3 strategic objectives are incorporated in USAID’s strategy:

1. Enhance the transition to low emission development via investments in clean energy and sustainable landscapes for climate change mitigation;
2. Grow resilience of people, places, and livelihoods through investments in climate change adaptation; and
3. Strengthen development outcomes through the integration of climate change in USAID programming, learning, policy dialogues, and operations.

“…the threat from climate change is serious, it is urgent, and it is growing. Our generation’s response to this challenge will be judged by history, for if we fail to meet it—boldly, swiftly, and together—we risk consigning future generations to an irreversible catastrophe.”

President Obama, United Nations Summit on Climate Change, September 22, 2009

The panel was moderated by Susan Dentzer, Editor-in-Chief of Health Affairs, and included representatives from USAID and several global health R&D partners from the public and private sectors (representing Product Development Partnerships – or PDPs).

• Hugh Chang, Director of Special Initiatives, PATH
• Rick King, PhD, Vice President, Vaccine Design, IAVI
• Emily Moore, Vice President for Business Development, Temptime Corp.
• Wendy Taylor, Senior Advisor for Innovative Finance and Public Private Partnerships, Bureau of Global Health, USA

World AIDS Day is a time to renew our commitment to the 34 million people living with HIV/AIDS worldwide and the recent developments revolving around HIV, including several scientific breakthroughs in HIV prevention research and Secretary Clinton’s recent remarks declaring that it is possible to reach an AIDS-free generation, make this an especially exciting time to reflect on the epidemic.

According to Dr. Bertozzi, the strategy of the Bill & Melinda Gates Foundation includes both decreasing new infections and improving quality of life of those currently infected. A large focus of this strategy is on the delivery of current strategies in large part through the Global Fund as well as smaller national programs.

Despite the proven effectiveness of existing prevention approaches, there are limitations. For example, many women are not in a position to insist that their partners wear condoms and daily adherence to prophylactic treatments is difficult. The development of a vaccine and other new prevention options is critical for successfully fighting the epidemic, especially in developing countries. The largest investment in newer technologies is currently in trying to develop a HIV vaccine. As such, a focus is on the success of the RV144 HIV vaccine trial, which recently showed encouraging results in Thailand and advancing that to the next generation of the vaccine with hopes of increased efficacy.

They are also investing heavily on products that can be used by individuals to protect themselves either topically in the vagina or systemically. While daily use of vaginal microbicides has shown mixed results, many reasons may contribute to this, especially lack of adherence which is a common problem with daily use products. To address these challenges, they are working on products which are less dependent on adherence such as a vaginal ring which slowly releases the antiretroviral compound dapivirine and can be left in for up to a month.

Another strategy is systemic daily antiretroviral prophylaxis which has also had mixed results and faces problems with adherence, but looks promising. They are focusing on injectables which can be injected every 1 to 3 months, decreasing the need for adherance. The Gates Foundation is currently supporting clinical trials to evaluate the effectiveness of Pre-exposure prophylaxis (PrEP) such as this for HIV prevention.

Images from the Bill & Melinda Gates Foundation

Additional efforts are on enhancing the delivery of male circumcision and scaling up these programs with fewer resources. Despite three clinical trials demonstrating the protective benefit of the procedure, donors and countries have been slow to invest in voluntary male circumcision for HIV prevention. The foundation is investing in advocacy efforts to encourage more rapid scale-up of male circumcision for HIV prevention and funding research on new technologies and methods for performing male circumcision safely and less expensively. This strategy is so cost effective that it costs more money to NOT implement such programs due to the future treatment savings.

The Gates Foundation is also working towards improving the delivery and effectiveness of current programs. With decreasing funding in a faltering global economy, scale up of treatment has continued at the same pace by improving efficiency of programs. Fortunately this has been happening in HIV treatment. Continuing efforts to reduce the cost of drugs, design and implement more efficient delivery systems and further task shifting and sharing among health providers is needed without compromising care and can even lead to improved quality of care.

