This editorial is based on a short trip I took to South Africa earlier this year.
April 2009

In 2006, then-U.S. Senator Barack Obama and his wife Michele traveled to Kenya, Obama’s father’s homeland where many of the senator’s extended family still lived. The Obamas publicly took an HIV test during their trip, an important moment as sub-Saharan Africa is the region most affected by the HIV/AIDS crisis, with more than 2/3 of the world’s infections.

For every outspoken leader on HIV/AIDS like Uganda’s Yoweri Museveni, there have been as many or more AIDS denialists like South Africa’s former president Thabo Mbeki and his shamefully ignorant health minister Manto Tshabalala-Msimang who at one time suggested that beetroot and garlic were effective treatments for HIV. Given the new U.S. president’s Kenyan heritage, Barack Obama may be uniquely placed to speak to the African people about the dangers of HIV and steps they can take to protect themselves. While Obama may have this special connection, larger currents will constrain his ability to advance the fight against HIV, a product of both the positive and negative legacies of the George W. Bush administration….

Given that there is no cure for AIDS, the extension of treatment to those who are HIV-positive is perhaps a deeper responsibility than people realize. Donors assume moral responsibility to extend ARV therapy for the remainder of those people’s lives.  Repudiation or interruption of that commitment would be extremely damaging, as those people would die unless the cost of treatment were picked up by some other donor, the person’s government, or the individuals themselves. Of course, people who never receive treatment will also die, but it would be even more unseemly to extend treatment only to later take it away. Before the donor community continues the practice of putting people on treatment when they are already quite sick, leaders should re-evaluate the efficacy of those efforts.

At the same time, it would be a tragedy if the global community decided to “walk off the field” by allowing their attention to lapse or stray. Nearly a decade into the world’s ambitious effort to address the AIDS pandemic in the developing world, there is a great danger that the financial crisis, other priorities, and the continued spate of new infections will cause donors to lose heart. The Obama administration should seize the moment to infuse the donor community with a new sense of purpose, focusing on the most promising avenues to reduce the rate of new infections. That would be change we could believe in.

Let me say that I normally like this pope. At least as much as a non-RC can.

But what he said in a one-off comment is more than “irresponsible”, as some have called it. It is a lie and will lead to unneeded deaths among those Benedict says need the world’s most special efforts—the poor.

And before anyone lectures me about the morality of drug legalization or illegalization, what I care most about is keeping people from getting HIV. “Harm reduction” (which includes things like needle exchange) is the best we’ve got right now. If we can figure out a better way that coincidentally legalizes or bans drugs, I’ll be for that.

U.N. Anti-Drug Efforts Contributing to Spread of HIV, Advocates Say

Members of the United Nations this week are expected to sign a declaration to extend a “war on drugs,” a policy that some critics argue is ineffective and contributes to the spread of HIV, Reuters reports. The U.N. Office on Drugs and Crime is drafting the declaration, which calls for a 10-year renewal on efforts to eradicate all narcotics by using law enforcement to target traffickers and producers and end drug use worldwide.

Some critics of the policy say the declaration’s lack of focus on harm-reduction strategies, including needle-exchange programs for injection drug users, has increased the spread of HIV and other diseases. In addition, some drug policy advocates, social scientists and health experts say that the strategy has not been successful, with statistics indicating that drug production, trafficking and use have increased during the past 10 years. The cost of law enforcement also has increased, according to statistics. UNODC Director Antonio Maria Costa said, “The crime and corruption associated with the drug trade are providing strong evidence to a vocal minority of pro-drug lobbyists to argue that the cure is worse than the disease. This would be a historical mistake, one which United Nations member states are not willing to make.” Reuters reports that the declaration is expected to be signed in Vienna, Austria, on Wednesday or Thursday (Baker, Reuters, 3/10).

A statement released on Wednesday by Human Rights Watch, the International AIDS Society and the International Harm Reduction Association called for member governments not to support the declaration because “critical elements” to prevent HIV were stripped from the final document. The statement said, “What is at issue is a series of measures known collectively as ‘harm reduction services,’ which have been endorsed by U.N. health and drug-control agencies,” including the UNODC, UNAIDS and the World Health Organization. According to the statement, such measures include needle- and syringe-exchange programs and medication-assisted therapy, inside and outside prisons, which are “essential to address HIV among people who use drugs.” According to the groups, a “wealth of evidence proves harm reduction is essential to HIV prevention for people who use drugs.” Up to 30% of all HIV infections outside sub-Saharan Africa occur through unsafe injecting drug use, the groups said, adding that there is “clear evidence that harm-reduction interventions can halt or even reverse HIV epidemics among people who inject drugs” (HRW/IAS/IHRA release, 3/11).

