During a recent Duke Global Health Institute talk as part of Global Health Week 2011, Ugandan physician and HIV/AIDS pioneer Peter Mugyenyi gave a talk on the unresolved AIDS crisis in Africa. In his talk, Mugyenyi reiterated that, although progress has been made in the fight against HIV/AIDS, the epidemic is far from over. He emphasized that the implementation of the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have played large roles in saving the lives of millions around the globe. For example, Mugyenyi directs the Joint Clinical Research Center in Kampala, which receives funding from these organizations to bring life-saving antiretroviral therapy to hundreds of thousands of Ugandans. In the following video of Mugyenyi’s talk at Duke, he shares his thoughts on the role of universities in the fight against HIV/AIDS and his hopes and concerns for the future.

Peter Mugyenyi: The Unresolved AIDS Crisis in Africa

Yesterday, the international donor community pledged $11.7 billion over the next three years to fund The Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. The fund had hoped to raise $20 billion. This shortfall in necessary funding will put at risk the 2015 goal to: eliminate HIV mother-to-child transmission worldwide, prevent the spread of multidrug resistant TB, and eradicate malaria as a public health issue.

A pressing question amongst global health advocates is how to finance global health in the midst of this global economic recession?

One solution proposed is the enactment of a financial speculation tax on the currency transactions market. The proceeds raised could fund global health initiatives such as the Global Fund and the President’s Emergency Plan for AIDS Relief (PEPFAR).

Sixty countries including France, Germany, Japan, Spain and the United Kingdom are publiclysupporting an international financial speculation tax on the $4 trillion dollar currency transactions market. In the United States, Congressman Pete Stark (D-CA), introduced H.R. 5783, the Investing in Our Future Act. Representative Stark proposes “a small tax — of five thousandths of one percent, or 0.005% — on currency transactions. Due to the extreme speculation that takes place, it would raise [at least] $28 billion a year and reduce currency speculation by 14 percent.”

Some may argue, as fiscal conservatives surely will, a tax on banks is ill advised at this time given the anemic state of our economy. However, David Stockman, director of the Office of Management and Budget under President Reagan, writes in the New York Times that “while supply-side catechism insists that lower taxes are a growth tonic, the theory also argues that if you want less of something, tax it more. The economy desperately needs less of our bloated, unproductive and increasingly parasitic banking system.” A proposed financial speculation tax — a financial “pinprick” for international banks — would be an important stream of revenue to fund domestic and global development initiatives as well as reduce the reckless financial speculation practices of international banks.

Global health is the moral litmus of our time. As Nelson Mandela once said “Sometimes it falls upon a generation to be great.” Fifty years from now, will we want to remember that we bailed-out AIG, Citibank, and Goldman Sachs? Or will we want to remember that we committed the necessary funds to end the scourge of AIDS, TB, and Malaria?

I urge President Obama and the United States Congress to support Congressman Stark’s Investing in Our Future Act. Together we can finance global health and protect Wall Street from the dangerous speculation practices that contribute to global economic instability.

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.

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)

Q: Roxana Rogers, USAID’s South Africa health team leader, said recently in South Africa that, “US government funding is going to come down dramatically over the next five years.” True?

A: No, it’s not true. Every year there’s been an overall increase in funding for PEPFAR, and we’ve also not been in a situation where we’ve had a decrease in any country, certainly not in South Africa. Our funding for South Africa is over a half billion dollars a year. Our resources that go into South Africa are having a huge impact, and I’m not understanding that (comment by Rogers).

We also committed to $120 million recently over two years to specifically address an unexpected shortage of funding for antiretroviral drugs in South Africa in nine provinces. The South African government asked us to be silent (about it during that time.) … It made a lot of sense for us to fund it for the simple reason that we not allow services to be interrupted and allow South Africa to respond to the increase in demand.

Roxana’s statement is based on the fact – I think – that she was used to PEPFAR funding that went up in huge increments every year — so much so they scrambled to find meaningful applications to use the funding for programs. Now we are in an economic crisis, with nowhere near the increase in funding like that, so on a relative level it may feel like a drop in funding.

Q: What happened in South Africa’s shortfall of funding for treatment?

A: PEPFAR has not run out of any antiretroviral drugs in any country, including South Africa. .. But for multiple times we’ve been asked to bail out a country for one or two months (because of drug shortages in the national program or funding shortages). South Africa had run out of resources to pay for the medication in nine provinces, starting in November. It was a significant outlay of resources for us and a real example of cooperation. In addition, we were able to work with the government to ensure their Treasury picks up the bill thereafter, so it doesn’t happen again.

Be sure to read the entire interview.