As students immersed in the study of biological sciences, and as future physicians anxious to provide care and improve lives, we can be frustrated when public health policy seems based on interests neither scientific nor beneficent. United States programs that fight global AIDS have accomplished tremendous good over the past eight years; however, recent stewardship by President Obama has been disappointing both scientifically and morally. Last fall, many of us at Harvard Medical School protested President Obama because we believed his failure to keep his promises to scale-up the fight against HIV/AIDS was proof that he was ignoring the science and neglecting his ethical obligation to save millions of lives around the world. However, on Tuesday, Secretary of State Hillary Clinton delivered an inspiring address that is at once evidence-based and morally laudable.

When we began our protests last fall, there was a growing body of research indicating that treating HIV also prevents its spread. Evidence from a localized study South Africa indicated that when people with HIV received antiretroviral treatment (ART), their partners were 92% less likely to contract the virus. [1] Initial modeling used this information to theorize that, with universal access to treatment, infections could plummet within 10 years. [2] With this growing evidence (as well as other studies), the phrase “treatment as prevention”—long used by health professionals working at the front lines of AIDS care—resonated in scientific communities. Not only does treatment save lives, but these recent studies show that treatment could dramatically reduce new infections, slowing or even halting the epidemic in the future. It was not until this year, however, that this could be said with such certainty. A multi-site, large-N, randomized control trial showed that ART reduces new infections by 96%. [3]

We have also been encouraged by the growing literature showing that investments in HIV treatment programs improve health systems and eases delivery of other life-saving interventions.[4,5]  Dr. Paul Farmer, co-founder of Partners In Health, described HIV treatment as the “battle horse” to drive the necessary expansion in infrastructure and political will for addressing other global health priorities.

The evidence is clear: now, more than ever, we know that investing in AIDS treatment will save millions of lives and reduce new infections. Yet in the first years of his administration, President Obama fell dreadfully short on campaign promises to significantly improve resources for AIDS funding.  Many fellow classmates from Harvard Medical School, as well as from colleges and medical schools across the east coast, joined in protests encouraging the administration to uphold its promises.  It is impossible to forget the numbers—a year of AIDS treatment costs less than $100, and the treatment program makes up far less than 0.2% of the federal budget.  Yet while hundreds of billions of dollars went to bank bailouts, no new money was found for the meager $1 billion dollar annual rise that was promised during the election cycle.

Secretary Clinton’s speech on November 8^th, therefore, was encouraging.  She declared that for the first time, it will be United States government policy to create “an AIDS-free generation.”  She emphasized prioritizing high impact interventions—prevention of mother-to-child transmission, circumcision, and treatment.  And she lauded the vital role of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has been an innovative and transparent engine for delivering resources where they are needed most.  Secretary Clinton’s speech had much of what is needed, except for the numbers.

To transform the Secretary’s vision into a reality, we will need bold treatment targets and solid commitments to increase funding.  Six million patients on treatment by the end of 2013 would be an appropriate goal for the United States government, which is on track to have four million on treatment by the end of this year.  Congress and the administration have responsibility for the 2012 budget, while the Super Committee debates 2013 and beyond.  We eagerly await President Obama’s address on World AIDS Day (December 1^st).  Lawmakers have the opportunity to transform one of the greatest human scourges of our generation, or to be held accountable for inaction by patients, activists and history books.  As medical students, we have the ability to hold lawmakers accountable by calling and writing our elected officials, and communicating publically the cost of inaction.

-Matthew Basilico, Nworah Ayogu, Arjun Suri; Harvard Medical School

References

1. Deborah Donnell, Jared M Baeten, James Kiarie, Katherine K Thomas, Wendy Stevens, Craig R Cohen, James McIntyre, Jairam R Lingappa, Connie Celum, “Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis,” The Lancet 2010;375:2092-2098.

2. Reuben Granich, Siobhan Crowley, Marco Vitoria, Ying-Ru Lo, Yves Souteyrand, Christopher Dye, Charlie Gilks, Teguest Guerma, Kevin M De Cock, and Brian Williams “Highly active antiretroviral treatment for the prevention of HIV transmission,” Journal of International AIDS Society 2010; 13:1

3. Cohen MS, Chen YQ, McCauley M, et al. “Prevention of HIV-1 infection with early antiretroviral therapy.” New England Journal of Medicine 2011;365:493-505.

