How should HIV and AIDS resources be allocated to achieve the greatest possible impact? This paper begins with a theoretical discussion of this issue, describing the key elements of an "evidence-based allocation strategy". While it is noted that the quality of epidemiological and economic data remains inadequate to define such an optimal strategy, there do exist tools and research which can lead countries in a way that they can make allocation decisions. Furthermore, there are clear indications that most countries are not allocating their HIV and AIDS resources in a way which is likely to achieve the greatest possible impact. For example, it is noted that neighboring countries, even when they have a similar prevalence of HIV, nonetheless often allocate their resources in radically different ways.These differing allocation patterns appear to be attributable to a number of different issues, including a lack of data, contradictory results in existing data, a need for overemphasizing a multisectoral response, a lack of political will, a general inefficiency in the use of resources when they do get allocated, poor planning and a lack of control over the way resources get allocated.There are a number of tools currently available which can improve the resource-allocation process. Tools such as the Resource Needs Model (RNM) can provide policymakers with a clearer idea of resource requirements, whereas other tools such as Goals and the Allocation by Cost-Effectiveness (ABCE) models can provide countries with a clearer vision of how they might reallocate funds.Examples from nine different countries provide information about how policymakers are trying to make their resource-allocation strategies more "evidence based". By identifying the challenges and successes of these nine countries in making more informed allocation decisions, it is hoped that future resource-allocation decisions for all countries can be improved.We discuss the future of resource allocation, noting the types of additional data which will be required and the improvements in existing tools which could be made. In 2001, demographers, epidemiologists and economists, under the direction of the World Health Organization and UNAIDS, were asked to estimate the resources required to achieve the newly developed UNGASS targets [One of the great successes in raising funds for the response to the HIV and AIDS pandemic has been the rapid increase in resources for the global response, as shown in Figure While no single factor can explain why the growth in spending has occurred so rapidly, it can be partially explained by a number of critical events, including:• The launch of UNAIDS in 1996;• The introduction of the World Bank MAP program, and the Bill and Melinda Gates Foundation in 2000;• The UN General Assembly Special Session on HIV and AIDS (UNGASS) in 2001;• The start of the Global Fund in 2002;• The launch of PEPFAR in 2003;• The G8 Summit in 2005 and the corresponding commitment to universal access.While the actual resources spent in 2005 came relatively close to the target of $9.2 billion, it is important to remember that the real goal was to scale up the delivery of services and to change behaviors, not to generate new resources.A review of the actual achievements relative to the expected achievements is not as impressive as the scale up of resources. The 2006 Report on the Global AIDS Epidemic concluded that of 6 targets evaluated, only one was achieved: the generation of between US$7-$10 billion in funding by 2005 . For exaThe original resource requirement estimates were based on an assumption that 6 billion condoms would be distributed annually; by 2005, 5 billion condoms were actually distributed  . ReachinThus, while the global response did succeed in rapidly generating new resources, it did not succeed in fully generating the services and the behavior change which was anticipated. This suggests that either the original projections were overly optimistic about what could be achieved with the resources, or the world spent its HIV and AIDS resources in a much more ineffective (or inefficient) way than what was originally assumed.Given the current financial crisis and the potential for donors to redirect their attention and resources to other priorities, it is important to assess how current resources have been spent and ask how resources might be allocated to assure the achievement of targets in the future. How can resources be spent to reach those groups most at risk? Will the allocation of resources be consistent with what is known about the effectiveness of interventions? Can the positive response of the past decade be sustained even if the rapid growth in resources does not continue?This paper was developed with three objectives in mind. The first objective is to identify some of the challenges and inconsistencies in the ways current HIV and AIDS resources are allocated at the national level. This section of the report will define an "evidence-based allocation strategy" and assess if countries are making allocation decisions based on such evidence.We will also look at how countries are currently spending their HIV and AIDS resources, with a particular focus on whether these current allocation patterns appear to be more driven by politics and wishful thinking, or if they are more driven by evidence and careful planning. This section will also discuss why some countries may not be following an evidence-based allocation strategy.The second objective is to review some of the national-level experiences in trying to improve the resource-allocation process. We will address this objective by identifying and explaining the experience of groups using evidence-based tools, such as the Resource Needs Model (RNM)  and the The third objective is to assess how resource allocation in the future might be improved through encouraging countries to pursue an "evidence-based allocation strategy". This section also discusses how current and future tools might be improved to address the growing need for better resource allocation.The simplest definition of an "evidence-based allocation strategy" is one in which resources are spent in a way that is, based on the best currently available evidence, likely to achieve the greatest possible result. In the case of HIV and AIDS, results are generally defined in terms of preventing new infections, providing care and treatment, and mitigating impact.An ideal approach for assessing how policymakers should optimally allocate resources would involve comparing a country's actual spending patterns on HIV and AIDS to some known optimal allocation pattern. Countries which differed significantly from the optimal allocation pattern would be considered to need to reallocate their funds. Countries closest to the optimal allocation would be the ones which would not need to reallocate .For example, perhaps Country A is currently spending only 2% of its HIV and AIDS prevention resources on reaching injecting drug users (IDU). The country's 5 year HIV and AIDS strategy indicates that IDU are not a priority and will continue to receive only a small proportion of all prevention resources. However, the optimal allocation pattern suggests that IDU are an important driver of the epidemic and Country A should be spending more than 20% of its resources on this population. In this case, policymakers might be encouraged to rethink their plans and increase spending on this critical subpopulation. If the misallocation was not corrected, the country might receive less money from international donors in the future, since the country is not allocating its resources effectively"Many governments have not acted in a fully responsive manner to protect their populations from HIV infection or death from HIV disease. Many countries, rich and poor, still fail to devote adequate resources to address their national epidemics, choose not to implement evidence-based programming, or ignore the needs of marginalized groups affected by HIV" [ by HIV" .Alternatively, Country B has pursued an "evidence-based allocation strategy", carefully assessing its epidemic, the cost-effectiveness of its interventions, synergies between interventions, the policy environment, etc. Using this evidence, Country B has established clear and logical priorities and has allocated its resources accordingly. In this case, donors may choose to assign more funds to Country B, because that country is more likely to have an impact on its epidemic.Unfortunately at this time, calculating this optimal allocation pattern is not entirely feasible, in part because there is no known optimal allocation of HIV and AIDS resources . With thEven countries with similar epidemics, similar modes of transmission and similar unit costs might choose to allocate their resources in different ways due to cultural and political differences . This is not to suggest that making decisions based on the political reality which exists in a country is wrong. In fact, in countries where behaviors such as homosexuality are illegal, it is particularly problematic to design programs which will successfully reach MSM. In this case, it might make more sense to first spend the limited resources to address the legal environment and then to scale up resources for MSM.However, even considering the current lack of data, one would still expect some consistency in the way resources are allocated, based on the epidemiological and economic data available. If resource-allocation decisions are actually being informed by an evidence-based allocation strategy rather than being made randomly or based on purely political factors, then one might expect that neighboring countries, with a similar prevalence of HIV, would allocate their resources in somewhat similar patterns. Is this the case?With the advent of National AIDS Spending Assessments (NASA), much more is currently known about the ways in which HIV and AIDS resources are being spent . The 200Figure As the figure shows, lower prevalence countries allocate a higher proportion of their resources to prevention, while higher prevalence countries spend a larger percentage on care and treatment. For example, the eight countries with prevalence below 2% spend 38% of their resources on prevention, and only 23% on care and treatment. Meanwhile, the five countries with a prevalence of over 15% spend 17% of their resources on prevention and 48% on care and treatment. This allocation is consistent with what one might expect; low-prevalence countries have a lower burden of treatment and therefore allocate a greater share of their resources to prevention. High-prevalence countries should be spending heavily on prevention but will have much greater need for treatment. "Other HIV expenditures" in Figures However, it is also worth noting that there appear to be some significant outliers. For example, the DRC reports spending 32% of its resources on administration, almost twice as much as the average for all 23 countries. Ghana, with a prevalence of only 1.9%, reports spending the highest proportion of any country on care and treatment . Even when comparing two high-prevalence countries, such as Botswana  and Swaziland , the