In the two decades since AIDS began sweeping the globe, it has often been labeled as the biggest threat to international health.
But with revised numbers downsizing the pandemic published last year — along with an admission that AIDS peaked in the late 1990s — some AIDS experts are now wondering if it might be wise to shift some of the billions of dollars of AIDS money to basic health problems like clean water, family planning or diarrhea.
"If we look at the data objectively, we are spending too much on AIDS," said Dr. Malcolm Potts, an AIDS expert at the University of California in Berkeley, who once worked with prostitutes on the front lines of the epidemic in Ghana.
Problems like malnutrition, pneumonia and malaria kill more children in Africa than AIDS.
"We are programmed to react quickly to small children with AIDS in distress," Potts said. "Unfortunately, we don't have that same reaction when looking at statistics that tell us what we should be spending on."
The world invests about $8 billion to $10 billion into AIDS every year, more than 100 times what it spends on clean water projects in developing countries. Yet more than 2 billion people do not have access to adequate sanitation, and about 1 billion lack clean water.
Children dying of hunger
In a recent series in The Lancet, experts wrote that more than one-third of child deaths and 11 percent of the total disease burden worldwide are due to mothers and children not getting enough to eat — or not getting enough nutritional food.
"We have a system in public health where the loudest voice gets the most money," said Dr. Richard Horton, editor of The Lancet. "AIDS has grossly distorted our limited budget."
But some AIDS experts argue that cutting back on fighting HIV would be dangerous.
"We cannot let the pendulum swing back to a time when we didn't spend a lot on AIDS," said Dr. Kevin De Cock, director of the AIDS department at the World Health Organization. "We now have millions of people on treatment and we can't just stop that."
Still, De Cock once worked on AIDS projects in Kenya, his office just above a large slum.
"It did feel a bit peculiar to be investing so much money into antiretrovirals while the people there were dealing with huge problems like water and sanitation," De Cock said.
Part of the issue is advocacy. From celebrity ambassadors to red ribbons, other diseases have been left by the wayside.
"No one is beating the drum for basic health problems," said Daniel Halperin, an AIDS expert at the Harvard University's School of Public Health.
Treatable diseases need money
Aside from southern Africa, most of the continent has relatively low rates of HIV, and much higher rates of easily treatable diseases like diarrhea and respiratory illnesses. Yet much of the money from the West, especially from the United States, goes into AIDS.
President George W. Bush has requested another $30 billion for the next five years for AIDS, mostly to be spent in Africa, and the leading Democratic candidates have proposed that figure be bumped up to $50 billion.
In comparison, the President's Malaria Initiative, launched in 2005, aims to reduce malaria deaths by half in 15 African countries. Its five-year budget is an estimated $1.2 billion.
Halperin recently wrote a commentary on the imbalance in AIDS spending versus other public health problems, published in the New York Times, and said he was astounded by the response. Most of the responses were positive, he said, with many AIDS experts agreeing it was time to re-examine spending.
Most AIDS officials say the solution is to boost the budget for all of public health.
"Why does the public health budget have to be so limited?" asked Tom Coates, a professor of global AIDS research at the University of California in Los Angeles. "Let's not drag AIDS care and prevention down to the level of every other disease, but let's bring everything else up to the level of AIDS."
That may be wishful thinking.
"At the end of the day, there are limits to how big the public health pie can be," Halperin said. "And meanwhile, there are important trade-offs to consider."
Parallel health systems
African doctors say that AIDS money has created parallel health systems, where AIDS patients may get free drugs, but people with other diseases are often forced to pay out of pocket.
Since the discovery of antiretrovirals to fight HIV in the 1990s, AIDS has virtually become a chronic, treatable disease in the West. But the disease has not been conquered so easily in Africa. Not only are the anti-AIDS drugs too expensive for most patients, but major problems in the health system need to be fixed first.
"It's hard to get Western donors to listen," said Dr. Richard Wamai, a Kenyan doctor at Harvard University's School of Public Health. Wamai said that some African health infrastructures are so weak they cannot absorb the donations, meaning that AIDS drugs are sometimes left sitting in warehouses because governments cannot distribute them.
Still, "trying to redirect AIDS money will take a long time," Wamai said. "It's a bit like trying to stop an ocean liner."