4. David Walton, Paul Farmer, Wesler Lambert, F. Léandre, Serena Koenig and Joia Mukherjee, “Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti,” Journal of Public Health Policy 2004:137-158.

5. World Health Organization, “An Assessment of Interactions Between Global Health Initiatives and Country Health Systems,” Lancet 2009;393:2137-2169.

Stay tuned to Global Pulse Blog for more views on this monumental speech and its implications.

Yesterday, Secretary of State Hillary Rodham Clinton declared the U.S. government’s intent to create an “AIDS-free generation.” Secretary Clinton outlined a bold plan to reduce new HIV-infections, globally, including the eradication of pediatric HIV by 2015. This new strategy builds upon the success of the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. program that addresses HIV/AIDS in resource-limited settings.

A notable feature of Secretary Clinton’s “AIDS-free generation” initiative is to strengthen healthcare systems in sub-Saharan Africa. Clinton stated:

“We know we can’t create an AIDS-free generation by dictating solutions from Washington. Our in-country partners — including governments, NGOs, and faith-based organizations — need to own and lead their nation’s response. So we are working with ministries of health and local organizations to strengthen their health systems so they can take on an even broader range of health problems.”

Strengthening African healthcare systems is a view echoed by many eminent voices in the global health community. Last year, the Institute of Medicine (IOM) of the National Academy of Sciences authored a report entitled: “Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility.” The IOM report recommended the urgent need to increase African healthcare workforce capacity to address the HIV epidemic.

I offer Secretary Clinton a solution to assist African healthcare workforces and ensure the success of the “AIDS-free generation” initiative. Last year, in an editorial in The New England Journal of Medicine, Vanessa Kerry, Sara Auld, and Paul Farmer reintroduced the idea of enacting a Global Health Service Corp (GHSC). The GHSC, compromised of U.S. healthcare professionals, would provide medical education and technical assistance to enhance the healthcare workforces in low-income countries. The GHSC’s goal would “go beyond that of filling a human resource void to focus on infrastructure development, knowledge transfer, and capacity building.” The GHSC could also offer partial student loan forgiveness for U.S. corps members who engage in service abroad for a specified time period similar to the loan forgiveness offered by the National Health Service Corp.

To address the African healthcare workforce shortage, I encourage Secretary Clinton to adopt the principles of the GHSC. The success of the “AIDS-free generation” initiative depends on the availability of skilled healthcare workers in African resource limited settings. Additionally, the eventual transition from a U.S. to African led HIV/AIDS response requires the U.S. to teach and train healthcare personnel in recipient countries through collaborative partnerships that eventually lead to African ownership of their domestic healthcare needs.

Some may argue that enacting the GHSC, especially in the era of U.S. government austerity measures, is not prudent. However, the funding for the GHSC already exists. In addition to HIV/AIDS prevention and treatment, PEPFAR’s congressional mandate requires the program to “strengthen partner government [healthcare] capacity to lead the response to this epidemic and other health demands.” Last year alone, PEPFAR committed over $734 million in healthcare capacity building initiatives.

Global health is the moral litmus test of our time. As Secretary Clinton asserted: “An AIDS-free generation would be one of the greatest gifts the United States could give to our collective future.” The U.S. should enact the GHSC to ensure the success and sustainability of the “AIDS-free generation” initiative.

-Anand Reddi, The Huffington Post

If you are interested in supporting the Global Health Service Corp please sign the petition to show your support. http://www.globalhealthservicecorps.org/index.php/petition/

Additionally, the Medical Student Section of the American Medical Association is considering a resolution endorsing the GHSC at its 2011 Interim Meeting in New Orleans, Louisiana.

Hosted by GHDonline in collaboration with PIH, the panelists include:

• Dr. Agnes Binagwaho, Minister of Health of Rwanda
• Ted Constan, Chief Operating Officer, Partners In Health
• Dr. Felix Kayigamba, Access Project Country Director
• Christina Bethke, Program Coordinator, Tiyatien Health
• James Pfieffer, NGO Code of Conduct author and Director of Mozambique Operations, Health Alliance International

To join the discussion, please sign up today!