resource-allocation patterns differ significantly. Botswana is currently spending the largest proportion of its resources on care and treatment, while Swaziland is spending most of its resources on orphans and vulnerable children. As a result, Botswana has 76% coverage with ART in 2006, while Swaziland had only 35% ART coverage .The allocation of resources appears to be even more random in Eastern Europe and Central Asia, as shown in Figure The analysis becomes even more revealing when specifically evaluating the allocation of resources on prevention programs. In Figure There are also numerous examples cited of misallocations of funds in Asia, as reported in Elizabeth Pisani's book "The Wisdom of Whores" . For exaNational policymakers are not the only stakeholders who appear to misallocate funds. In Accra, Ghana, for example, it has been estimated that 76% of all new HIV infections occur between sex workers and their partners, while the remaining 24% of all new infections occur within the general population . HoweverOne caveat is worth noting in regards to the appropriate allocation of funds. If the cost to reach the general population and to change their behavior is much higher than the cost of reaching and changing the behavior of sex workers, it may be quite logical to allocate more funds to the general population than sex workers. In other words, an appropriate allocation of funds takes into consideration not only where new HIV infections are occurring, but also considers unit costs of reaching each population.Reviewing the ways in which countries allocate their resources, it becomes difficult to demonstrate that countries are actually pursuing an "evidence-based allocation strategy". Neighboring countries with similar HIV prevalence levels spend resources in radically different ways. Spending patterns appear to be only nominally related to the severity of the epidemic in sub-Saharan Africa, and are totally unrelated to prevalence in the rest of the world. Prevention resources appear to be allocated randomly, with no evidence showing that countries allocate their spending based on evidence about the source of new HIV infections.If countries are not pursuing an "evidence based allocation strategy", the next question is to ask why. A number of possible explanations are listed below.One possible explanation for poor resource allocation is that countries don't have access to the information required to make rational decisions regarding the allocation of HIV and AIDS funds. This is a very plausible explanation, given that most countries don't have access to data about the cost-effectiveness of different interventions. While there are data which suggest that some interventions may be more cost-effective than others -17, thesHowever, the lack of data cannot fully explain the path some countries take in allocating resources. Even when data are available and reliable, it has been our experience that they are only used to a limited extent when make planning decisions.When effectiveness and/or cost-effectiveness data do become available, there are often contradictory messages derived from these results. For example, early economic analysis suggested that PMTCT interventions would not be affordable in South Africa . SubsequRetrospective data from Uganda about the country's success in reducing HIV prevalence rate also has produced contradictory results. In some cases, it has been suggested that prevalence reductions were attributable to behavior change which occurred as a result of a rapidly scaled-up VCT program . HoweverData about the effectiveness of STI treatment has also demonstrated mixed results. On the one hand, an early randomized control trial suggested that STI treatment would have a significant impact on the prevalence of HIV . HoweverOther analyses have produced contradictory results about where current infections are actually occurring. In Zambia, for example, it has been argued that commercial sex is not a significant driver of that country's epidemic, with only 7% of new infections occurring among traditional vulnerable groups . The Goals model analysis, however, indicated that commercial sex represents a much more significant problem, with 21% of all new HIV infections within this population .Contradictory results have also been reported in Uganda, where David Wilson of the World Bank has argued that 65% of all new infections occur among married couples, thus justifying an allocation of resources which is more generalized . HoweverA third possible explanation why resources are not better focused on key interventions is that HIV and AIDS is viewed as a disease requiring a multisectoral response. An example of this argument is contained in the statement below, from the Tanzanian National Strategic Plan (NSP) (2003-2007)."All major elements of the National Response have to be in place if the response is likely to achieve its desired impact. The NMSF does not attempt to prioritize among those objectives or strategies. It insists on the comprehensiveness of the response, knowing that due to preferences, experiences, resources available, etc. priorities will have to be established in distinct areas once Operational Plans and Activities are developed. It is one of the most important tasks of TACAIDS as the main guardian of the National Response to ensure that all areas are covered and balances between the areas are maintained or (re-) established" [blished" .This perspective has merit for a number of reasons. It has been shown that a multisectoral response not only generates more resources, but also takes advantage of synergies which can exist when people are approached with HIV and AIDS messages from varying sources  . An apprThis argument, however, must be balanced against the temptation to scatter resources across all interventions, with little or no priority given to those interventions likely to produce the greatest possible impact. As illustrated by the 1998 UNAIDS Strategic Planning Guidelines, countries should avoid the temptation of using a multisectoral process as an excuse to avoid prioritization."The complexities of HIV sometimes have led governments to attempt planning for all eventualities. Moreover, donors and other external agencies have frequently added their own agendas to already unwieldy plans that cover many areas, resulting in generally low implementation rates, poor performance, and overburdening of scarce national staff. A more strategic approach concentrates on planning in priority areas, through identifying the epidemic's most important determinants" [minants" .Another explanation for why countries don't allocate resources using an evidence-based approach is that countries lack the political will or support to address particular risk groups  . In manyFigure The argument about spending resources on the general population rather than already stigmatized groups does have some merit. By focusing attention on MSM, for example, as a primary target population in Latin America, there is a possible risk that MSM would become further stigmatized and blamed for spreading the epidemic. However, a country's national strategic goals are unlikely to be achieved if a predominance of resources is being spent on interventions that focus on relatively low-risk populations, rather than on those subpopulations where the epidemic is actually spreading.Another possible explanation for why resources are not achieving the expected outputs is that the money is spent on interventions that are delivered inefficiently . Thus, aIn a number of cases, a poor allocation of resources occurs as a result of poor planning. As has already been noted, countries such as Tanzania have avoided explicitly prioritizing interventions in their strategic plan, and have instead passed this responsibility on to their AIDS program . Other cIt is also not uncommon to find NSPs which prioritize certain interventions or populations, but then allocates the largest share of funds to interventions which are not prioritized. In Kenya, for example, the Ministry of Health's 1999-2004 HIV/AIDS Strategic Plan indicated that the largest part of the budget should be for the procurement and distribution of STD drugs, even though the plan itself did not emphasize STD drug procurement as a priority in the plan .Another possible reason why resources may not be allocated to produce the greatest possible impact is that the country itself cannot control how resources are being spent. For example, some international donors such as PEPFAR have their own agenda to fulfill in regards to allocating resources. In this case, recipient countries are likely to be hesitant to turn down resources, even if those resources will skew the national response towards interventions which planners don't believe will be successful.In conclusion, there are various reasons why countries may not pursue an "evidence-based allocation strategy". The most common reasons include a lack of data, contradictory results from research, the perceived need for a broad, multisectoral response, various political factors and inefficiency. Each of these reasons has some validity, yet the overall result is that resources are being spent in a way that does not maximize the impact of resources being spent. The next section, therefore, addresses how some countries have used evidence-based tools to better allocate available resources.As described previously, there are various reasons why resources are not spent more strategically or based on the growing evidence about how best to allocate resources. The following section will review some of the experiences of countries that have tried to improve their resource-allocation strategy.While determining resource requirements may be an ongoing process for most countries, the challenge of estimating resource needs becomes most acute when a country is either designing a new  HIV and AIDS strategic plan or developing a request for resources from donors .Unfortunately, the costing of a strategic plan or a Global Fund proposal is usually conducted after all decisions about strategies and priorities have already been made. Thus, the costing usually entails putting a monetary figure on decisions that have already been made, with little or no discussion about how different strategies or priorities may or may not be feasible given the available resources.The Resource Needs Model (RNM) has been widely used to encourage countries to develop costed plans which are evidence-based . The preWithout careful consideration of feasibility, a strategic plan can quickly become a "wish list". An example of this is Zambia's Round 5 Global Fund application. In 2005, Zambia unsuccessfully requested US$1 billion over 5 years from the Global Fund. As it turned out, the 26 countries which did receive immediate approval for their Global Fund applications had requested a cumulative total of $977 million over 5 years. In other words, Zambia had requested funds greater than the combined amount requested by the 26 countries with successful applications. While Zambia is a country that is severely affected by HIV and AIDS, their "wish list" approach to costing its Global Fund proposal concluded with a failure of