President's Emergency Response for AIDS Relief" ("PEPFAR"). The proposed $15 billion of funding for PEPFAR (over five years) represents the most significant jump in resources for Global AIDS (by far). PEPFAR has a number of characteristics with significant implications for AIDS policy, including limitation to 15 countries, limitation to $200m / year to the Global Fund, and a mandate to spend at least 33% of funds on abstinence and monogamy training. What AIDS organizations were influential in shaping the final bill?

A new report by Derek Hodel entitled "At the Crossroads: A Study of Federal HIV/AIDS Advocacy", includes, among other things, a detailed case study of advocacy efforts leading to final passage of the Bill. Hodel names about 30 organizations and individuals that played key roles, including:

AIDS Advocacy Groups:

AIDS Healthcare Foundation
Elizabeth Glaser Pediatric AIDS Foundation
Global AIDS Alliance
Health GAP
San Francisco AIDS Foundation

Development Organizations:

Global Health Council
Catholic Relief Services
Church World Services
Episcopal Church
World Visions
RESULTS
DATA

Individuals:

Paul Farmer / Partners in Health
Jean Pape / GHESKIO
Eric Goosby / Pangea Global AIDS Foundation
Nils Daulaire / Global Health Council
Peter Lamptey / FHI

What is notable about the case study is that it doesn't name any of the organizations that think of themselves as leading authorities on global AIDS policy: UNAIDS, WHO, World Bank, various UN reference groups, Gates Foundation, or others. It's true that these groups may have exerted influence quietly or indirectly, but I suspect more likely is that they really weren't involved. It isn't the job of, say, UNAIDS to lobby Congress, but at the same time if the most important AIDS policy organizations aren't clearly linked to the most important AIDS policy development in the last two years, the ties, even if indirect, should be strengthened. Two recommendations would be for these organizations to a) include in all policy recommendations notional budget allocations, and b) improve the dialog with advocacy groups that clearly have influence in AIDS policy and finance.

The study is not available online but is available from Suzan Ekmekjian at Ford Foundation, which funded the study.

Over five billion dollars will be allocated by international donors in 2004 to combat global AIDS. Is that money allocated appropriately?

Ideally, funding decisions would reflect experts' best advice on the smartest use of resources. Unfortunately, the policy recommendations emanating from UNAIDS, the Global HIV Prevention Working Group, or other normative bodies rarely give dollars and cents recommendations on how to allocate budgets. Decisions are therefore left to government officials who may have some understanding of effective interventions, but will be heavily influenced by both politics and guesswork. How could this situation be improved?

1) Policy bodies should provide not only policy recommendations, but budget recommendations. Much as the Copenhagen Consensus allocated a fictional $50 billion, policy groups should routinely include notional budgets (by region and intervention) in their recommendations.

2) UNAIDS, Kaiser, or one of the other capable organizations that review statistics should compile annual global expenditures by region and intervention type.

3) An annual conference, potentially overseen by UNAIDS, should compare recommended spending with actual spending and advise on "rebalancing the portfolio". Experts frequently comment on areas receiving inadequate funding (see for example Helene Gayle's recent comments on this), but rarely are these comments backed up by any sort of comprehensive analysis.

The gap between what should be funded and what is funded in global AIDS is enormous -- certainly representing one of the most serious problems to be tackled in confronting the disease. There are clear steps that can be taken to minimize this gap.