Bill Gates and Rotarians make the “This Close” gesture on the steps of the U.S. Capitol in Washington, D.C. on World Polio Day, October 24, 2011, to promote Rotary’s End Polio Now campaign and show how close the world community is to eradicating the scourge of polio

Learn more about World Polio Day and global efforts to eradicate this disease which has been decreased thus far by 99% thanks to efforts including vaccination campaigns.

For more reflections on the event, tune into the Kaiser Family Foundation event - What Happened at the UN High-Level Meeting on Noncommunicable Diseases? Diverse Perspectives on the Meeting’s Outcomes and Next Steps tomorrow Thursday, September 29, 2011 from 12:30-2:30pm EST. You may RSVP at: http://smartglobalhealth.org/outcomesUNHLM

The Director of the Office of Global Health Affairs at the U.S. Department of Health and Human Services, Dr. Nils Daulaire, will introduce the event with a keynote address on the major achievements and outcomes of the high-level meeting, areas of unresolved tension and disagreement, and critical follow on steps over the next two years. This will be followed by a panel of diverse commentators, including:

Ambassador Ebrahim Rasool, South African Ambassador to the United States
Dr. Trevor Gunn, Senior Director of International Relations at Medtronic
Dr. Peter Lamptey, President of Public Health Programs, FHI 360

WHO Photo

Phots from the UN website

• The House State and Foreign Operations Appropriationsbill for Fiscal Year 2012;
• Movement on the Foreign Relations Authorizations Acts in the House and Senate; and
• A Government Accountability Office report on the President’s Emergency Plan for AIDS Relief (PEPFAR).

The Policy Tracker is a great feature of the Kaiser Family Foundation’s Global Health Gateway, an online source for information on the U.S. role in global health, with policy analysis, polling and other research; daily global news synthesis via the Kaiser Daily Global Health Policy Report; and country-level data through Kaiser’s Global Health Facts.

Rachel Nugent has an interesting take on these new estimates and the methods behind them in her recent op-ed published in the New York Times International Edition. She suggests that we think about how fertility and mortality differentially affect population levels and growth rates instead of thinking about “population.”  Additionally, she suggests that discussions of population growth consider how effective family planning policies can lead to lower fertility and therefore reduce maternal and child mortality. This approach, she suggests, is more effective in bringing about actual change.

• Beth Tritter, Managing Director, The Glover Park Group; Former Legislative Director for Congresswoman Nita Lowey, Ranking Member of the House Appropriations Subcommittee on State and Foreign Operations.
• Todd Summers, Senior Advisor for Global Health, ONE Campaign.
• Allen Moore, Senior Advisor for Global Health Security Program, Stimson Center, and Adjunct Professor in Global Health, George Washington University; Former Deputy Chief of Staff and Policy Director for Former Senate Majority Leader Bill Frist.
• Jennifer Kates, Moderator, Vice President and Director, Global Health & HIV Policy, Kaiser Family Foundation.

They will examine the new legislative landscape of the 112th Congress and the ways in which recent changes will impact global health programs and foreign assistance.

You can watch the live studio webcast on kff.org. Viewers can also email questions before or during the live webcast at infocus@kff.org.

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

The following resources provide more information on the interactions between international trade and health:

• Is International Trade Impacting Health? Challenges for This Decade by Josh Ruxin. Virtual Mentor. 2010; 12:213-217.
• Trade and Health 101 from the Global Health Council.
• Understanding Private Sector Involvement in Health Systems Fact Sheet and Research Brief from the Global Health Council.
• Trade, foreign policy, diplomacy and health from the World Health Organization
• Counterfeit & Substandard Drugs in Low Income Countries fact sheet from the Global Health Council.
• The Impact of Tariff & Non-Tariff Barriers on Access to Essential Drugs for the Poorest People policy brief from the Global Health Council.
• World Trade Report from the World Trade Organization.
• AIDS, drug prices and generic drugs from AVERT.org.
• Global Trade and Public Health by Shaffer, E, Waitzkin, H, Brenner, J, Jasso-Aguilar, R. January 2005, Vol 95, No. 1 | American Journal of Public Health 23-34
• Foreign policy, trade and health: at the cutting edge of global health diplomacy by Drager, N and Fidler, D. Bull World Health Organ. 2007 March; 85(3): 162.