the country to obtain any HIV and AIDS funds in Round 5.In the case of South Africa's 2007-2011 NSP, the estimated resource requirements from domestic and international sources were calculated to be R45 billion (approximately US$4.6 billion) . While tHowever, the resources required are calculated to rise from R4.7 billion in 2007 to R11.3 billion in 2011. South Africa's NSP calls for a 36% increase in spending in 2008 and a 140% increase in spending overall between 2007 and 2011. Thus, South Africa will need to continue to make a substantial increase in its effort to generate new resources and meet the resource generation targets that the plan defines. Is South Africa's NSP a "wish list" or a 'feasible plan"? Only time will tell.When most strategic plans are costed, there is little or no effort to assess what would happen if the levels of resources do not become available. A costed strategic plan should ideally consider alternative scenarios, aligning the priorities to assumptions about various levels of funding actually becoming available. A country, for example, might cost its strategic plan at $2 billion over 5 years, but then quickly realize that the level of funding for the program is unlikely to exceed $1 billion. Should the country cut all of its targets in half? Are there ways to reallocate funds to ensure that the targets can still be achieved despite the limited funds? Which budgetary items are the most critical and therefore should be fully funded, as opposed to those items which are important but not critical?The Goals model is a key tool in HIV-related strategic planning, evaluation and proposal development. The Goals model is a resource-allocation tool that has been used to answer the following types of questions:• What resources are required to expand coverage of prevention, care, treatment and mitigation services to all who need them?• What goals can be achieved with the available resources?• How can resources be allocated most efficiently to provide the greatest benefit?• What is the gap between resources required and those available?• What will be the impact of cuts in current levels of funding?The Goals model allows users to test alternative patterns of resource allocation and observe how these decisions are likely to affect the overall achievement of specific targets. For example, countries can assess if spending more money on interventions with sex workers is likely to have a greater or lesser impact on the prevalence and incidence of HIV than interventions focused on youth.One challenge with the Goals model, as with all models, is that they can only be effectively used in policymaking with up to date and accurate input data. This is particularly important because it has been observed that the HIV epidemic rapidly evolves. As shown in Figure Thus, if a country is responding to their epidemic using outdated epidemiological information, they are likely to find that their resource-allocation strategy is highly ineffective. Old data from Brazil, for example, would suggest that interventions should be focused on IDU, while more recent data would indicate that more resources should be spent on MSM.While later sections will focus largely on the experience of countries in using the Goals model, it is worth noting that other resource-allocation models exist and have been applied. These include the ABCE model, an optimization model which focuses on identifying the most cost-effective prevention interventions . ABCE waThe S4HARA model was developed for the purpose of expanding resource-allocation decisions beyond factors of efficiency, but also tries to take into consideration non-quantifiable factors such as equity . This moThe Goals model has been used to improve the resource-allocation process in seventeen countries since 2002, including eight of the fifteen PEPFAR countries. Of the seventeen countries where the Goals model has been used, twelve are in Africa, three are in Asia and two are in Latin America: Uganda, Lesotho, Kenya, South Africa, Ghana, Ethiopia, Namibia, Zambia, Mozambique, Rwanda, Malawi, Mali, Honduras, Mexico, China, Cambodia, Ukraine. All seventeen applications were conducted between 2002 and 2008, with two countries (Ethiopia and Kenya) utilizing the model twice.The following section provides information on resource-allocation exercises conducted in eight countries between 2002 and 2008 . These eight country examples were selected and discussed in this report because of their geographic diversity, as well as the illustrative "lessons learned" from these examples. The purpose of this review is to focus on the key experiences from countries which have tried to better allocate their HIV and AIDS resources.In 2000, the government of Lesotho completed its 2001-2003 NSP, which was estimated to cost a total of US$1 billion, or US$333 million per year . While LBy using the Goals model, the costing of the NSP was revised . WorkingA new priority setting team was then developed and assigned responsibility for ensuring that the budget was consistent with the NSP. The team identified interventions that could achieve their goals at a much lower cost. For example, the priority setting team noted that the budget for community mobilization was excessive and they were able to propose changes which would make this intervention much less costly. By identifying those items which were most critical for Lesotho's national response, it was possible to develop a new budget of approximately US$40 million per year, or 12% of the original costing.This new costed plan may have appeared to be less ambitious, but in reality it still represented a 4-fold increase in spending. As a result, Lesotho was able to use this information to successfully apply for additional donor funding. In 2003 Lesotho requested and received US$29 million in additional HIV and AIDS funds from the Global Fund. In 2006, Lesotho received approval for an additional $40 million of HIV and AIDS funds and in 2008 Lesotho successfully requested another US$33 million.The key lesson learned from this resource-allocation exercise appears to be that developing more realistic, yet still ambitious, budgets is likely to produce more funds than developing a "wish list" approach to resource allocation. The Goals model was successful in getting policymakers from Lesotho to recognize that HIV and AIDS spending remains limited, and therefore a more prioritized resource-allocation strategy was required. As a result, Lesotho was successful both in prioritizing and generating new resources.The Goals model was used in Kenya both in 2002 and in 2004 ,42. The The modeling exercise revealed that Kenya's HIV and AIDS response was succeeding at reducing HIV prevalence, but that the reductions were probably not going to reach the expected 20%-30% target by 2005. The modeling exercise did reveal that the target was still feasible if the country was able to both reallocate existing resources and obtain new funds. The allocation exercise indicated that interventions with sex workers, STI treatment, workplace interventions and voluntary counseling and testing were particularly cost-effective. Conversely, there was much less evidence that interventions such as community mobilization, outreach to out-of-school youth and mass media would have much of an impact in reaching Kenya's targets.In terms of the country's treatment goals, the modeling exercise related the country's treatment target for 2005  to the resources required (estimated to be between US$64 and US$76 million). By calculating more carefully the resource requirements, Kenyan policymakers were better prepared to assess their resource needs and to successfully seek out these resources.The result of this exercise was that the country was able to submit a successful Global Fund application which defined why additional resources were required both for prevention and treatment. Using data from the Goals model, the application was also able to more accurately define what could be achieved with the resources requested. A total of $107 million was approved in 2003 for Kenya from the Global Fund.The resource-allocation exercise was less successful at getting the country to reallocate its HIV and AIDS funds. In many ways, the country viewed the exercise as important for obtaining additional funds, but less important in terms of developing priorities and ensuring that those priorities were actually achieved. Furthermore, as new PEPFAR funds became available, Kenya appeared to be less concerned about issues of sustainability.In 2004, the National AIDS Control Council began preparation of its new strategic plan for 2005-2010. A team working on resource allocation applied the Goals model to estimate the resources that would be required to fully scale up prevention and treatment programs, and the impact that could be expected if full scale-up were achieved. Significant effort was put into collecting up-to-date unit costs for prevention and treatment programs implemented by the Government of Kenya and by other implementing organizations. The resulting goals formed part of the vision statement for the plan. The resources required exceeded the expected availability of funds and formed the basis for a renewed effort at resource mobilization.The Goals model application in South Africa was conducted in 2003, half-way through the country's 2000-2005 NSP . The modThe analysis did find a number of areas where additional funds should be spent, including interventions with sex workers, MSM and IDU. The analysis also showed that funding for condoms was insufficient, and that the government should allocate additional resources to distribute additional condoms. The Goals model was also used to estimate the cost of a national PMTCT program; confirming previous cost estimates for this intervention. Finally, the Goals model confirmed that the general provision of ART would be affordable for the government.There were numerous positive outcomes based on these observations. For example, the government prioritized and allocated additional funds for sex-worker interventions, condom distribution, PMTCT programs and general ARV access. However, while the government agreed to research the needs of MSM and IDU in South Africa, they did not agree to additional funding to reach these populations. In other words, despite some evidence to the contrary, South Africa remained unwilling to address existing political barriers which limited their ability to work with sensitive subpopulations such as MSM.In the 2004 Goals model application, an assessment of the country's NSP (2003-2007) was performed; the model was used to assess the impact of a potential decision by the Global Fund to discontinue funding the Honduran HIV and AIDS program . This apThe NSP indicated that Honduras required US$25 million over the 5-year life of the plan . There wAn analysis of the resources required to fully cover all HIV and AIDS services and reach all vulnerable subpopulations indicated that US$285 million would be required over the 5 years of the plan. This full-coverage scenario was deemed unlikely to be feasible.A third scenario was developed which would require that the Global Fund continue