The Global Pulse Journal Blog

The World Bank and USAID are hosting a series of debates exploring emerging issues in global responses to HIV/AIDS and worldwide evolving approaches to development aid, .  The debates attempt to lay out the best evidence and information available to assist world governments, civil society organizations, and other development organizations in interpreting and responding to the shifting dynamics of the epidemic and our collective responses to the challenges it presents.

This global discussion series began this past May with a debate entitled “Test and Treat: Can We Treat Our Way Out of the HIV Epidemic?” which looked at testing and treating strategies with a focus on their role in Africa.

In June, a debate on “Behavior Change in HIV Prevention” took place looking at dynamics involved in behavior change approaches and their past ineffectiveness.

Check out these past debates and the ones still to come including theis week’s August 26th debate on “Discordant Couples and HIV Transmission” and continue to follow this debate series for future conversations.

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.

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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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.

In an anti-drug conference held in Moscow recently, Russian President Dmitri Medvedev called for an a more globally unified effort to end the drug trafficking of opium from Afghanistan and the social problems that are a direct result from its trafficking. With over 90% of the world’s opium originating from Afghanistan, President Medvedev believes that that current efforts by international organizations such as the United Nations, NATO and Shanghai Cooperation Organization, are not enough. Opium poppies are the raw material used to make heroin.   According to the U.N. Office on Drugs and Crime, heroin has created a market worth $65 billion and caters to 15 million addicts world-wide.

The effects of Afghanistan’s 375 ton per year opium and heroin export are also felt at home through direct use and passive exposure such as  second-hand and third-hand exposure.  A new study that will be finalized this summer is expected to show that in Afghanistan 1.5 million people out of a total population of 30 million are addicts and that a quarter of those users are thought to be women and children.

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Farheen Qurashi, AMSA’s Jack Rutledge Legislative Director 2009-2010, and Mary Carol Jennings, AIDS Advocacy Network Chair 2009-2010, contributed to this post.  To join this event in NYC on May 13th, please contact Farheen at jrld@amsa.org.

On the campaign trail, President Obama pledged “to provide at least $50 billion by 2013 for the global fight against HIV/AIDS, including our fair share of the Global Fund, in order to at least double the number of HIV-positive people on treatment and continue to provide treatments to one-third of all those who desperately need them.”  HIV/AIDS patients and their advocates, including AMSA members, were important in getting then-candidates Obama, Clinton, and Biden to commit to these figures.

However, since taking office, the Obama Administration’s budgets have flatlined funding for AIDS programs.  Our commitments to fighting AIDS have not even kept pace with inflation: PEPFAR funding increased by only 2%  in 2010, while annual  inflation in most African countries is 7%.  Now, clinics around the world are reporting turning away patients with clinical AIDS who would previously have been treated, due to funding cuts (ITPC, 2010).

On May 13th, AMSA will be gathering for a white-coat protest at a Democratic Party fundraiser at St. Regis Hotel in NYC, to remind President Obama of his promises.  We will be joining activists from ACT UP, Africa Action, African Services Committee, NYC AIDS Housing Network, VOCAL-NY Users Union, Housing Works, Health GAP, Philadelphia Global AIDS Watchdogs, and other allies.  Join us, and let the President know that extending AIDS funding to meet the global need is important to you!  Please contact Mary Carol Jennings (marycaroljennings@gmail.com) for more details.

UPDATED: [05.11.2010] More information and disclaimer after cut. Read the rest of this entry →