In 2007, the UK surpassed the United States as the largest donor to IDA, the World Bank’s wing for the poorest countries in the world. The UK has also shouldered a disproportionate share o funding for global AIDS efforts. Should Brown be ousted in a leadership competition or if the Conservatives win, will Brown’s successor be as pro-development? Will Britain even be able to sustain its contributions at the level it has over the past decade? Donors haven’t come close to meeting their pledges of an additional $50bn per year by 2010. With advanced industrialized country economies struggling, campaigners should be worried that foreign assistance funds may subject to much greater fiscal discipline by donors and AIDS funding may be subject to donor fatigue.

Given the variety of demands from advocates, competition for those funds will likely increase, and campaigners in the public health arena need to be thinking about political priorities — sustained and/or deepened provision of ARV’s, more support for health systems, a turn towards other health priorities like maternal health and child survival, a focus on other issues like climate change and education, etc. These are critical times for the global economy and could signal a turning point in the political effectiveness of the development advocacy in coming years.

Postscript: We may be poised to be entering a global recession or at least a downturn among the world’s advanced economies. One of the most prescient and clear voices on the global economy, Nouriel Roubini, had this to say this morning in the FT:

The real economic side of this financial crisis will be a severe US recession. Financial contagion, the strong euro, falling US imports, the bursting of European housing bubbles, high oil prices and a hawkish European Central Bank will lead to a recession in the eurozone, the UK and most advanced economies.

Even if foreign assistance constitutes a small proportion of donor budgets, aid and development circles are worried their concerns are among the most vulnerable to cuts, or at the very least, stagnant budgets.

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.

Looks like Sen. Jim Demint made an ass of himself before his colleagues on Friday when he insisted on a Friday evening procedural vote on cloture and then didn’t show up. He called for cutting the bill’s pricetag down to $35bn.

In so doing, he likely ensured that the full $50 billion gets appropriated (which was more than what the President wanted). The bill no longer has a mandate that 55% of funding be spent on treatment (which was part of the previous PEPFAR authorizing language and what the bloc of holdout Senators wanted). The legislation leaves it a little vague and says more than half will be spent on treatment.

While this is good news, the bill hasn’t passed yet. Debate is this week. Republicans are offering a series of amendments to try to divert the spending for domestic purposes.

Here is an excerpt on Demint’s gift to his colleagues.

After finally breaking a procedural logjam, the Senate this week will move ahead with a $50 billion AIDS initiative that has the support of Democrats, Republicans and the White House. It would seem like a sure bet – except for Senator Jim DeMint.

Mr. DeMint, a Republican from South Carolina, forced the Senate last week to take a rare Friday evening procedural vote in order to begin debate on the legislation that seeks to step up AIDS treatment and prevention efforts in Africa, Asia and elsewhere. He then missed the vote he had instigated, provoking scattered boos from the floor – an occurrence more typical of the House than the Senate.

In one of the chief challenges to the AIDS bill, Mr. DeMint is scheduled to offer a proposal to reduce the five-year cost of the legislation to $35 billion. He has complained that Democrats were unfairly trying to limit efforts to change the bill. Given that both Republicans and Democrats were very unhappy with his decision to force them to take a Friday vote he then missed, it is hard to envision a successful outcome for his proposal.

Japan on Friday announced that it had pledged $560 million to the Global Fund To Fight AIDS, Tuberculosis and Malaria, AFP/Google.com reports. Prime Minister Yasuo Fukuda said the funds will be allocated “in the coming years” from 2009, but he did not specify over how many years the aid will be disbursed. A foreign ministry official said that the pledge aims to “demonstrate Japan’s diplomatic efforts to help Africa” as Japan prepares to host an internal conference on aid to the continent next week, as well as the Group of Eight industrialized nations summit in July. According to AFP/Google.com, Japan hopes to make Africa a primary focus while it chairs the G8.

The Japanese appear to be wanting to make a big splash at the upcoming G8 meeting. These summits seem to occasions in which international donors like to fall over themselves to make grand promises. Germany did something similar last year when it hosted the G8 Summit. Campaigners have done a good job making global health a popular development cause, and this may prove to be a more politically tractable issue for the Japanese to garner international prestige compared to climate change, which has been touted as another signature issue for the Japanese at the upcoming G8 meeting (lots of luck there with the Bush Administration!).