their funding of the Honduras program. In this scenario, Honduras would have access to US$58 million over 5 years. This scenario was estimated to result in a 14% reduction in HIV prevalence and a 51% reduction in HIV incidence. The expected number of HIV infections averted was 22,000, at a cost of US$1,100 per infection averted.The analysis was effective at demonstrating to the Global Fund that their contribution to the HIV and AIDS response was critical and was likely to have significant benefits, especially in terms of infections averted. As a result of the analysis, along with various commitments from the government of Honduras, the Global Fund decided to continue funding of the Honduran HIV and AIDS program.A Goals modeling exercise was conducted in Namibia, a year after the start of their NSP (2004-2009) ,49. WhenThe exercise in Namibia was designed to: 1) assess if the NSP had accurately been costed and 2) to evaluate how additional resources might be allocated to achieve the greatest possible impact.The modeling indicated that a more realistic costing of the country's NSP would require approximately $175 million to reach the desired coverage of services. It was determined that, relative to a scenario of constant funding from 2005 to 2009, HIV incidence would be reduced from 2.26% to 1.63%. The additional funding would result in more than 16,000 HIV infections averted. The proposed funding would further decrease HIV prevalence by a small amount (from 19.3% to 18.6%). The model calculated that ART coverage could be increased from 21% to 58%.The exercise in Namibia confirmed what the government already suspected, which was that the NSP had been significantly undercosted. While the government of Namibia recognized that the Goals model could help to improve their costing, they did not choose to revise the costing of the NSP.Namibia is currently beginning to develop a new NSP, and have indicated a desire to conduct a new Goals model application which will improve the country's ability to devise more tenable cost estimates. Policymakers also hope that more realistic cost estimates will assist the country in generating new resources for its NSP and achieve universal access for prevention and treatment services.In 2005, Zambia requested support in learning about and utilizing the Goals model . As prevZambia at the time of the Goals application was completing its HIV and AIDS strategic plan for 2002 to 2005 . It was Three scenarios were developed for the Zambian government. In the first, universal access would be achieved by 2009 for ARVs, PMTCT and blood screening, but there would be no additional spending on prevention programs. This first scenario would require that Zambia increase its annual HIV and AIDS expenditures from US$100 million per year in 2004 to US$260 million per year by 2009. Of this amount, the largest expenditures, by far, would be on the provision of ART (estimated to cost US$190 million by 2009). This treatment-intensive scenario would result in HIV prevalence rising, from the projected prevalence of 13.3% in 2009 to 15.4%. HIV prevalence rises as ART scale-up occurs due to the increased life expectancy of those on treatment. However, this rise in prevalence can in part be counteracted with a corresponding increase in prevention scale-up.The second scenario assumed universal access would be achieved for all prevention, care, treatment and mitigation interventions by 2009. This full-coverage scenario resulted in only a slight increase in HIV prevalence (13.7% in 2009). However, this second scenario was estimated to cost much more than the first scenario (US$442 million in 2009).The third scenario assumed that the targets for the first scenario would be achieved, but an additional US$30 million would be made available for Orphans and Vulnerable Children (OVC) interventions and the most cost-effective HIV prevention interventions. This third scenario was projected to result in Zambia spending a total of US$290 million in 2009, with prevalence rising to 14.2%.A review of these three scenarios indicates a number of important observations regarding the allocation of HIV/AIDS resources in Zambia. Scenario 1 provides some indication regarding the cost of providing full coverage for the 3 identified services. While this scenario was likely to represent a significant achievement, it also suggests a concern because of rising levels of HIV prevalence. While Scenario 2 was likely to produce the best possible results, it remained unclear if this level of increased funding was likely to become available. Finally, Scenario 3 suggested that an allocation of resources which balances prevention, care and treatment - and invests in those interventions that are likely to have the largest impact - will probably produce extremely impressive results, without requiring the very high costs required of Scenario 2.While Zambia did not adopt all the conclusions from the Goals report, Zambia's national strategic plan did indicate that US$255 million would be required in 2009, an amount very similar to that calculated in Scenario 1. Furthermore, the strategic plan noted that the "Availability of ART will decrease the mortality rate and, therefore, in the short to medium term prevalence could in fact increase as ART becomes more readily available." A similar conclusion was made from the Goals model exercise, with all three scenarios resulting in a projected increase in the prevalence of HIV.The Goals model in Ethiopia was first applied in 2006, sixteen months after the country had launched its 2004-2008 NSP ,53. The The country's 2004-2008 NSP indicated that approximately US$170 million per year is required to achieve the desired targets. This would represent an increase of more than 50% from the estimated 2005 level of resources. However, the Goals model calculations suggest that this increase in funding would still not be sufficient to achieve universal access.The Goals model exercise in Ethiopia indicated that universal access  could be achieved in 2010 with an 8-fold increase in spending, reaching US$1 billion per year by 2010. However, a review of the country's capacity constraints, as well as access to donor resources, suggested that this type of rapid growth was unlikely to be achieved in such a short period of time.Another scenario reviewed involved prioritizing interventions in the costed strategic plan (to achieve greater coverage in certain areas) and also striving for higher levels of funds. In this scenario, Ethiopia would need to generate US$300 million in 2010, triple the level of 2005 funding but less than a third of the resources required for full coverage. The result would be to decrease prevalence (from 5.3% to 5.1%) and incidence (0.78% to 0.60%) and provide ART coverage to 230,000 people infected with HIV. Of all the scenarios, this seemed to be the one which created the best combination of feasibility and ambition.It should be noted that Ethiopia's first Goals model application utilized the epidemiological data and prevalence trends that were available in March 2006. The Goals model concluded that, without additional behavior change, prevalence would rise from 4.7% in 2005 to 6.5% in 2010. However, when the 2005 Demographic and Health Survey (DHS) and Antenatal Surveillance (ANC) data became available later in 2006, it revealed that prevalence among 15-49 year olds was between 1.4% (DHS) and 3.5% (ANC), both of which were well below the estimates used in the Goals report. Following an extensive analysis of the DHS and the ANC data, Ethiopia agreed on a single point estimate of 2.1%, less than half of the prevalence calculated when the first Goals application was performed. Thus, in 2009, the calculations are being revised and will be used as an input into Ethiopia's next NSP.There are a number of important lessons learned from this exercise. First, it appears that the 2004-2008 NSP was not ambitious enough, despite a projected 50% increase in the calculation of resources needed. On the other hand, the resources needed to ensure universal access of services in Ethiopia ($1 billion in 2010) were determined to be infeasible, given capacity constraints and an unrealistically rapid growth in donor funding. Thus, by conducting a Goals modeling exercise, it was possible to develop a scenario that would achieve ambitious levels of coverage while still targeting resource levels that were likely to be achievable.Another lesson learned from the Ethiopia exercise involved the importance of having accurate epidemiological data. As noted above, the Goals model was conducted at a time when it was determined, based on ANC data, that HIV prevalence was nearly 5%. Subsequent data obtained from the country's 2005 DHS and ANC data suggest that prevalence was actually closer to 2%. This will clearly have implications on the resource estimates for achieving universal  access.In 2006, the Uganda AIDS Commission (UAC) began to prepare its new HIV/AIDS Strategic Plan for the years 2007/8 - 2011/12 . The worThe team used the Goals model to estimate the future funding required to scale up coverage of all key prevention, treatment and mitigation interventions to reach full coverage by the end of the plan . They esThe resource-allocation team used the Goals model to estimate the impact of different allocation scenarios. Impact was measured by several indicators, including two for prevention , two for treatment (ART coverage and the number of AIDS deaths) and one for mitigation (coverage of support services for orphans and vulnerable children). Several different allocation schemes were analyzed, including:• Prevention first: fully fund all prevention programs, allocate the remaining funds to treatment and mitigation• Cost-effective prevention first: fully fund the most cost-effective prevention interventions, keep other prevention constant, allocate the remaining funds to treatment and mitigation• Treatment first: achieve universal access to treatment, allocate the remaining funds to prevention and mitigation• Mitigation first: increase funding for OVC programs by 6-fold, allocate the remaining funds to prevention and treatment.Allocation scenarios that prioritized prevention prevented many new infections but did not have as much impact on reducing deaths or mitigating the effects on children. Allocating funding to treatment averted the most deaths and achieved high ART coverage but did not prevent as many new infections.This information was presented in meetings with the UAC, civil society, donors, government departments, and parliamentary committees. At these meetings, participants discussed the benefits of each allocation strategy and voiced their opinions about priorities for the new plan. This had happened before but what was different this time was that these discussions were informed by information on the impact of their decisions on key indicators of impact. After much discussion, it was decided to give top priority to fully funding the most cost-effective prevention strategies.Ukraine has the most severe epidemic in all of Europe, with a prevalence estimated to be 1.63% . EstimatUkraine is preparing for their next HIV and AIDS strategic