Monday, April 28, 2008

2. Discussion

AIDS-Specific Aid
Global funding to combat HIV/AIDS in low- and middle-income countries has nearly quadrupled since 2001, most likely due to heavy political pressure. Three major funding mechanisms have fueled the overall financing and their bureaucratic organizational procedures foreshadow the politics of AIDS-aid that have emerged in recent years.

In fiscal year 2001 The World Bank Multi-Country HIV/AIDS Program (MAP) began using International Development Association (IDA) funds and interest on other World Bank loans to finance AIDS-specific projects and programs. MAP aid is disbursed most often to World Bank-created national entities known as National AIDS Control Councils (NACC) for 3-5 yearlong programs. In this paper, MAP aid is defined by the date on which the aid was approved and the amount at that time allocated to the recipient NACC.

In 2002 The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) began giving grants for 2-year programs, offering renewals to good performers for 1-3 years. Money comes from governments on the Global Fund Board as well as from foundations, private companies, and rich individuals. Although given to a variety of both government and non-governmental partners, in this paper Global Fund aid is defined by the Program Start Date and the Total Amount Disbursed, and only includes HIV/AIDS or HIV/Tuberculosis earmarked funds given to the category of Government.

In fiscal year 2004 President Bush launched The President’s Emergency Plan for AIDS Relief (PEPFAR) as the umbrella of all United States international AIDS-related funding. PEPFAR allocated $15 billion from 2003-2008 for AIDS specific programs, predominantly to 15 ‘focus countries,’ and is set to approve and additional $50 billion for the next 5 years. Funds are received by non-governmental organizations (NGOs), for-profits contractors, and Ministries of Health, however in-country American coordinators exclusively manage the aid. In this paper, PEPFAR aid is defined as the aid given in the fiscal year it is recorded under in PEPFAR public records.

The world collectively spent over $8 billion on AIDS relief in 2005 , led by MAP, Global Fund, and PEPFAR Funds, however the United Nations Joint Programme on HIV/AIDS (UNAIDS) recently reported that it will take $42 billion a year by 2010 to properly address the AIDS pandemic. The Report specifies that wise investments might include “427,500 medical personnel and 1.5 million teachers…. 10 billion condoms and 2.5 million circumcisions,” resources and approaches that are all evidenced to prevent new HIV infection, intimating that health outcomes will rely on smart spending decisions. In an analysis of AIDS-aid efficacy the institutional and political environment in which such spending decisions are made must be important.

HIV Transmission
I measure aid efficacy as the change in national HIV prevalence rate, so understanding the potential drivers of HIV is necessary to understanding under what conditions AIDS-aid will succeed. Although UNAIDS reports national infection rates of nearly 40% in countries like Swaziland and Botswana, with many sub-Saharan communities suffering startling 80-90% infection rates, HIV transmission is well understood. General methods of transmission of and protection from HIV are biologically established, however little consensus exists on the social, political, and economic factors that can influence changes in HIV rates. Beyond the establishment of AIDS-specific medical and social services that can decrease HIV, more general factors that decrease prevalence include management of ethnic fractionalization and political stability , promotion of gender equality , and reduction of general poverty, including the availability of adequate nutrition, water, and sanitation and access to education.

The AIDS-Aid Paradox
The sudden large-scale response of rich nations and international organizations suggests that AIDS-aid is intended for AIDS relief. Indeed, in many cases this has appeared to be true. Djibouti received $33 million from the MAP from 2000-2003, and between 2001 and 2003 saw a 78.72% decrease in their HIV rate, from 11.75% to 2.9%. Similarly, Ethiopia received $126.8 million from the MAP from 2002-2003, as well as $270 million from the Global Fund and $131.8 million from PEPFAR between 2004-05. Ethiopia observed a 50% decrease in HIV rate, from 4.4% in 2003 to 2.2% in 2005.

However this is not always the case. Curiously, many HIV-burdened nations have observed a decrease in HIV prevalence independent of AIDS-aid, while some countries receiving massive AIDS-aid experience an increase in national HIV prevalence. Table 1 shows the breakdown of changes in HIV rates for observations included in this study.


Interestingly, decreases in HIV rate are slightly more prevalent when AIDS Aid is not given, rather than when AIDS aid is given. Table 2 more specifically highlights a few instances of the paradox in which three geopolitically diverse AIDS-aid recipients have witnessed increased HIV levels, while one nation who with relatively small aid has witnessed a decrease in HIV.


Even with substantially less aid than Angola and Vietnam, Cote d’Ivoire managed to oversee an overall decrease in HIV over the time period, in which three nations with large amounts of aid saw tragic increases in national HIV prevalence. More aid is clearly not a guarantee of AIDS relief, and this study intends to better understand the factors that ultimately determine AIDS-Aid efficacy.

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