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Cultural obstacles to the rollout of antiretrovirals: language, region and the backlash against AIDS funding

Year: 2009
Working paper number: 253
Author: Nattrass, Nicoli
Unit: ASRU

This paper employs quantitative analysis to explore the issue of cultural barriers to accessing highly active antiretroviral treatment (HAART) in developing countries. It begins with an econometric analysis of potential socio-economic determinants of HAART coverage, i.e. the number of people on HAART as a percentage of the total number needing it. The analysis suggests that language fractionalisation (a widely used indicator of cultural diversity) acts as a barrier to HAART coverage, whereas ethnic fractionalisation is not significant, although politically salient ethnic divisions may be. The most important drivers of HAART coverage are: region (notably, living in the hyper-epidemic region of the Southern part of the African continent); and access to donor funding.

The effect of 'region' may, of course, be proxying for unmeasured 'cultural' variation that is not being picked up by the language and ethnic diversity variables. But it may also be picking up other imperfectly measured variables such as level of economic development and institutional strength or even unmeasured factors such as different variants of HIV. One thus cannot conclude from the fact that regional differences exist, that these have roots in cultural differences.

The question of 'cultural barriers' to HAART is usually interrogated at a domestic or local level where understandings of disease aetiology and healing, stigma, conceptions of masculinity etc can be explored (e.g. Ashforth, 2005; Nattrass 2005; Ashforth and Nattrass, 2005; Nattrass, 2008a; Steinberg, 2008). Similarly, country-level research can help shed light on how political factors, such as government leadership on AIDS and civil society mobilisation in favour of HAART, also affect the pace and level of HAART coverage (e.g. Nattrass, 2007; Robbins, 2009). Political factors are crucial in shaping access to HAART (Bor, 2007; de Waal, 2006; Iliffe, 2006; Nattrass, 2008b) but these are not immutable and can be transformed rapidly through domestic and international pressure. The same is true of cultural understandings of HIV and HAART which can change quickly in the presence of civil society mobilisation and in response to the lived experience of successful antiretroviral treatment.

This paper, by virtue of its focus on cross-country differences in HAART coverage, does not address the kinds of cultural and political obstacles that are more appropriately addressed through ethnographic research. However, the analysis highlights a potentially important over-arching cultural issue which is easily missed by country-level analysis – namely the role of donor attitudes and beliefs in shaping access to HAART. Donor funding is typically seen as an economic issue. But to understand it merely as a resource flow is to miss the importance of 'donor culture' in shaping and sustaining that resource flow.

Global funding for AIDS rose from $1.6 billion in 2001 to $10 billion in 2007 and $13.7 billion in 2009 (UNAIDS, 2008: 188; Sidibé, 2009: 4). Foreign aid through bilateral initiatives, especially the US President's Emergency Plan for AIDS Relief (PEPFAR) and multilateral initiatives such as the Global Fund to Fight AIDS, TB and Malaria, were crucial in driving HIV prevention and treatment efforts – contributing almost half of total resources for AIDS (the rest being made up primarily of government resources and private contributions). This unprecedented international effort, which resulted in the number of people on HAART in developing and transitional countries rising from a few hundred in the early 2000s to over 4 million in 2009 (Sidibé, 2009), was underpinned by a sea-change in donor attitudes. Up until 2002/3 the prevailing view in donor circles was that HAART was 'too expensive' and impossible to administer in developing countries. This orthodoxy was overturned in a remarkably rapid time by civil society mobilisation, the development of generic antiretrovirals (which lowered costs significantly), and by more sophisticated understandings of the benefits of rolling out HAART, both in terms of lives saved, health costs averted and promoting development (e.g. CMH, 2001).

Given the massive flow of international funding for AIDS, it is unsurprising that the cross-country analysis found donor support to be a key determinant of HAART coverage. Yet the very donor culture which made the international HAART rollout possible, is in the process of changing – largely because of the emerging backlash against AIDS funding. In this regard, donor culture is in danger of becoming an important cultural obstacle to HAART coverage, albeit and external one.

The second part of the paper sketches out the key arguments of the backlash, paying particular attention to the claim that 'too much' is spent on HIV and that Africans themselves agree. This assertion about what Africans believe is challenged, once again by employing quantitative analysis, by looking at opinion poll data in Africa. The analysis suggests that high levels of support exist within Africa for continued spending on AIDS, even in the presence of other challenges.

Publication file: WP253.pdf