plan, which will run from 2009 to 2013. As part of that preparation, a team applied the Goals model to evaluate a number of different scenarios. These scenarios include:1. Constant expenditures: Funding remains constant from 2008 to 2013.2. Universal access: Funding increases to achieve universal access.3. Prevention focus: Universal access is achieved for prevention; treatment spending increases by 50%.4. Treatment focus: Universal access is achieved for treatment; prevention spending increases 50%.5. Limited funding: Budget based on the commitment of the Ministry of Finance and the Global Fund.Each of these five scenarios was evaluated in terms of cost, impact on incidence and prevalence, and levels of coverage for care and treatment services. The results are shown in Table The result of the exercise was to provide Ukrainian policymakers with different scenarios which relate resources to the achievement of different targets. While the Ministry of Finance had originally proposed that the country pursue Scenario 5, there was a recognition following the exercise that the level of funding was insufficient to achieve the country's goals. As a result, the Ukrainian Ministry of Finance agreed to higher levels of government funding. In addition, the Ukrainian Ministry of Health agreed to conduct further negotiations with ARV manufacturers, with the intent of lowering the price of ARVs in the country.This final section discusses the possible future of resource allocation in the field of HIV and AIDS, including improvements in existing resource-allocation tools, the improved willingness of countries to link priorities and resources, the barriers that lie ahead for improving the resource-allocation process, and some key actions that could be pursued in the next few years to overcome those barriers.There are various ways in which countries can be encouraged to think beyond their current paradigm regarding HIV and AIDS resource allocation. Perhaps the first step in allocating resources effectively is to ensure that policymakers truly understand their own epidemic. In other words, it is critical to assess not only where HIV infections have occurred , but also to understand where the next infections are likely to occur. Countries need to move beyond the oversimplified conclusion that "everyone is at risk", and instead truly understand whether certain subpopulations are at greater risk than others. UNAIDS has been supporting a series of regional activities known as "Know Your Epidemic, Know Your Response" in which country teams assemble information on the status of the epidemic and their national program. The Modes of Transmission model is applied to estimate the sources of new infection. The results from this modeling are compared to the current allocation of efforts to determine how the response might be improved.Next, countries need to have a clear grasp on the costs of different interventions. In the earlier years of the epidemic, it may have been acceptable that countries lacked information about a reasonable range of unit costs for a set of prevention and treatment interventions. However, at this stage of the epidemic, it is totally unacceptable that countries cannot provide even a reasonable range of unit costs for particular interventions. Where unit cost data are not available, it should be a high priority to collect such information. Most organizations implementing interventions know their own costs, since they need to prepare budgets to request support from funding agencies. This information needs to be compiled systematically and used to estimate resource requirements. This is important not only for the purpose of allocating resources, but also for identifying potential inefficiencies in scaled-up programs.A key way to improve their resource-allocation process is to integrate resource allocation into each country's entire planning process. Most countries assess their resource needs as a final step in the planning process, rather than throughout the overall planning process. This is not to suggest that the planning process should be limited by some arbitrary financial limits. However, countries should be encouraged to consider throughout the planning process a set of different scenarios based on assumptions about what level of resources may be realistically available.Finally, countries should design their own plan for financial sustainability. This is important because most countries today plan no further than their next budget cycle, paying very little attention to how the priorities of donors and governments might shift in the future. This is particularly critical for countries which rely heavily on a small number of donors . All plans should include contingencies to cover worst-case scenarios, which is particularly important given the current global financial crisis. What happens if PEPFAR funding is reduced or "flat-lined"? What happens if a country doesn't win any further Global Fund applications? What if the priorities of a country shift away from HIV and AIDS?The future of evidence-based planning will ultimately require that existing tools that are used to address issues of resource allocation are greatly improved and that new tools are developed. A critical first step in improving resource-allocation tools involves improving knowledge about the costs and cost-effectiveness of interventions. Existing tools rely on an incomplete database of cost and cost-effectiveness studies. Little is known, for example, about the cost-effectiveness of community outreach interventions or interventions designed to reach MSM. A concerted global effort should be made to expand the current literature on the cost and cost-effectiveness of HIV and AIDS interventions, with an emphasis on providing data that can specifically be used by policymakers as they allocate resources.It is also imperative that resource-allocation tools reflect current knowledge about new interventions. For example, the Goals model has recently been updated to reflect new data regarding the effectiveness of male circumcision. As future interventions become available , resource-allocation tools need to remain current with these new interventions.Next, the way in which treatment and prevention are linked remains poorly understood. For example, little is known about the extent to which increased access to treatment will affect the future incidence of HIV. It is inevitable that as access to ART increases, the prevalence of HIV will similarly rise. However, it is much less clear how this will affect new HIV infections ,58. FurtResource-allocation models also need to better take into consideration synergies between interventions. Mathematically, synergies are difficult to adequately model, but the accuracy of future projections depends critically upon the way that these models work. Experience shows that spending large sums of money on only one intervention is unlikely to be successful. The success of STI treatment, for example, depends critically on the effectiveness of condom distribution programs. The uptake of VCT is likely to be strongly affected by efforts to limit stigma and discrimination, and by treatment availability . IncreasThere also remain areas where significant additional research needs to be conducted. For example, little is known about the resource-allocation strategies of countries which have been able to successfully address the HIV and AIDS epidemic. Up until recently, the lack of such research was understandable, given the paucity of data about the way resources are spent and the very limited information about the historical prevalence trends in various countries. However, at this point in time, there is an increasing level of data about both spending and prevalence trends. This information should be rigorously analyzed so that countries are better able to make resource-allocation decisions.This paper was designed to challenge national policymakers to consider how resource allocation is being conducted, and to reevaluate how it might be pursued better in the future. As seen from numerous countries, there are few outstanding examples of countries which have carefully assessed their resources allocation strategy and acted in a way which could be considered "evidence-based". Furthermore, few countries have incorporated into their own strategic planning process an assessment of financial sustainability. Given the current global financial crisis, countries cannot afford to ignore the issues of accountability and sustainability .How can these problems be addressed? A review of current efforts to understand and improve the resource-allocation process indicates both successes and failures. Countries have seen resource-allocation modeling as merely another tool imposed upon them by international donors, rather than an essential process that should be integrated into the country's planning process. Few if any countries have taken the opportunity to conduct resource-allocation modeling so that they can actually shift resources from low priority interventions to those which are a higher priority.However, countries such as Lesotho, Kenya and Honduras have used resource-allocation modeling as a way to demonstrate to donors the potential benefits of investing in the country's HIV and AIDS response. Countries such as South Africa and Ukraine have used resource-allocation modeling as a way to increase domestic commitment and to generate new resources. Namibia has used resource-allocation modeling to confirm that their NSP was severely undercosted. Uganda used modeling to provide the information for a vigorous debate among stakeholders about priorities for allocating scarce resources.For the national resource-allocation process to be improved over the long term, both countries and the global community must move forward. Research must be performed on costing and cost-effectiveness. Much more is needed in terms of understanding how resource allocation has helped countries to develop an effective response, while also understanding how poor resource-allocation decisions have limited the impact of available resources.The authors declare that they have no competing interests.SF was responsible for the overall writing of this paper with review and additional input provided by Lori Bollinger and JS. The description of the resource allocation models was written largely by LB and JS. The country-specific Goals applications were conducted by a combination of the three authors.ABCE: (Allocating by Cost-Effectiveness Model); AIDS: (Acquired Immune Deficiency Syndrome); ANC: ; BCC: (Behavior Change Communication); DHS: ; ART: ; HIV: (Human Immunodeficiency Virus); IDU: (Injecting Drug Users); PMTCT: (Prevention of Mother to Child Transmission); MAP: (Multi-Country HIV/AIDS Program); MARPs (Most At-Risk Populations); MSM: (Men Who Have Sex with Men); NASA: ; NMSF: ; NSP: ; OVC: (Orphans and Vulnerable Children); PEPFAR: (President's Emergency Plan for AIDS Relief); PMTCT: (Prevention of Mother to Child Transmission); RNM: (Resource Needs Model); STI: ; TACAIDS: (Tanzania Commission for AIDS); UNAIDS: (United Nations Joint Programme on HIV/AIDS); UNGASS: ; VCT: (Voluntary Counseling and Testing).


