EDITORIALS
HIV/AIDS and the rest of the global health agenda
Jeremy Shiffman
The Maxwell School of Syracuse University, 306 Eggers Hall Syracuse, NY 13244-1020, USA (e-mail: jrshiffm@maxwell.syr.edu)
HIV/AIDS has reached the pinnacle of the global health agenda. More than 26 000 individuals attended the most recent international AIDS conference, one of the largest gatherings on international health in history. Annual funding to address HIV/AIDS in lowand middle-income countries has risen 28-fold since 1996, reaching $8.3 billion in 2005.1
The emergence of HIV/AIDS as a global health priority is reason for celebration, because the tide may be turning against this humanitarian crisis, and because this prioritization may have galvanized commitment to addressing other health problems in the developing world. It is also reason for concern, because the extensive focus on one disease may be crowding out resources and policy-maker attention for the many other causes of death and illness of the world's poor people, a phenomenon that occurred in the past with powerful cause-specific campaigns. While HIV/AIDS imposes a high burden, as of 2001 it was far from the dominant cause of illness and mortality in low and middle-income countries, representing 5.3 % of deaths and 5.1 % of disability-adjusted life-years,2 figures that are unlikely to have changed significantly since then.1
Ideally, governments and other actors would provide sufficient resources to address all major health conditions effectively, including HIV/AIDS. The reality is different. Health budgets in most developing countries are small.3 Official aid for health as of 20034 was less than a third of the US$ 27 billion recommended by a WHO commission.5 Insufficient funding reflects inadequate global political commitment to address health problems particularly those that affect poor people. This situation forces health initiatives into the unfortunate position of having to compete against one another for scarce resources. If one cause becomes dominant, others may suffer.
There is increasing evidence that HIV/AIDS may be having just such crowding-out effects. The percentage of official aid for health and population devoted to HIV/AIDS is rising rapidly, more than tripling over the years 1998 to 2003 from 7.2 % to 23.8 %.4 Aggregate amounts are stagnating for all other major causes except infectious disease control4 (although the Gates Foundation may be countering some of these trends). In the United States of America's budgets, the percentage for HIV/AIDS funding increased, from 9.4 to 43.1, overtaking all other categories.4 Funding in the health sector capacity category nearly vanished, dropping from 20.2 % to 1.1 %.4 Up-to-date comparative figures are available only through the year 2003. If we include two more recent funding sources for HIV/AIDS the Global Fund and PEPFAR (The President's Emergency Plan for AIDS Relief) the crowding-out effects may be even more marked. Displacement effects are also apparent at the country level. For instance, with an HIV prevalence of 3.1 %,6 Rwanda has been allocated US$ 187 million since 2003 exclusively for HIV/AIDS from three international programmes (the Global Fund, PEPFAR and the World Bank's Multi-Country AIDS Programme), compared to only US$ 37 million annually in government expenditure on health.7 These funds threaten to overwhelm a weak health system.
Some organizations that work on HIV/AIDS including UNAIDS and the Global Fund are aware of these problems and issue warnings of possible displacement8 and call for support of health sector strengthening.9 However, most HIV/AIDS champions have been so impassioned about their own fight that they have lost sight of possible adverse effects on other health initiatives.
Given past neglect and a high burden, HIV/AIDS unquestionably deserves special attention. I argue that its prioritization should not come at the expense of other health initiatives. We need to reorient HIV/AIDS advocacy so that this agenda does not harm, and ideally benefits, other causes of ill-health a Hippocratic Oath for health advocacy. I offer three suggestions:
(1) Prioritize health sector strengthening in the AIDS agenda
Health sector strengthening is a growing, but still peripheral element, of the AIDS agenda. It should be central, as stronger health systems will both benefit HIV/AIDS control and help address other high-burden conditions.
(2) Avoid insularity
AIDS champions should be more sensitive to the effects of their rapidly growing political power on politically weaker health initiatives, and build bridges to promote these initiatives.
(3) Consider the greater goal
Presumably, health advocates share a desire to ensure that poor people avoid illness and death arising from any major cause. Consideration of this greater goal may provide the rationale and the normative underpinning for moving AIDS advocacy away from its insularity and towards explicit links with other health initiatives, in order to benefit the developing world. 
1. UNAIDS. 2006 Report on the global AIDS epidemic. Geneva: UNAIDS; 2006.
2. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJL. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet 2006;367:1747-57.
3. Musgrove P, Zeramdini R. A summary description of health financing in WHO Member States. Geneva: WHO; 2001.
4. OECD. International development statistics 2005. Paris: OECD; 2005.
5. World Health Organization. Macroeconomics and health: investing in health for economic development. Geneva: World Health Organization; 2001.
6. UNAIDS. Rwanda. Available from: http://www.unaids.org/en/Regions_Countries/Countries/rwanda.asp.
7. Ministry of Health. Republic of Rwanda. Rwanda national health accounts 2003. Kigali: Ministry of Health; 2006.
8. UNAIDS. 2004 report on the global AIDS epidemic. Geneva: UNAIDS; 2004.
9. Global Fund to Fight AIDS. Tuberculosis and Malaria. Annual report 2005. Geneva; Global Fund; 2006.