The 2010 UNAIDS report highlights updated information regarding the epidemic, including the growing number of people practicing safe sex, and gaining access to antiretrovirals in many parts of the world. Offering hope that progress is being made to quell the epidemic, UNAIDS reports that at least 56 countries have either stablized or achieved significant declines in rates of new HIV infections, with new HIV infections declining almost 20% in the last five years. At the same time that rates of new infections are declining overall worldwide, the number of new infections are increasing in areas like Eastern Europe and Central Asia, in large part due to injection drug use.

Highlights of the UNAIDS 2010 Report on the Global AIDS Epidemic

Kaiser Family Foundation recently held a webcast on “The Future of US Multilateral Engagement on Global Health“ as part of the Foundation’s US Global Health Policy: In Focus live webcast series. This question and answer format webcast featured an expert panel including Mark Abdoo the director for Global Health and Food Security, Natasha Bilimoria the president of Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria, and Jennifer Kates the vice president and director of Global Health Policy & HIV for the Kaiser Family Foundation, moderated by senior analyst Josh Michaud.

This discussion explores the approach taken by the United States to address Global Health funding historically and looking into the future. Discussions on global health funding often involve a division between bilateral approaches to funding versus multilateral funding engagement. Bilateral funding involves the provision of direct assistance from one government to, or for the benefit of, one or more other countries, with the donor having significant control over the target, approach and content of assistance. On the other hand, multilateral organizations such as the World Health Organization, the United Nations and the Global Fund, bring together global stakeholders to develop and collaborate on global health targets.

Historically, the US has commonly supported global health priorities via bilateral funding and programs but the focus on promoting multilateral organizations is growing. For example, the US was the first and is currently the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and a key component of the Obama Administration’s Global Health Initiative includes a renewed and increased commitment to multilateral engagement. The shifting approach has led to questions regarding the appropriate focus for US global health engagement, the proper balance between multilateral and bilateral funding efforts and the appropriate role of the US government and other organizations in international treaties and other collaborative agreements.

Check out this and more global health-related webcasts and other valuable resources on global health policy at the http://www.kff.org/ website. A more detailed discussion on the US Government’s Global Health Policy Architecture is also available.

Check out the webcast from the recent “The Future We Make” meeting on the Bill and Melinda Gates Foundation website for an engaging and insightful discussion of issues related to the Millennium Development Goals such as child mortality rates, birth rates, literacy, HIV/AIDS and more on a global level.

TEDxChange Webcast

• End Poverty and Hunger
• Universal Education
• Gender Equality
• Child Health
• Maternal Health
• Combat HIV/AIDS
• Environmental Sustainability
• Global Partnership

The Millennium Development Goals Report 2010 summarizes the progress which has been made thus far while striving to meet these goals as well as potential actions, strategies and policies which could be implemented to continue positive progress.

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.

With the highest recorded global population growth rate and the most enormous demographic shift ever between the more developed and less developed regions, the century from 1950 to 2050 saw dramatic changes in global development. It is still unforeseen whether this pattern of human development will remain sustainable. This paper explores the ways in which policy could respond to unmet human needs, many of which have arisen from human choices rather than biophysical necessities.

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.

In order to achieve such coverage for only two dollars a year, the government of Rwanda must receive supplemental help from outside organizations such as Partners in Health, The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US government. Additionally, the plan requires co-pays which can be cost prohibitive for many patients. For example, a Caesarean section requires a five dollar co-pay which many patients cannot afford.

For more on this issue check out the New York Time’s recent article, this info sheet from the World Bank and this article in the bulletin of the World Health Organization.

A related webcast and fact sheets on maternal and child health and family planning are also available.