As HIV-related deaths increase in a population the usual association between low socioeconomic status and child mortality may change, particularly as death rates from other causes decline.As part of a demographic surveillance system in northern Malawi in 2002-6, covering a population of 32,000, information was collected on socio-economic status of the households. Deaths were classified as HIV/AIDS-related or not by verbal autopsy. Poisson regression models were used to assess the association of socio-economic indicators with all-cause mortality, AIDS-mortality and non-AIDS mortality among children. There were 195 deaths in infants, 109 in children aged 1–4 years, and 38 in children aged 5–15. All-cause child mortality in infants and 1–4 year olds was similar in households with higher and lower socio-economic status. In infants 13% of deaths were attributed to AIDS, and there were no clear trends with socio-economic status for AIDS or non-AIDS causes. For 1–4 year olds 27% of deaths were attributed to AIDS. AIDS mortality was higher among those with better built houses, and lowest in those with income from farming and fishing, whereas non-AIDS mortality was higher in those with worse built houses, lowest in those with income from employment, and decreased with increasing household assets.In this population, since HIV infection among adults was initially more common among the less poor, childhood mortality patterns have changed. The usual gap in survival between the poor and the less poor has been lost, but because the less poor have been disproportionately affected by HIV, rather than because of relative improvement in the survival of the poorest. Associations between socioeconomic status and mortality have long been recognised. Among rich and poor populations even fine gradations in relative poverty have been associated with differences in survival.The HIV epidemic has produced some parallels with this historical situation. In many populations HIV initially affected the better off, more educated and more mobile sectors of the community.In populations with high HIV prevalence, HIV is the predominant cause of death in young adults, and an important cause in young children–directly, through vertical transmission, and indirectly, through orphanhood and parental illness.In a rural area of northern Malawi we have documented mortality patterns through a demographic surveillance system over the period leading up to the wide-spread use of antiretrovirals. HIV infection was first recorded in this area in 1982.In the adult population in this area, in the early stages of the HIV epidemic in 1988–90, HIV infection was more common among non-farmers, those with higher education and among people born outside the district.We have already shown that just before the introduction of antiretrovirals, two thirds of deaths in those aged 15–59 were attributable to AIDS.Ethics statement: The work was approved by the Health Sciences Research Committee, Malawi and by the ethics committee of the London School of Hygiene and Tropical Medicine, UK. The methods of the demographic surveillance system have been described in detail elsewhere.After an initial house-to-house census, a continuous registration system was set up in a population of around 32,000. Trained community members (“village informants”) recorded births, deaths and migrations against pre-printed lists for their area. Each informant covered 15–60 households. Births and deaths were followed up monthly, and migrations annually, by project staff. A re-census after two years showed that the routine system had registered 97% of births, 99% of deaths, and 92% of migrations.Verbal autopsy interviews were conducted in the local language by a medical assistant or health worker with the mother or most immediate caregiver. Verbal informed consent was obtained before the interview. The verbal autopsies were similar to the INDEPTH tool,Socio-economic data were collected at the household level during the baseline census and at the registration visit for in-migrating, newly-formed, or moved households. Several measures of socio-economic status were used: education level of the mother and father; main source of income of the household; household possessions; and dwelling construction. Parental education status was only known if the parent was included in the baseline census or registration visit, and so was missing for parents who had died before this time, and for those who were not normally resident in the demographic surveillance area.Previous field work and a pilot census had shown that there was little formal employment and that for their livelihood households commonly relied on a variety of different income-generating activities in addition to subsistence agriculture. Specific income-generating activities were initially collected as free-text descriptions during the pilot census and then classified into 11 categories: sale of own agricultural produce, sale of own fish, regular employment, small scale trading, piecework, manufacturing, preparation and sale of snacks or drinks , letting of houses or land, providing a service , gathering natural products . Households were asked to name all income generating activities they had engaged in over the last 12 months and then to rank the listed activities by importance. For the analysis, the main source of household income was grouped into 6 categories .A standard inventory of household possessions appropriate to the setting  was converted into an approximate monetary value. To avoid over-estimating the wealth of households with many cattle, the asset category was calculated first without the cattle, and then increased by a maximum of one or two categories according to the number of cattle owned.Dwelling construction was classified according to the materials used to make the roof, walls and floor. The “best” houses had concrete floors, iron sheet or tile roofs, and burnt brick or concrete walls. The “worst” had mud floors, no iron sheet or tiles on the roof, and walls of unburnt brick, mud, or other materials.All analyses were carried out in Stata 10.0 . Observation time for each child was defined from the time they were first seen in the baseline census, from birth (if the mother was a member of a household in the observation area at the time of birth) or from the time of migration into the area after the baseline census. Observation time ended at the time of death (if the child was still a member in a household in the area at the time of death) or at the time of migration out of the surveillance area. Multiple episodes of observation and gaps were allowed if children moved out of the surveillance area and later returned.For the estimation of AIDS mortality, the failure event was death from AIDS, while deaths from all other causes (known or unknown) were censored. For the estimation of mortality from other causes , the failure event was death from causes other than AIDS, and deaths from AIDS and from unknown causes were censored.The age groups <1, 1–4 and 5–14 years were analysed separately as mortality rates are dramatically different in these age groups. The reliability of verbal autopsy and the relative contribution of HIV to mortality are also likely to vary.a priori confounders. The overall strength of association for each variable was assessed using the likelihood ratio test, comparing the model with and without the variable of interest. Formal tests for trend across categories were conducted where appropriate. Analyses were repeated using Cox models, to allow for changing rates by age, and using robust standard errors to allow for non-independence of data from children with the same mother. The results were almost identical; only the Poisson regression results are presented.Poisson regression models were used to assess the association of mortality with background characteristics. Age, sex and area of residence were considered as Between August 2002 and the end of February 2006, a total of 20,389 children under 15 years were observed in the study population, of whom 10,415 were under 5 years and 5,237 were under 1 year. There were 195 deaths in infants (<1 year), 109 in those aged 1–4 years, and 38 in those aged 5–14 years.In p = 0.02), and this pattern persisted in those thought to have died from non-AIDS causes (p = 0.06). There were no strong or statistically significant associations with any of the other measures of socio-economic status.Among the infants, 22 deaths were attributed to AIDS, 167 to non-AIDS and 6 to unknown causes. The mother was known to be HIV positive by the time of birth in 7/22 AIDS deaths and 13/167 non-AIDS deaths. Mortality rates were higher in those whose fathers had 