Global Pulse Blog

Today’s post continues to explore the debate over U.S. contribution to funding for combating global AIDS. It features contributions by Anand Reddi, author of the article highlighted earlier (United States global health policy: HIV/AIDS, maternal and child health, and The President’s Emergency Plan for AIDS Relief).  A former Fulbright Scholar, Anand serves on the board of directors of the AIDS Healthcare Foundation, and is a student at the University of Colorado School of Medicine.

In a recent article on Huffington Post, Dr. Ezekiel J. Emanuel, special advisor for health policy in the OMB, defends the Obama Administration’s decision to shift some of the funding away from successful AIDS treatment efforts:

This comprehensive and integrated approach is what the President’s Global Health Initiative is all about. It recognizes that we can’t treat our way out of the HIV-AIDS epidemic. The key to ending it is to reduce the number of those who become HIV-positive in the long-term – and that takes improving their overall health and the health systems around them. After all, patients don’t come to doctors with one disease or condition, and our response shouldn’t focus on one as well.

Dr. Emanuel writes in response to widespread criticism of the Obama Administration during the International AIDS Conference in Vienna, as well as to the July 20^th New York Times op-ed by Archbishop Desmond Tutu, who writes:

During my life, I’ve witnessed amazing advances in medical science. New treatments turn H.I.V. infection from a death sentence to a manageable illness. The cost of treating it is a small fraction of what it was 10 years ago. Meanwhile, more and more African nations have invested in the public health infrastructure needed to distribute AIDS drugs. I appreciate that tough financial times require the United States government to cut spending. But scaling back America’s financial commitments to AIDS programs could wipe away decades of progress in Africa.

Anand Reddi responds on Huffington Post and specifically counters the argument that “we can’t treat our way out” of the epidemic:

Results by Dr. Julio Montaner published in The Lancet demonstrated that provision of antiretroviral therapy in British Columbia halved the rate of new infections. The Economist writes the study by Montaner is “the strongest confirmation yet that treatment and prevention are two sides of the same coin.”  Treating our way out is indeed possible.  In our recent article in AIDS, Sarah Leeper and I demonstrated the unique dynamic-reciprocal relationship that HIV/AIDS, TB, and Malaria have on maternal and child health and vice-versa in the resource limited setting. I salute Dr. Emanuel for forwarding the dialogue on global health and advocating for comprehensive, integrated, cost-effective models of care that advance not just HIV/AIDS but other important health priorities including maternal and child health. Given that the provision of antiretroviral treatment can actually lead to prevention, eradication of new HIV infections is possible if the world community remains fully committed to funding cost-effective antiretroviral treatment initiatives.

Further reading:

• Anand Reddi’s previous article about AIDS funding on Huffington Post.
• The CID journal article by Rochelle Walensky and Daniel Kuritzkes, from the Center for AIDS Research at Harvard Medical School, that Archbishop Tutu references in his letter.

A  new survey from the Centers for Disease Control and Prevention (CDC) suggests that  heterosexuals living in impoverished communities are as much as five times more likely to be HIV-positive than the general U.S. population, regardless of race or ethnicity. In the US, the overall HIV prevalence rate for African Americans is eight times the rate for whites, and the rate for Latinos is three times the rate for whites. Yet in very-low income areas this CDC study found that these disparities do not exist. The study examined 9,000 people in 23 cities, finding that 2.1% of heterosexuals living in high-poverty urban areas were infected with the HIV virus, including 2.4% of those living below the poverty line and 1.2% of those living above it. This is in comparison to the 0.45% rate of HIV infection in the general US population. The authors hypothesize that the findings could account for many of the ethnic and racial disparities in HIV infections in this country, since African Americans are 4.5 times as likely and Latinos four times as likely as whites to live in poverty.

In today’s guest post, recent medical graduate Laura Janneck, MD, MPH reflects on an elective course in social medicine she took in Uganda. Dr. Janneck is an AMSA alum, and now a resident in Emergency Medicine at Brigham & Women’s Hospital, Boston. For further information about the course, see details below.

Over the course of my involvement in global health during medical school, I began to narrow my interests toward humanitarian assistance and global health delivery in post-conflict settings. Last year, during my fourth year of medical school, I participated in a new course on social medicine being taught in Gulu, northern Uganda, a region that is recently recovering from a 20 year civil conflict. This course, called Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness was very well organized, with didactics on a range of topics from the health consequences of internal displacement, to the portrayal of Africans in the Western media. We also were able to spend time on the wards seeing patients with a range of diseases and syndromes common in the region. The keystone of this course, however, is the international student body. Half of the medical students study at Gulu University and hailed from around Uganda. The other half were American and European. This enabled fantastic discussions with different perspectives on the issues we were studying, and planted the seeds of long-term friendships between colleagues from around the world. I enjoyed my time there so much that I went back to Gulu for another clinical rotation later that semester.

If you have any questions about the course or are interested in applying, please email the course directors at: social.medicine@yahoo.com. Applications are due July 30, 2010.

