The number of people infected with HIV/AIDS in sub-Saharan Africa is projected to far outstrip available resources for treatment by the end of the decade, forcing African nations to make difficult choices about how to allocate inadequate supplies of lifesaving antiretroviral therapy (ART), says a new report by the Institute of Medicine. It calls for a renewed emphasis on reducing the rate of new infections, promoting more efficient models of care, and encouraging shared responsibility between African nations and the U.S. for treatment and prevention efforts, which could greatly improve prospects for 2020 and beyond.

In 2008, more than 33 million people globally had HIV/AIDS, 67 percent of whom were in Africa. In addition, more than 90 percent of the 2.7 million new infections reported that year occurred in Africa, and only half of Africans who should have received ART according to World Health Organization guidelines then in place were treated. By 2020, the number of infected people in Africa will grow to over 30 million, with just 7 million of the approximately 12 million who should be treated under current guidelines likely able to receive ART, estimated the committee that wrote the report.

The report notes that because treatment can only reach a fraction of those who need it and its costs are “not sustainable for the foreseeable future,” preventing new infections should be a central tenet of a long-term response to HIV/AIDS in Africa. In the meantime, decision makers in Africa will need to expand local capacities for choosing how to allocate scarce resources ethically. Because patients requiring treatment now generally were infected years ago, policymakers can do little to reverse the short-term course of the epidemic.

“Already in Uganda and a few other nations, we don’t have enough health care workers or ART to meet demands, and health centers are increasingly turning away patients who need these drugs to survive,” said David Serwadda, professor and former dean of the School of Public Health at Makerere University, Kampala, Uganda, and co-chair of the committee. “There is an urgent need for African countries and the U.S. to share responsibility and initiate systematic planning now for the future. If we don’t act to prevent new infections, we will witness an exponential increase in deaths and orphaned children in sub-Saharan Africa in just a couple of decades.”

The report says that despite increasingly more affordable ART drugs and the tremendous success of the U.S. President’s Emergency Plan for AIDS Relief in galvanizing global efforts to fight HIV/AIDS, the gap between infections that require treatment and availability of treatment resources continues to grow and could persist for decades to come. The lack of trained health care workers, for example, already is impacting many African nations’ abilities to provide care. In addition, the global financial crisis presents significant challenges to the U.S. and other donor nations in maintaining current levels of support for treatment and prevention in the region, making it essential that African governments take up their share of the responsibility.

“It’s going to take careful long-term planning to build adequate work-force and infrastructure capacities for HIV/AIDS prevention and treatment programs in Africa,” said Thomas C. Quinn, associate director for international research at the National Institute of Allergy and Infectious Diseases and committee co-chair. “It is absolutely critical that more coordinated efforts between the U.S. and African governments be negotiated and formalized now to enable better planning that will reduce the impact of the HIV pandemic in the future.”

The committee developed models to track the course of HIV/AIDS in the next few decades under different scenarios of prevention and treatment. Several plausible scenarios indicate that the proportion of African nations’ health budgets devoted to HIV/AIDS treatment could begin to shrink, enabling African governments to move toward greater ownership of treatment, care, and prevention efforts, the report says.

For beyond 2020, the U.S. should develop a road map for HIV/AIDS that makes prevention the focus of a sustainable response and requires shared responsibility with African nations for controlling HIV/AIDS. A more binding, negotiated contract approach should be instituted at the country level when providing funding, the report says. Contracts should offer incentives to African nations who invest in prevention and treatment by giving matching funds based on each country’s means.

African countries should begin to develop projections of the future burden of their HIV/AIDS epidemics and assess implications of alternative policies on human welfare and resources in their own nations. In addition, leaders in Africa at multiple levels need assistance in expanding national capacities for making ethical choices about how to allocate limited treatment resources.

African nations will require greater resources at all levels - from national governments to local communities - to become full partners in fighting HIV/AIDS, the report says. In particular, African governments and international organizations should plan how to meet the greater national work-force requirements for responding to the long-term burden of HIV/AIDS.

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The study was sponsored by the Doris Duke Charitable Foundation; Atlantic Philanthropies; (BD) Becton, Dickinson, and Co.; Bill & Melinda Gates Foundation; Carnegie Corporation of New York; Ford Foundation; Institute of International Education; Johnson & Johnson Services; Merck; Pfizer; and the Rockefeller Foundation. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. For more information, visit http://national-academies.org. A committee roster follows.

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Pre-publication copies of Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility are available from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242 or on the Internet at http://www.nap.edu. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above). A Report in Brief is also available.

INSTITUTE OF MEDICINE
Board on Global Health

Committee on Envisioning a Strategy to Prepare for the Long-Term Burden of HIV AIDS:
African Needs and U.S. Interests

Thomas C. Quinn, M.D., M.Sc. (co-chair)
Director
Johns Hopkins Center for Global Health
Johns Hopkins University
Baltimore

David Serwadda, Ch.B., MMed, M.P.H. (co-chair)
Infectious Disease Epidemiologist and Professor
School of Public Health
Makerere University
Kampala, Uganda

Salim S. Abdool-Karim, MBCh.B., Ph.D.
Infectious Diseases Epidemiologist and Pro Vice-Chancellor
University of KwaZulu-Natal
Durban, South Africa

Jennifer G. Cooke, M.A.
Director
Africa Program
Center for Strategic and International Studies
Washington, D.C.

Amaboo Dhai, MBCh.B., FCOG, LLM
Director
Steve Biko Centre for Bioethics
University of the Witwatersrand
Johannesburg, South Africa

Geoff Garnett, Ph.D.
Deputy Director
Institute for Global Health, and
Director
Master’s Programme in Epidemiology
Imperial College of London
London

Peter Ndumbe, M.D.
Dean
Faculty of Health Sciences
University of Buea
Molyko-Buea, Cameroon

Francis Omaswa, M.D.
Executive Director
African Center for Global Health and Social Transformation
Kampala, Uganda

Mead Over, Ph.D.
Senior Fellow
Center for Global Development
Washington, D.C.

Carmen J. Portillo, R.N., Ph.D., FAAN
Nurse Researcher, Professor, and Vice Chair
Department of Community Health Systems
School of Nursing
University of California
San Francisco

Jessica E. Price, Ph.D.
Rwanda Country Director
Family Health International
Arlington, Va.

Marla E. Salmon, Sc.D., R.N., FAAN
Robert G. and Jean A. Reid Endowed Dean in Nursing and
Professor in Psychosocial and Community Health
School of Nursing
University of Washington
Seattle

STAFF
Elizabeth A. Haytmanek, M.H.S.
Study Director

Contact: Molly Galvin
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202-334-2138
National Academy of Sciences