5–8 years primary education than in those with more or less . Of the 28 AIDS deaths, 9 had a mother who was known to be HIV positive at the time of death, though only 4 were known to have been positive at the time of birth. Five of 76 children dying of non-AIDS causes had HIV positive mothers.p = 1.0), mortality rates from AIDS were higher among those from the better built houses (p = 0.0004), and mortality rates from other causes were higher among those living in houses with inferior construction (p = 0.03). Overall mortality was similar in households with different main sources of income, but AIDS mortality was lowest in those with income from farming and fishing, and highest in those with income from employment and “other” sources, and non-AIDS mortality was lowest in those with income from employment. “Other income sources” included activities such as providing services , producing and selling snacks or beer and relying on support from outside relatives. Among the 1–4 year olds who died, 18% of AIDS deaths and 75% of non-AIDS deaths were in those with the main family income from farming.There was a “U-shaped” pattern of all-cause mortality associated with parental education, with the lowest levels in those with mothers or fathers with 5–8 years primary education . When diWe have shown a marked shift from the usually observed pattern of socio-economic determinants of child mortality, in a population with high HIV prevalence and declining background levels of child mortality. In Karonga District in the 1990s we observed lower under-5 mortality in those whose fathers were traders or salaried workers compared to subsistence farmers or casual labourers, and lower mortality in those whose mothers had higher levels of education Under-5 mortality in this population was 85 per 1000 births, lower than the national average estimate from the 2004 DHS (133 per 1000),The comparative analysis of risk factors for AIDS- and non-AIDS mortality revealed that the absent or weak associations of socio-economic factors with child mortality from all causes were explained by the differential distribution of AIDS and non-AIDS deaths in the population. Almost all AIDS deaths in children in this population are likely to have been caused by transmission of HIV from mother to child and the distribution of paediatric AIDS deaths is therefore likely to mirror the distribution of HIV infection in women of reproductive age. It is possible that women of higher socio-economic status are more likely to be HIV tested, and knowledge of the mother's HIV status may have influenced classification of the death, but only about one third of the AIDS deaths in those under 5 years were in those whose mothers were known to be HIV-infected.In contrast to the 2004 Malawi DHS, in which children of mothers with secondary school education had approximately 40% lower infant mortality and 60% lower under 5 mortality,p = 0.03). Separation into AIDS and non-AIDS mortality showed a clearer pattern, with high AIDS mortality in those with higher scoring dwellings, and high non-AIDS mortality in those with lower scoring dwellings and few assets.Measurement of economic status at the household level in this study included ownership of household assets and dwelling construction, adapted to the local setting. Such indicators have shown close association with school enrolment and moderate correspondence with the traditional wealth indicators of household expenditure in India, Indonesia, Pakistan and Nepal,For 1–4 year olds the pattern of deaths by household income source reflects the distribution of HIV in the population, with AIDS deaths dominating in households with employment, and non-AIDS deaths among those relying on subsistence farming. Higher HIV prevalence in wealthier adults  has been shown in DHS+ surveys from 8 countries in sub Saharan Africa, including in Malawi. There are no clear patterns for association with the household level measures for infants either overall or when divided into AIDS and non-AIDS mortality. This may reflect the greater difficulty of accurate assignment of cause of death as AIDS or non-AIDS in this age group. The sensitivity and specificity of verbal autopsy for the classification of infant and child AIDS deaths are poor,There was evidence that registration of births and deaths was near complete, from the re-census, from scheduled follow-ups of births after 1 year and from the distribution of ages at death. This makes it unlikely that child deaths were selectively missed (e.g. from poorer households and in remote areas). Parental and household characteristics were obtained by linking to other individuals in the study population. 95% of the mothers and 85% of the fathers of children below 5 years of age whose parents were not known to have died at baseline were among the population under surveillance, resulting in a high degree of completeness of information on parents. Asset score and main source of income were determined by interview, while dwelling construction was determined by direct observation by the field staff.It is possible that other factors led to the lack of association between socio-economic status and child mortality. Differential migration could affect the trend if, for example, better off individuals stay in the district because of sickly children, but migration could affect all socio-economic levels.The finding of the expected trends of higher non-AIDS mortality in children of households with few assets, poor dwelling construction, and relying on subsistence farming, suggests that the socio-economic indicators are measuring what they are supposed to measure. The lack of association with overall mortality is explained by the different trends in AIDS deaths. AIDS mortality was much higher in children from higher socio-economic status households, mirroring the distribution of HIV infection in the adult population. The usual and unwelcome gap in survival between the poor and the less poor has been lost, but because the less poor have been disproportionately affected by HIV, rather than because of relative improvement in the survival of the poorest.Since HIV infection is associated with relative wealth in many parts of sub-Saharan Africa, It is probably a temporary phenomenon. A shift in the distribution of HIV in the population towards the poorer individuals has been predicted,


Despite the fact that the first case of HIV in Bangladesh was detected in 1989, there has been a strong and coordinated approach to preventing HIV and AIDS in the country since 1985. Guided by the National AIDS Committee and its technical subcommittees and led by the National AIDS/STD Programme within the Directorate General of Health Services, Bangladesh has seen the roll out of a National Strategic Plan (NSP) and comprehensive guidelines relating to the prevention and management of HIV and AIDS . The situation regarding hospitalization and care of acutely-ill patients is even worse. The Government of Bangladesh has a dedicated centre for treating PLHIV but this single ward is dependent on a single doctor who obviously cannot be available 24 hours a day. PLHIV frequently report that they do not disclose their status to healthcare providers for fear of stigma and of being denied care which further complicates the situation, but perhaps the greatest barrier to providing inpatient care to PLHIV is the lack of trained clinicians—doctors, nurses, counsellors, and others—and the lack of a team-based approach to the care of individuals in a holistic manner. As the case report by Pervez et al. in this issue of JHPN demonstrates, even well-meaning clinicians who are not used to treating PLHIV are likely to make understandable errors in the management of such individuals .One of the five priority areas for the NSP is the provision of services and care for PLHIV, and yet for most PLHIV, the only accessible healthcare services are provided by non-governmental organizations (NGOs). NGOs provide a limited range of services, including voluntary counselling and testing, counselling, treatment for sexually transmitted infections, and outpatient-based management of medical problems, including opportunistic infections . The provision of antiretroviral drugs (ARVs) is patchy and depends on the NGO's funding and support as there is still no national provision of ARVs. ARVs are manufactured by two companies in Bangladesh but they provide only limited first-line treatment, and no paediatric formulations are available. CD4 counts and more complicated diagnostic tests are available only in Dhaka, and even in Dhaka, basic diagnostic tests for common opportunistic infections are not available  is addressed quickly, a disaster looms.


