Abstract #305  -  Is the vertical struggle stuck in the fire-fighting mode? Rationales and obstacles to using the AIDS-money for integrated upstream prevention in Tanzania
Authors:   Presenting Author:   Mr Moritz Hunsmann - Graduate School of Social Sciences (EHESS)
Additional Authors:
Aim: In Tanzania, the extraordinary efficiency of international fundraising for HIV/AIDS lead to a situation where AIDS-related expenditures equal the countrys general health budget. This situation appears paradoxical as a great number of recent studies converge on the fact that HIV spreads easier in populations with poor general health and compromised immune systems. Accumulating evidence on the role of group-level biological cofactors (due to malnutrition, lack of safe water and sanitation) in the spread of the epidemic make the efficiency of a vertical, mainly behaviour-based, prevention approach questionable. Focussing specifically on issues of cost-effectiveness, this contribution analyzes why some epidemiologically sound preventive interventions are not considered for implementation.
Method / Issue: Drawing on a brief review of the epidemiological rationales for the integration of biological cofactors into HIV prevention approaches, this contribution scrutinizes current approaches to cost-effectiveness estimation of preventive interventions. Informed by these insights, 40 key informant interviews with Tanzanian and international AIDS policymakers have been conducted to assess their awareness of the role of biological cofactors in the spread of the epidemic and their appreciation of the potentials of and obstacles to the implementation of an integrated upstream prevention approach.
Results / Comments: The high cost-effectiveness of public health measures in the domains of nutrition, deworming, safe water and sanitation are well-known. Their cost-effectiveness improves even further when taking into account their synergistic effects and positive externalities on the reduction of HIV-transmission. Cost-effectiveness, however, is not a criterion systematically employed to discriminate among different preventive interventions in Tanzania. Rather, the anticipated time span before a prevention measure shows effects is a major concern for Tanzanian policymakers. Indeed, while general awareness of the role of cofactors is low, the more informed players generally consider cofactor-based interventions as long-term responses to be implemented once the traditional (allegedly rapid-impact) behaviour-based prevention measures are in place. The stigma caused by an integrated approach under the banners of HIV-prevention is mentioned as a potential obstacle.
Discussion: Some cofactor-related preventive interventions are easy to implement and would result in clear win-win outcomes. Others would require substantial political commitment as they question existing hierarchies and resource allocation compromises. Serious methodological obstacles to meaningful cost-effectiveness analyses of HIV-prevention interventions exist. There is an urgent need for more comprehensive evaluation tools that are based on an integrated vision of ill health and fully account for existing spillovers and externalities. While acknowledging all the specificities of HIV/AIDS, HIV-prevention policies should become an integral part of a broader infectious disease prevention policy. Due to its three-tier nature, the Global Fund has the institutional potential to lead the way to a more integrated upstream HIV-prevention approach. At the country-level, already established implementing organizations in various health-related activities in Tanzania are trying to get a piece of the �AIDS-pie�. The players and the incentive structure are thus already in place. The challenge is to prioritize and coordinate activities according to a national strategy.
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