Is funding for global HIV/AIDS programs too “vertical”?  Faced with funding shortfalls, should donor countries put the brakes on AIDS funding in favor of other  initiatives, ones that propose to address a broader range of health problems?  This proposal has drawn the anger of AIDS activists the world over, and is now the subject of passionate debate in Vienna. Back home, two medical students examine the Obama Administration’s plan to let PEPFAR funding flatline while promoting a new Maternal and Child Health (MCH) initiative.  In a commentary published in AIDS, Sarah C. Leeper (Warren Alpert Medical School of Brown University) and Anand Reddi (University of Colorado School of Medicine) take on the claim one argument at a time:

The architects of the Obama administration’s Global Health Initiative recommend funding the Mother and Child Campaign at the expense of future funding increases for PEPFAR. The idea that differing global health initiativesmust compete with each other lacks not only ethical legitimacy but also scientific merit. Confronting illness in isolation – whether by funding PEPFAR at the expense of programs that targetMCH or vice versa – cannot be our way forward. Policies that de-emphasize PEPFAR threaten to undermine,rather than support, MCH in countries with high HIV/AIDS prevalence [PubMed; full-text].

The strongest scientific-journal rebuttal yet to the Obama Administration’s proposal to shift resources to maternal and child health at the expense of HIV/AIDS treatment scale up comes from two medical students, who in a commentary just published in AIDS make a clear and convincing case that such a move would actually undermine the health of women and children around the globe, not improve it.

UNAIDS estimates that the cost needed to continue global HIV treatment in 2009 will be about US$9 billion.

Related reading:

• Denny CC and Emanuel EJ. “US Health Aid Beyond PEPFAR: The Mother & Child Campaign.” (JAMA,  11/2008.)
• “At Front Lines, AIDS War Is Falling Apart” (NYTimes, 05/05/2010)
• “Donor AIDS” (The Lancet Student, 05/14/2010)
• Jennifer Weinberg’s post on the Administration’s effort to address global maternal, newborn, and child health needs (GP Blog, 06/17/2010)
• “Obama ‘hurt’ by AIDS funding criticism” (The Guardian, 06/21/2010)

The International AIDS Society in partnership with the Kaiser Family Foundation is providing online access to various developments taking place at the XVIII International AIDS Conference (AIDS 2010),  in Vienna, Austria.

Selected sessions are webcast live each day with past sessions also available for viewing. Find the complete guide-to-coverage as well as the webcasts already available for viewing including the Opening Session, Monday’s plenary with former President Bill Clinton, and Tuesday’s session on the study which found Microbicides containing HIV drugs lower the infection risk in women.

Today’s schedule includes:

This week at the International AIDS Conference in Vienna, Austria, the World Health Organization announced that 5.2 million people in low- and middle-income countries received antiretroviral drugs for their HIV infections in 2009. This represents the largest increase in the number of people accessing treatment in a single year, with an additional 1.2 million people added to the four million who received antiretroviral therapy in 2008. While the increasing access to antiretrovirals is encouraging, over 10 million people infected with the HIV virus worldwide are still in need of therapy.

The WHO is calling for earlier treatment of those infected with the HIV virus, suggesting that if people are treated before their immune systems become weakened by the virus, HIV-related mortality can be reduced by 20% between 2010 and 2015. In addition, early therapy also has a benefit in preventing transmission of the virus. These new guidelines expand the number of people eligible for antiretroviral therapy from around 10 million to about 15 million people. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that the cost needed for HIV treatment in 2010 will be about US$ 9 billion.

Figure 1.

For the first time in the 15 year-long search for an HIV prevention method that women can control, a vaginal microbicide gel called Viread has been shown to decrease the risk of HIV infection by as much as 54%.  Even though the microbicide does not prevent transmission in every woman who uses it, this is the first promising tool that women are able to use without the cooperation of the male partner.  This is an important consideration most of the new HIV infections in women living in Africa were acquired through forced sex with infected men who refuse to wear condoms. Women and girls represent 60 percent of the 22 million people infected with HIV living in Africa.

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A recent article in the Christian Science Monitor by the SEVEN Fund’s Michael Fairbanks explores a potential approach to addressing Haiti’s need for long-term economic support. While several different groups have contributed to relief efforts after the devastating January 12th earthquake, many are looking to develop a more long-term solution. A challenge to building private-sector support is the atmosphere in a country where the elite and wealthy have often supported business initiatives which favor big business and are not developed to lend support to those most in need.

In order to create prosperity for the average Haitian citizen, innovative solutions are needed to develop “attractive export market segments to serve with unique products, building new distribution systems, lowering energy costs, and providing skills to Haitian citizens who will be compensated for the high value they create” according to Pierre Marie Boisson, a Harvard-educated, Haitian international banker.

Researchers at the Vaccine Research Center at the National Institute of Allergy and Infectious Diseases have identified three naturally occurring monoclonal antibodies that are able to kill 91% of strains of the HIV virus. One of these antibodies, named VRC01, has a high affinity for the virus and works by mimicking the HIV receptor. This discovery makes the development of an effective vaccine against the virus a real possibility.

The Bill & Melinda Gates Foundation, the Health Institute of Carlos Slim Foundation and the government of Spain have each contributed $50 million to fund the Salud Mesoamerica 2015 Initiative.  The Inter-American Development Bank will coordinate and commission independent evaluations as well as manage the combined contributions of the donors. The project’s primary aim is to reduce health inequities by fighting dengue fever and malaria and improving nutrition and maternal health in Belize, Costa Rica, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, and Panama. The funding amount received by each country will be based on their poverty and health inequity status.  While each government will determine what programs to finance with the Initiative,  incentives will be placed for more equitable allocation of domestic funding and for policy that improves the health of the poor.   This project is expected to generate globally-relevant knowledge of how to scale up cost-effective health interventions in poor communities.

This is not the first time that Slim and Gates have partnered up.  They have been working together at Prodigy MSN, which has just celebrated its 10^th anniversary.