Increasing access to antiretroviral therapy (ART) is a critical goal endorsed by the United Nations and all of its member states. At the same time, anecdotal accounts suggest that the promotion of unproven AIDS 'cures' and remedies are widespread, and in the case of The Gambia, Iran and South Africa, have been promoted by governments directly. Although a range of legislative and regulatory measures have been adopted by some governments, and technical assistance has been provided by international agencies to address counterfeit medicines generally, the threat of counterfeit antiretroviral drugs is not being addressed.Countries, charged with fulfilling the right to health and committed to expanding access to ART must explicitly recognize their obligation to combat unproven AIDS treatments and ensure the availability of a safe and efficacious drugs supply. International donors must help support and coordinate these efforts. In the last few years governments around the world have pledged to massively scale up the delivery of antiretroviral drugs (ARVs) to achieve universal access to all. To date attention has focused on how to finance this effort and how to strengthen health care delivery systems, including how to conduct mass HIV testing programs and increase the number of health care providers worldwide. Less attention has been paid to the responsibilities of governments and international agencies to address the widespread prevalence of unproven AIDS 'cures' and the threat of counterfeit ARVs.Treatments to cure HIV/AIDS have been falsely promoted since AIDS was first identified and claims of cures continue in spite of the development of ARVs, which can dramatically slow the progression to AIDS but do not rid the body of HIV. The uncertainty and fear engendered by this incurable, stigmatizing and life-threatening disease can make people easy prey to promises of cures. But in addition to fear, there are specific factors, related to government functioning, that facilitate false claims of HIV cures, including: little or no access by people living with HIV and those populations most at risk to health care generally and ARVs specifically; stigmatizing and discriminatory treatment of people living with HIV/AIDS (PLWHA) in health care settings; high prices for legitimate pharmaceuticals when available; little or no regulatory oversight over the fields of traditional medicine and complementary treatments; and a lack of promotion by governments of the availability and efficacy of ARVs.In some cases, government endorsement of unproven 'cures' has created confusion regarding the legitimacy of AIDS medicines, and governments and international organizations have done a poor job separating out their appropriate recognition of the important role played by traditional medicines in physical and psychosocial care, ,2 from tIt is important at the outset to differentiate between legitimate and fraudulent promotion of herbal and other remedies. While there is very little data documenting the global use of herbal remedies, nutritional supplements, and traditional medicines, they are believed to be widely used by PLWHA to enhance their wellbeing. Unproven AIDS 'cures', on the other hand purport not just to enhance wellbeing but to specifically eradicate HIV. Less clearly definable is the promotion of HIV treatments which fall short of promising a 'cure' but advertise specific health benefits or biologic effects. Some of these, for example those that promote general immune boosting, may be considered akin to a supplement. Others, such as those which suggest an impact on HIV viral load are more properly considered a medicine or 'treatment'. Despite being promoted as 'traditional' or 'herbal', many supplements, 'cures', and treatments are produced using modern mass manufacturing techniques and with industrial chemicals.guandamiti' – developed with support from the United Nations Educational, Scientific and Cultural Organization (UNESCO), Kellogg Foundation, the US National Cancer Institute and the World Health Organization – has been promoted as significantly reducing viral load (variously reported as 60–76% or 90%) and opportunistic infections , should be completely secure and reliable", and stated that this is true in the new medicine In 2004 the Kenyan newspaper 'The Nation' documented an active informal market for ARVs, including AIDS cures and counterfeit drugs, in Tsavo Road in Nairobi . A 2003 The trafficking of counterfeit ARVs has been specifically documented in two cases to date. In 2003 the WHO issued an alert that a product called 'Ginovir 3D', marketed in Cote d'Ivoire as a triple ARV combination product, contained only one of the drugs (zidovudine) on the label, none of the other 2 drugs (lamivudine and indinavir), and an additional drug not on the label (stavudine) . In 2004Unlike the merely rhetorical response by governments and UN agencies to unproven 'cures', a range of actions have been taken at both levels to combat the proliferation of counterfeit medicines. Governments have adopted and refined legislation opposing counterfeiting and have targeted specific highly counterfeited medicines with special protections . International agencies have led regional and international initiatives aimed at sharing information and reporting incidences of trafficking, and have provided technical support to countries and regional coalitions.To address the high levels of the counterfeit anti-malaria drug artesunate in Thailand, most malaria is treated at no cost in government malaria clinics where drug supplies can be more closely monitored . In ChinWhen governments have been more aggressive towards counterfeiting syndicates, the result has often been violence. Enforcement officers in India  have beeWHO has proactively tried to establish international norms regulating pharmaceuticals and addressing the trafficking of counterfeit products, although the result has been less than fully successful. In the 1980s, the WHO initiated a voluntary, confidential international system to report counterfeiting. However, countries were reluctant to report and only a few did so . In 1999Almost 2 billion people lack access to essential medicines . ImproviInternational legal standards impose on governments a responsibility to respect, protect and fulfill certain enumerated rights of individuals. The right to life, to be protected from harm and exploitation, the right to the progressive realization of access to health services, and the right to receive and impart information are all relevant to protection from unproven AIDS treatments and counterfeit medicine.The international recognition of the right to health began with a reference to health in the United Nations Charter and was affirmed in the preamble to the 1946 Constitution of the World Health Organization. The WHO Constitution, in Article 21, empowers the World Health Assembly to adopt regulations that are binding on Member States related to, among other things, the safety, purity and potency and the advertising and labeling of biological, pharmaceutical, and "similar products" moving in international commerce . The gloUN guidelines on HIV/AIDS and human rights emphasize the need for states to take affirmative action to provide adequate, accessible and effective HIV-related prevention and care education, information and services. The guidelines say specifically:States should take legislative and other measures to ensure that medicines are supplied in adequate quantities and in a timely fashion, and with accurate, current and accessible information regarding their use. For example, consumer protection laws or other relevant legislation should be enacted or strengthened to prevent fraudulent claims regarding the safety and efficacy of drugs, vaccines and medical devices, including those relating to HIV [g to HIV .In 2006, the United Nations issued a declaration on HIV/AIDS committing all member states to pursue "all necessary efforts" to scale up HIV/AIDS treatment programs towards the goal of providing universal access to HIV/AIDS treatment by 2010 . UN membThe first step towards addressing unproven AIDS treatments and counterfeit drugs must be to increase our knowledge and understanding of the problem. The distribution of medicines and 'cures' in developing countries has long been recognized as chaotic and occurring through commercial and other informal networks in addition to health care settings -73. A nuand confidence in ART as an effective treatment for HIV/AIDS [The second step is to continue to aggressively scale-up ART programs and to widely promote their availability – to all who need it, in an equitable and non-discriminatory manner. Through the widespread promotion of ART and expanding routine HIV testing linked to treatment, Botswana has been able to achieve nearly universal knowledge of, HIV/AIDS ; achieviHIV/AIDS . In ZambHIV/AIDS , and unpHIV/AIDS . Most coIn most countries, information on ART is provided passively, by health care providers to those who are able to access treatment. Outreach, provided through treatment literacy campaigns emphasizing the effectiveness of ARV drugs, the importance of adherence to prescribed regimens, and the danger of untested 'cures' have been insufficiently funded, and have been largely implemented by NGOs and networks of PLWHA. To be effective, these campaigns must be expanded and conducted through multiple channels, involving NGOs and PLWHA networks, but also public and private sector Western medical providers, traditional healers, and mass media.A third step would be for governments to enact or revise legislation against counterfeit medicines and the fraudulent promotion of unproven remedies. States must cooperate with international efforts to combat the trafficking of counterfeit medicines and unproven cures. Alternatively, the issue of counterfeit medicines and unproven remedies could be addressed within a framework convention on global health. Advocates for such a convention  stress tFinally, WHO and UNAIDS must more forcefully promote the message that only ARV drugs have been proven to be effective against AIDS, and must regularly and consistently speak out and challenge governments that promote unproven 'cures' or fail to regulate claims of AIDS treatments. Following the publication of a letter in November 2007 by Human Rights Watch to the Kamran Baqeri Lankarani, Iran's Minister of Health and Medical Education concerning the promotion of IMOD , the webWhile the lack of universal access to ART is one factor in the proliferation of unproven AIDS 'cures' and counterfeit drugs, there are much broader considerations. ART, even when recognized as life-saving and when widely available, can not 'heal' all wounds experienced by those infected by HIV. The promoters of unproven AIDS remedies – be they traditional medical providers, faith healers, or Presidents – often prey not only on the lack of understanding of ART, but the broader fears and hopes of PLWHA for respect, dignity, and a healthy future free from dependence, stigma and discrimination. ART programs inevitably exist in the political sphere and, as we have seen, governments use the promotion of unproven AIDS remedies as part of larger political campaigns to express benevolence or promote 'indigenous' solutions.Paul Farmer has written eloquently about the introduction of ART in a rural clinic in Haiti, emphasizing the hope felt by his patients upon receiving the drug and experiencing the 'Lazarus'-like effects of it . But Far"He cured me of AIDS, I can feel it. I just know"[Contrast Farmer's experience with that of modern, global, faith healers such as the Canadian Benny Hinn who promises deliverance from a wide range of ailments as part of a ministry that is alleged to have revenues of $100 million per year. In 2007 Hinn preached in Uganda to a crowd of 50,000 people at a football stadium. A journalist attending the event interviewed a 19 year old woman living with HIV who attended. She described how she was living with her brother after her parents kicked her out of her home when they discovered she was infected with HIV. The article did not identify if the woman was taking ART, but she clearly longed for more than just the medical management of her condition. She said of Hinn: ust know".Everyone, everywhere, involved in the fight against AIDS wants there to be a cure, and a cure as simple and as painless as words spoken to a crowd at a football stadium. But until a cure is found, ART represents our only form of life-saving treatment. States and the global community have committed billions of dollars to increasing access to effective medicine to fight AIDS, but have done little to address unproven AIDS drugs and the threat of counterfeit ART. The extent to which this failure represents actual harm is as yet largely unknown, but the existence of it is an unfortunate testament to the limitations of governments to fulfill their mandates to protect from harm and realize the right to health of those living with HIV/AIDS.The author(s) declare that they have no competing interests.JA conceived and conducted the research and wrote the manuscript.