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Lessons from the global response to HIV/AIDS

Since 2001, the response to HIV/AIDS has evolved into an unprecedented global health effort, extending access to treatment to 17 million people living with HIV across the developing world, some considerable successes in HIV prevention (especially regarding mother-to-child transmission), and becoming a very significant aspect of global development assistance. The present is characterized by a shift in the global health and development agenda (giving HIV/AIDS much less weight), a declining outlook on HIV/AIDS funding, and a prospect of ending AIDS as a major global health challenge through renewed investments in the HIV/AIDS response. To motivate such investments against competing objectives, but also to inform policy responses to future health shocks, it is important to understand the health and development impacts of HIV/AIDS, and the extent to which they have been reversed by the response to it.

Large Adverse Health Shocks, Measured by Drop in Life Expectancy by Markus Haacker. Used with permission.

While the global HIV/AIDS response has in part been motivated by development and security concerns, the direct and obvious impacts arise in the sphere of health. Indeed, the magnitude of the health shock caused by HIV/AIDS has been staggering – the only examples of catastrophic declines in life expectancy surpassing the impact of HIV/AIDS in the worst affected countries are two examples of extreme genocidal violence, and HIV/AIDS has been the sole or partial cause of 15 of the 20 worst examples of declines in national-level life expectancy, with drops in life expectancy of between 5 years and 21 years, according to data from the United Nations Population Division. On top of this, HIV/AIDS-related health shocks have been much more persistent than those caused by violence, famine, or economic crises.

While the global response to HIV/AIDS has been framed as an economic development (as well as health) challenge, HIV/AIDS is not a disease generally associated with low levels of economic development. Similar to TB and malaria, HIV/AIDS contributes very little to the burden of disease across high-income countries. The burden of disease from TB and malaria, however, is more geared towards low–and lower-middle–income countries. HIV/AIDS stands out as its impacts are highly concentrated – largely in Southern and Eastern Africa – where the disease and response to it have been the dominant drivers of health outcomes over the last decades.

One of the biggest achievements of the global response to HIV/AIDS is the comprehensive scaling-up of treatment, reversing much of the steep declines in life expectancy. In Kenya, the loss in life expectancy owing to HIV/AIDS peaked at 8 years, which has now fallen to around  2 years. Remarkably, treatment coverage (as of 2014) has been uncorrelated with GDP per capita, and has generally been high in the countries worst-affected by HIV/AIDS. The HIV/AIDS response has been successful in overcoming capacity constraints associated with a low level of economic development, or caused by a steep increase in demand for health services. While the global effort at scaling up treatment for people living with HIV started out with projects providing proof of the concept that antiretroviral treatment could (and should) be delivered in resource-limited settings, the global HIV/AIDS response has proven that effective large-scale delivery of specific health services is possible in almost any setting.

Apart from the health impacts of HIV/AIDS, the global response to HIV/AIDS was in part motivated by concerns about the socio-economic consequences, and potential reversals of gains in economic development owing to HIV/AIDS. However, the evidence on such economic consequences of HIV/AIDS is thin, and the apparent impacts small. Growth of GDP per capita in countries with the highest prevalence of HIV has not been noticeably lower than in other countries, and empirical studies including a measure of the impacts of HIV/AIDS in a growth regression tend to find a statistically or substantially insignificant effect.

HIV Prevalence and Changes in Poverty by Markus Haacker. Used with permission.

Perhaps more surprisingly, HIV/AIDS also did not have an obvious impact on poverty rates. While the adverse impacts of HIV/AIDS or deaths overall on affected households are well-documented, nation-wide poverty rates did not increase in countries with high HIV prevalence. This could suggest that surviving household members recover economically following a death and its immediate adverse consequences, or that some members of a community gain (e.g., from employment opportunities) as others lose from illness and deaths.

In conclusion, the global response to HIV/AIDS has delivered in terms of reversing a catastrophic health shock, and extending access to treatment across developing countries, and has created a template for advocacy and the planning of large health interventions. Much of the feared broader development consequences of HIV/AIDS have not materialized, raising questions on the form or magnitude of economic returns to investments in health, and the linkages from health events to economic outcomes.

Featured Image Credit: World Healthcare map pill by Jnittymaa0. Public Domain via Pixabay.

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