"HIV/AIDS continues to take a tremendous toll on the populations of many countries, especially in sub-Saharan Africa. In some countries with high HIV prevalence rates, life expectancy has declined by more than a decade and in a few cases by more than two decades. Even in countries with HIV prevalence of around 5 percent (close to the average for sub-Saharan Africa), the epidemic can reverse gains in life expectancy and other health outcomes achieved over one or two decades. This volume highlights work conducted under the umbrella of a World Bank work program on "The Fiscal Dimension of HIV/AIDS," including country studies on Botswana, South Africa, Swaziland, and Uganda. It covers four aspects of the fiscal dimensions of HIV/AIDS: First, it aims for a comprehensive analysis of the fiscal costs of HIV/AIDS, with a wider scope than a costing analysis focusing on only the policy response to HIV/AIDS. Second, it embeds the analysis of HIV/AIDS costs in a discussion of the fiscal context, and interprets these costs as a quasi-liability, not a debt de jure, but a political and fiscal commitment that binds fiscal resources in the future and cannot easily be changed, and very similar to a pension obligation or certain social grants or services. Third, it develops tools to assess the (fiscal dimensions of) trade-offs between HIV/AIDS policies and measures that take into account the persistence of these spending commitments. Fourth, most of the fiscal costs of HIV/AIDS are ultimately caused by new infections, and this study estimates the fiscal resources committed (or saved) by an additional (or prevented) HIV infection. Building on these estimates, the analysis here is able to assess the evolving fiscal burden of HIV/AIDS over time."

'HIV and AIDS in South Asia: An Economic Development Risk' offers an original perspective on HIV and AIDS as major development issues for the region. Although the impact of HIV and AIDS on economic growth appears to be very small, three risks to development are associated with HIV and AIDS in South Asia: the risk of escalating concentrated epidemics, the economic welfare costs, and the fiscal costs of scaling up treatment. As the authors show, South Asian countries have relatively low estimated national HIV prevalence rates, but prevalence is growing rapidly among vulnerable groups at high risk, such as sex workers and their clients, men having sex with men, and injecting drug users and their partners. The cost benefits of targeted prevention programs are high, and the financing of prevention measures such as comprehensive harm reduction and condom use is a sound economic investment in low-prevalence countries with concentrated epidemics. Interventions that reduce the risks and stigma associated with HIV and AIDS have benefits beyond the cost of lives saved; they improve the welfare of those who are at risk and those who fear contracting HIV. Treatment for AIDS in South Asia is limited at present, with weak health systems contributing to low access to and use of services. The challenges of a comprehensive scaling up of antiretroviral treatment are substantial, underscoring the crucial role of effective prevention today. The authors conclude that the limited ability of many households to pay 'catastrophic' health expenses associated with treatment, as well as the negative consequences associated with poor adherence to treatment, suggest a large and central role for the public sector in the provision of antiretroviral therapy. 'HIV and AIDS in South Asia: An Economic Development Risk' will be of particular value to readers with interests in the areas of economic policy, microfinance, public health, and epidemiology.

The global response to HIV/AIDS has been a major aspect of global health and development policy over the last three decades. The book illustrates the devastating health impacts of the epidemic, with life expectancy in some countries falling to the lowest levels observed anywhere, and the remarkable success of the global HIV/AIDS response in reversing such extreme outcomes. Concerns about the implications of HIV/AIDS for economic development have played a role in motivating the global HIV/AIDS response. However, evidence on the impacts of HIV/AIDS on economic growth or poverty is weak, and the magnitude and relevance of such economic effects appears trivial compared to the consequences for life and health. Because of the success in extending access to treatment globally, HIV/AIDS has effectively transitioned into a chronic disease. This means that HIV/AIDS absorbs not only a substantial chunk of current global and national financial resources, but that these spending needs are projected to persist over decades. The costs of the HIV/AIDS response thus resemble a long-term financial liability, shaped by past and current policies. Relatedly, the calculus of cost-effectiveness of HIV/AIDS interventions has changed. People who become infected with HIV can now expect to not die because of AIDS; at the same time, each HIV infection results in medical needs and expenditures extending over decades. The book presents a framework for integrating these financial consequences and the transmission dynamics of HIV in the analysis of cost-effectiveness of HIV/AIDS interventions and in the design of HIV/AIDS programs.