• Scaling Up: Imperative and Affordable

As the tide of illness and death from AIDS rose in Africa, some two decades ago, one or two countries reacted quickly, mobilizing people from all walks of life to join forces against HIV and the unprotected sex that spreads it. Other countries waited rather longer before moving into top gear, but they, too, are being rewarded for their efforts. Success stories, including those of Senegal, Uganda and Zambia, are described in the comprehensive Report on the Global HIV/AIDS Epidemic published in June 2000 and in other UNAIDS Best Practice documents (http://www.unaids.org).

The fact that these success stories are confined to a small number of examples which are cited over and over again is one of the great tragedies of the late twentieth century. Most countries in Africa -- and indeed worldwide -- lost valuable time because AIDS was not fully understood and its significance as a new epidemic was not grasped. Some action was taken, but not on the scale that would have been required to stem the tide of the epidemic.

Needless to say, the scale of action necessary to make a difference has increased exponentially along with the epidemic. Early on in a heterosexual epidemic, most new infections are acquired and passed on by a minority of people with an especially high turnover of partners. If condoms are used in most of these transactions, the epidemic can be contained relatively easily. But once HIV has become firmly established in the general population, most new infections occur in the majority of adults who do not have a specially high number of partners. This means that prevention campaigns have to be expanded greatly, making them harder and costlier, though still very worthwhile.

Most countries in Africa are at this stage. Yet few have expanded their HIV prevention programmes to the scale that would be needed to make a significant dent in the number of new infections. Since past prevention failures eventually turn into current care needs, failure to head off the epidemic early on also imposes a greater burden of care on countries where HIV prevalence is high. And as the HIV-infected fall ill and die, alleviating the impact on orphans, other survivors, families and communities becomes the third challenge.

Scaling Up: Imperative and Affordable

Recently, researchers have tried to determine how much money would be needed to make a real difference to the AIDS epidemic in Africa, both in terms of expanding prevention programmes to a level where they might be expected to be truly effective at a population level, and in terms of providing basic care and support for infected individuals and their families. The exercise is not an easy one. For one thing, it is not clear how much money buys how much prevention or care. For another, it is not easy to set prevention or care targets that are both achievable and realistic. Thirdly, it is hard to be sure of the exact relationship between behaviour change and new infection at different levels of HIV prevalence, and in different populations. Most of the available information on both costs and effectiveness of HIV prevention programmes comes from a small number of carefully implemented and evaluated projects. It is unlikely that either the unit costs or the outcomes of these small projects would remain the same if they were applied on a national scale.

Fortunately, different methods of estimating costs have generated remarkably similar estimates -- and the good news is that the costs are affordable. If countries set ambitious but achievable targets for the period 2000 and 2005, according to current thinking they will need the following resources annually to expand the response to AIDS to a scale that might have a major impact on the African epidemic:

• At least US$ 1.5 billion a year could make it possible to achieve massively higher levels of implementation of all the major components of successful prevention programmes for the whole of sub-Saharan Africa. These would cover sexual, mother-to-child and transfusion-related HIV transmission, and would involve approaches ranging from awareness campaigns through the media to voluntary HIV counselling and testing, and the promotion and supply of condoms.

• In the area of care for orphans and for people living with HIV or AIDS, costs depend very much on what kind of care is being provided. It is estimated that, with at least US$ 1.5 billion a year, countries in sub-Saharan Africa could buy symptom and pain relief (palliative care) for at least half of AIDS patients in need of it; treatment and prophylaxis for opportunistic infections for a somewhat smaller proportion; and care for AIDS orphans. At the moment, the coverage of care in many African countries is negligible, so reaching coverage at these levels would be an enormous step forward.

• Making a start on coverage with combination antiretroviral therapy would add several billion dollars annually to the bill.

Of course, providing AIDS prevention and care services involves more than just these funds. A country's health, education, communications and other infrastructures have to be well enough developed to be able to deliver these interventions. In some badly-affected countries, these systems are already under strain, and they are likely to crumble further under the weight of AIDS. Then, too, money can only be used wisely if people are available to use it wisely. The shortage of men, women and young people trained in counselling, care and prevention skills is already acute. And skills in strategic thinking, planning and management are in high demand but not widely available. Already, local demand outstrips the local supply, and as more funds become available for expanding the response to HIV, the demand is likely to grow further still.

These are serious challenges that the International Partnership against AIDS in Africa must confront. African countries and their partners in the global community will have to do far more to build infrastructure and human capacity if they are to make a difference to the epidemic.

At the same time, the global community can and must do more to help finance a credible assault on AIDS in Africa. With an investment of US$3 billion a year, the world can make a massive difference in the quality of life of millions of Africans. This seems like a small price to pay to help a whole continent avoid a future dominated by the social disruption that defines the "AIDS era" at the start of the third millennium. Indeed, the cost pales in comparison with spending on other preventable conditions. It is estimated, for example, that the United States alone spends around US$ 52 billion coping with the medical consequences of obesity -- more than 15 times what would be needed to change the face of AIDS in Africa.