Japan’s changing position on international AIDS funding is interesting. They have lagged behind other contributors, as I’ve written about here. They are just coming out of a long recession, during which Japan’s ODA contributions declined dramatically. Anybody with an inside story of these transformations in Japan’s approach to global AIDS funding (which still seems largely directed multilaterally rather than bilaterally like other donors) should e-mail me.

I have written on the particular salience of international cooperation for the Japanese in my piece on debt relief that came out in International Studies Quarterly last year. On the issue of AIDS, the Japanese appear to be particularly proud that the idea for the Global Fund came out of a meeting hosted in Japan by Prime Minister Mori in 2000. I also have a draft manuscript on the politics of HIV/AIDS donors that I’ve been working on for about three years. Get in touch if either piece is of interest.

As promising as this change in Japan’s policy promises to be, there is some concern in the advocacy community about the ambiguous time frame for when Japan will actually make good on its pledge. Japan’s move I understand may also signal a renewed concern from the donor community to address support for health systems, as I have previously supported here on this blog before (see here, here).

On that theme, Michael Reich and his co-authors have an important article in March 2008 Lancet on Japan opportunity to boost support for health systems at the upcoming G-8 Summit. They write:

The G8 summit in Toyako offers Japan, as the host government, a special opportunity to influence collective action on global health. At the last G8 summit held in Japan, the Japanese government launched an effort to address critical infectious diseases, from which a series of disease-specific programmes emerged. This year’s summit provides another chance to catalyse global action on health, this time with a focus on health systems.

However, as optimistic as they are about this emerging direction of the donor community, it is unclear if anybody actually knows how to build health systems. It seems like the record on this may be as poor as the one on broader development and good governance. Reich et al. write:

What can be done when a health system is broken—ie, when a health system is unable to deliver its services effectively, or efficiently, or fairly? Governments around the world (in both rich and poor countries) have struggled with this question for decades. One conclusion is clear: there are no easy solutions to the problems that arise in health systems. National efforts aimed at reforming such systems have achieved mixed results.

The mechanics and politics of health systems support requires much greater development. The U.S. Congress, for example, strongly supports treatment programs in part because you can scale up quickly, in part with American contractors, and track the number of people on drugs. How can you judge success in health systems capacity? It’s not, as Reich et al. note, just a function of training doctors and counting them up. This is a huge task, and one that foreigners may fail at markedly, particularly in places where the quality of governance is so bad.  I think this is why Senator Coburn, as short-sighted as his logic may be, wants to support treatment so heavily as part of PEPFAR. From his perspective, money spent on health systems will get siphoned off in ways that ultimately don’t generate capacity, only graft and consultancy fees.

One interesting question is how can islands of excellence be established? I’m reading Tracy Kidder’s account of Paul Farmer’s clinics in Haiti. Certainly, some people have more success than others in building local capacity. Are these scale-able? We’ll certainly revisit this topic.

Michael Gerson, Bush’s former speechwriter, flagged this egregious action to set up an internal Republican dispute. As Gerson notes, Coburn objects that more of PEPFAR money is being spent on things other than treatment.

The seven, led by Coburn, complain that the reauthorization is too costly. They object to “mission creep” — the funding of “food, water, treatment of other infectious diseases, gender empowerment programs, poverty alleviation programs” — as though people surviving on AIDS treatment do not need to eat, work or get their TB treated.

They want 55% by law to be spent on treatment (which was how the first PEPFAR authorization worked) but this is stupid, as we’re not succeeding on prevention, meaning that more and more people are getting HIV and ultimately needing treatment. As Gerson writes:

Given that there are about 2.5 new HIV infections for every person starting on AIDS drugs, there is no way to control the pandemic through treatment alone. And because treatment is less expensive than it used to be, PEPFAR is meeting its treatment goal for less money. The 55 percent treatment floor would force the program to waste money in pursuit of an arbitrary, nonsensical spending target — the worst kind of congressional earmark.

You may want to give Coburn and company an earful about this nonsense. The ONE campaign has a letter to sign here. Direct contact info is available here.

UPDATE: Here is part of Coburn’s response where he rails against Gerson, touts his own credentials as a physician who has cared for AIDS patients and a consistent champion of HIV/AIDS programs. What he seems to be worried about is that the absence of a directive that 55% of PEPFAR money be spent on treatment will result in the program spending more money on consultants rather than services. I’m not sure if those funding directives are the best or only way to ensure that problem doesn’t occur.

