Politics and Policy of HIV/AIDS

As the global AIDS community prepares for the conference beginning Sunday in Mexico City, President Bush is signing the reauthorization bill for PEPFAR today. It has been named after Tom Lantos and Henry Hyde, Democratic and Republican members of Congress who passed away within the past year. When Elizabeth Dole attempted to name the bill for recently deceased Senator Jesse Helms, there was much backlash, given Helms’ early opposition in the 80’s and 90’s to AIDS spending, a disease he saw as a result of deviant behavior. Helms would go on to have a near deathbed conversion to support the cause of HIV/AIDS, at least in the developing world, but naming the bill after him would have been a bridge too far.

In any case, it is the Lantos and Hyde bill which includes authorization for $48bn for PEPFAR for 2009 (and, as I understand it, will require Congressional appropriation in the coming months). More than half of the money will have to go to treatment, but the restriction that 1/3 of the prevention money be spent on abstinence and fidelity programs has been lifted. Given that there were still more than 2.5 million new infections last year, the inadequate focus on prevention is troubling, as we have blogged about here and for which there is a new CGD blogpost.

The Washington Post has an interesting story on how the open-ended commitment to treatment is unprecedented in terms of U.S. foreign assistance. The article: “AIDS Funding Binds Longevity of Millions to U.S.: Open-Ended Commitment of Money Is Implied” is worth a read.

Foreign aid for health care has traditionally been used to put up buildings, buy equipment and train workers. Direct medical care of individuals was limited to one-time interventions such as vaccinations, emergency treatment after natural disasters, and curative treatments of limited duration for diseases such as tuberculosis or leprosy.

Bush’s program is fundamentally different. So far, it has purchased vast quantities of antiretroviral drugs and supported day-to-day medical care for more than 1.4 million people whose survival depends on continued treatment.

“It is the first time I can think of where we have foreign aid treating a chronic disease,” said Michael H. Merson, director of Duke University’s Global Health Institute and a former head of the World Health Organization’s AIDS office. “It’s a challenge to take this on. I think the questions it raises are going to be important ones for the future.”

We have a moral obligation to continue treatment for those who are on it already. Taking someone off treatment who is on it would constitute a death sentence. However, unless we really put much more emphasis on prevention, the treatment budget is going to continue to grow.

For our readers out there, I know that ARV therapy in the West has enabled people to live an indefinite amount of time. In developing countries, my understanding is that donors are extending ARV to people, for the most part, who are already very sick, meaning that treatment, on average, only extends people’s lives for years, maybe 3-5 years. However, we don’t actually have that many years of experience with people on treatment in developing countries so I wonder if those averages are being extended. For people who have experience administering these programs, we would welcome comments and feedback about how this is carried out in practice. I wonder if those worried about this “entitlement” have incorporated into their estimates of future costs that a good proportion of the people donors have “saved” will die in the coming years.

From a moral perspective, the important thing is that the lives of people on treatment are extended, giving them more hope for the future. They can hope they are among those who exceed the average and at the very least, they’ll have more time with their children before.

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Filed under: Politics and Policy