gency Plan for AIDS Relief (PEPFAR); the World Health Organization’s (WHO) 3-by-5 campaign; the William J. Clinton Presidential Foundation; the World Bank’s Multi-Country HIV/AIDS Program for the Africa Region (MAP); and the courageous efforts of the afflicted countries themselves, such as ART scale-up in South Africa—have contributed to this historic opportunity to develop and implement the global scale-up of ARV therapy (ART). Each of these efforts is briefly reviewed in turn below. Issues related to coordinating these and other elements of the global response to the HIV/ AIDS pandemic are then examined. Next, the crucial issue of fiscal sustainability is addressed. The final section examines the ethical issues and challenges at both the local and international levels.

CURRENT EFFORTS

The Global Fund: Scale-Up of Antiretroviral Therapy in Action

The Global Fund to Fight AIDS, Tuberculosis, and Malaria, sponsored by the United Nations (UN), is a performance-based financing mechanism and network whose purpose is to provide countries with substantial resources that can be used at the national level and in a way that promotes country ownership. The goal is to help launch programs designed to combat these three devastating diseases. Although the Global Fund has been operating legally for nearly 2½ years, it has been functional for only about 2 years. Thus far the program has pledged $4.8 billion to fund 214 proposals among 121 countries through 2008; however, only $2.1 billion of these funds had been received from donors as of November 2003 (see Figure 2-1) (The Global Fund, 2003a). The proposals include specific plans for HIV/ AIDS, tuberculosis (TB), and malaria, as well as joint efforts (e.g., HIV/ AIDS–TB), and both country-specific and cross-border initiatives. Of these 214 proposals, 135 have moved forward in terms of having a specific work plan in place, and about $250 million had been dispersed as of January 2004 (Schwartlander et al., 2004) (see Box 2-2).

Global Fund monies are expected to provide enough ARVs to treat approximately 700,000 people over the course of the next several years. About 60 percent of Global Fund resources have gone or will go to sub-Saharan Africa, and about 60 percent toward HIV/AIDS (The Global Fund, 2003b). Of the amount dedicated to HIV/AIDS, a little less than half is dedicated to commodities, and about half of that amount to ARVs. The majority of project plans that have HIV/AIDS components include prevention elements, although the primary focus of most is treatment (i.e., ART).

After technical review and negotiations, the majority of funded HIV/ AIDS projects in African countries spend, on average, about US$400 per patient per year for ART (Schwartlander et al., 2004). Global Fund–sup-



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