PEPFAR, national governments, and other stakeholders are investing unprecedented resources to provide HIV treatment in developing countries. This study reports empirical data on costs and cost trends in a large sample of HIV treatment sites.

Cost information is needed at multiple levels of health care systems to inform the public health response to HIV. To date, most attention has been paid to identifying the cost drivers of providing antiretroviral treatment, and these data have driven interventions that have been successful in reducing drug and human resource costs. The need for further cost information, especially for less well-studied areas such as HIV prevention, is particularly acute given global budget constraints and ongoing efforts to extract the greatest possible value from money spent on the response. Cost information can be collected from multiple perspectives and levels of the health care system (site, program, and national levels), and it is critical to choose the appropriate methodology in order to generate the appropriate information for decision-making. Organizations such as United States President’s Emergency Plan for AIDS Relief, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and other organizations are working together to bridge the divide between the fields of economics and HIV program implementation by accelerating the collection of cost data and building further local demand and capacity for their use.

The support of global health initiatives in recipient countries has been vigorously debated. Critics are concerned that disease-specific programs may be creating vertical and parallel service delivery structures that to some extent undermine health systems. This case study of Ghana aimed to explore how the Global Fund-supported HIV program interacts with the health system there and to map the extent and nature of integration of the national disease program across 6 key health systems functions. Qualitative interviews of national stakeholders were conducted to understand the perceptions of the strengths and weaknesses of the relationship between Global Fund-supported activities and the health system and to identify positive synergies and unintended consequences of integration. Ghana has a well-functioning sector-wide approach to financing its health system, with a strong emphasis on integrated care delivery. Ghana has benefited from US $175 million of approved Global Fund support to address the HIV epidemic, accounting for almost 85% of the National AIDS Control Program budget. Investments in infrastructure, human resources, and commodities have enabled HIV interventions to increase exponentially. Global Fund-supported activities have been well integrated into key health system functions to strengthen them, especially financing, planning, service delivery, and demand generation. Yet, with governance and monitoring and evaluation functions, parallel structures to national systems have emerged, leading to inefficiencies. This case study demonstrates that interactions and integration are highly varied across different health system functions, and strong government leadership has facilitated the integration of Global Fund-supported activities within national programs.

The remarkable rise in investments for HIV control programs in 2003-2010 enabled an unprecedented expansion of access to HIV services in low-income and middle-income countries. By the end of 2010, more than 5.2 million people were receiving antiretroviral therapy (ART), which transformed HIV infection, once a death sentence, into a long-term illness. The rapid expansion in the number of persons receiving ART means that health systems must continue to provide acute life-saving care for those with advanced HIV/AIDS although also providing chronic care services to expanding cohorts of more stable patients who are doing well on ART. This expansion also means a transition from an emergency response to the epidemic, characterized by a public health approach, to a more integrated and durable approach to HIV prevention, care, and treatment services that fosters individualized care for those requiring long-term antiretroviral treatment. Yet most low-income and middle-income countries, which have weak health systems, are poorly prepared to make this transition. In this article, we highlight the challenges health systems face in developing a sustained and durable response to HIV/AIDS. The article analyses the readiness of health systems to combine rapid expansion of ART access with long-term treatment and continuity of care for a growing cohort of patients. We argue that effective management of a transition from an emergency AIDS response to long-term programatic strategies will require a paradigm shift that enables leveraging investments in HIV to build sustainable health systems for managing large cohorts of patients receiving ART although meeting the immediate needs of those who remain without access to HIV treatment and care.