Part of Gerson’s moral outrage is focused on my controversial stance that AIDS treatment dollars be spent on treatment. I want to preserve PEPFAR’s original formula that sends at least 55 percent of all dollars to AIDS treatment so widows and orphans and actual patients, not program officers and consultants, will be the primary beneficiaries of the program. This formula is made all the more important because the new authorization calls for a three-fold increase in funding from $15 billion over five years to $50 billion over five years. Moreover, this smart and well-designed policy, which Gerson once supported but now scorns, is a major reason why PEPFAR has been a Marshall Plan-like response, rather than a Katrina-like response, to the AIDS crisis in Africa.

Gerson’s determination to critique not just our policy concerns but our morality suggests that he is viewing this debate as proxy battle in the broader struggle in the Republican Party between what he views as “seedy” or “anti-government” conservatism and the “compassionate” conservatism he helped shape in the White House. That’s a broader debate that I welcome.

I don’t see a coherent answer to Gerson’s concern about prevention. I suppose that with an increased budget there would be enough money for treatment and prevention, even with the 55% limit, but 55% seems like an arbitrary Congressional mandate.

U.S. global AIDS spending is helping to prolong the lives of more than a million people and is widely seen as a foreign policy and humanitarian success. Yet this success contains the seeds of a future crisis. Life-long treatment costs are increasing as those on treatment live longer, and the number of new HIV infections continues to outpace the number of people receiving treatment. Escalating treatment costs coupled with neglected prevention measures threaten to squeeze out U.S. spending on other global health needs, even to the point of consuming half of the entire U.S. foreign assistance budget by 2016.

This paper describes the dimensions of these problems and argues that the United States has unwittingly created a new global “entitlement” to U.S.-funded AIDS treatment that currently costs about $2 billion per year and could grow to as much as $12 billion a year by 2016— more than half of what the United States spent on total overseas development assistance in 2006. And the AIDS treatment entitlement would continue to grow, squeezing out spending on HIV prevention measures or on other critical development needs, all of which would be considered “discretionary” by comparison.

Over suggests ways to substantially restructure the President’s Emergency Plan for AIDS Relief (PEPFAR) in order to avert a crisis in which Americans would have to choose among indefinitely increasing foreign assistance spending on an entitlement, eliminating half of other foreign aid programs, or withdrawing the medicine that millions of people depend upon to stay alive. His suggestions include consolidating treatment success and leveraging treatment for prevention by making the extension of further AIDS treatment financing conditional on success in both treatment adherence and prevention outreach; shifting to a focus on prevention by underwriting male circumcision efforts and expanding HIV testing and counseling for couples more so than for individuals; and intensifying the effects of
prevention interventions by mapping high risk locations and targeting them with tailor-made prevention programs.

In the past few years, clinical trials in Kenya, Uganda, and South Africa confirmed that male circumcision (MC) reduces the risk of transmission of HIV infection by approximately 60%.

In its Fourth Annual Report, the program [PEPFAR] announced that it had allocated $16 million in fiscal year 2007 for MC activities, up from $600,000 the year before. In FY 2008, funding may rise to $30 million.

The average cost to circumcise an individual has been estimated to be about $50. Thus, the $16 million for FY 2007 could be providing services to large numbers of people. Even assuming high start-up costs for training and administration, if only a quarter of these resources were dedicated to actual service delivery, that would still mean that more than 80,000 men could have received MC services by now. Unfortunately, while PEPFAR does a good job counting the number of individuals on anti-retroviral treatment, analogous data for circumcision services are not available. However, there is concern among experts and observers in the field that the number of people who have received MC services to date through PEPFAR is very, very low – probably fewer than 2,000.

A large part of the problem is that there are simply not a sufficient number of trained professionals nor properly equipped facilities to safely carry out the circumcision surgery for the large numbers of people who might request it. More worrisome still is the concern that MC funds are not being dedicated to organizations with the most experience and/or capacity to train people to carry out the procedure. In some cases, funds may be targeted to social marketing of the procedure and to encouraging local populations to support MC, without sufficient investment in the actual capacity and infrastructure necessary to meet that demand.

Male circumcision offers the same sort of compounded benefit that most effective vaccines offer to populations – herd immunity. As more men are circumcised, not only is their own risk of acquiring HIV reduced, but their current and future partners and their partners’ partners also are at lower risk.

While concerns about cultural acceptance should inform where and when MC services are provided, the main problem holding back the wider availability of such services appears to be supply, not demand. If training and infrastructure are the primary barriers to more expansive rollout of MC services, then it is incumbent on PEPFAR, now undergoing reauthorization before Congress, as well as on other donors, to respond. They need to do a better job channeling funding to those purposes and to implementing organizations that can translate support into effective service provision. To miss the potential of MC through squandered resources, oversensitivity to cultural concerns , and ineffective programming will only prolong the tragedy of HIV/AIDS in Africa.