Activists question Obama’s AIDS plan

By John Donnelly 

WASHINGTON — The global fight against AIDS is a high-wire act these days, teetering between the Obama administration’s lofty promise of an “AIDS-free” generation and the grounded realism of those who fight the epidemic and say they just don’t see the commitment needed to deliver on such a promise.

In the middle of this tightrope, the end of AIDS appears closer than ever because of new scientific discoveries that could dramatically reduce new HIV infections all over the world. But at the moment, there’s new danger of falling because political leaders in the United States as well as the developing world may have lost their sure-footedness for the way ahead, no longer talking about AIDS as a pressing matter of life and death and putting crucial funding in jeopardy.

“On one side is the end of the epidemic, defeating a disease that has plagued us for 30 years,” says Paul Davis, the Nairobi-based director of global campaigns for Health Gap, an AIDS activist group. “But at the same time, we are equally as likely to fall back off the other side … by not doing enough. We are so close and yet it feels as far away as ever.”

In July, Washington will host the International AIDS Conference, the first such conference on US soil in 22 years, bringing to the US more than 20,000 AIDS activists from every corner of the world and drawing global attention to whether the historic commitment made by America in the past to fight the deadly virus can ramp up sufficiently to reach the next bold goal.

While President Obama announced new ambitious goals for the end of next year, many activists do not detect urgency on behalf of his administration nor do they see a detailed roadmap of how to get to an “AIDS-free generation,” as Secretary of State Hillary Clinton described the administration’s broad goal in a speech late last year. For these activists and critics, the urgent push against AIDS that sprung forth from the Bush administration, the architects of the President’s Emergency Plan for AIDS Relief, or PEPFAR, has mostly not materialized in a government led by someone in whom they had great hope.

“The Obama administration has turned out to be a big disappointment,” said Gregg Gonsalves, a longtime AIDS activist now at Yale University. “They talk big but they have no new money behind it. They talk about an AIDS-free generation, but they cut the PEPFAR budget.”

In this first of a series of stories over the next two months, GlobalPost will examine several key issues in the Obama administration’s approach to fighting AIDS. This includes looking at whether the US government can effectively deploy new tools to prevent infections, including: Expanding treatment, which has been proven to prevent new infections in 96 percent of cases; rapidly expanding male circumcision, shown to reduce female-to-male infection by more than 60 percent; and trying to end all mother-to-child infections of infants during birth and breast-feeding.

They are ambitious goals for sure, but many critics believe there is less force of will in the Obama administration than George W. Bush showed in his historic initiative to fight AIDS around the world. When Bush announced the creation of PEPFAR in 2003, roughly 50,000 people in the developing world — a large number of them in Brazil — were taking AIDS antiretroviral drugs. Today the US government supports more than 4 million people on AIDS medications.

Looming over this turning point in the global fight against AIDS is the global economic crisis and a deeply divided political landscape in Washington where serious questions are emerging about US funding. The Obama administration, despite its lofty goals, is recommending that Congress cut its own AIDS initiative by $550 million. While many advocates first blamed fiscal austerity for the decrease in funding, the real accounting reveals a complex set of facts that critics say has been kept quiet for too long. That is, the US has $1.5 billion backed up in a pipeline of funds to African countries, and wants to spend that already allocated amount down before asking for another increase.

Beyond the intricacies and shifting parameters of accounting for such a vast and sprawling global effort, there is a clear question on the minds of experts and advocates around the world: If a proposed cut is approved by Congress, will the United States be able to fund the fight against AIDS at levels necessary to meet Obama and Secretary Clinton’s big promise for an “AIDS-free” generation?

Many fear not and, with the Global Fund to Fight AIDS, Tuberculosis and Malaria facing uncertain fiscal support, they see a future in which the medical tools to effectively fight AIDS are becoming available just at the point when the world decides it may not be able to pay for them.

The leader of America’s global effort to fight AIDS, US Ambassador Eric Goosby, remains optimistic. Goosby said in an interview with GlobalPost that Obama’s goals of America supporting the treatment of 6 million people and performing 4.7 million male circumcisions by the end of next year are reachable. The other target announced by the administration: Ending newborn and infant infections by 2015.

“We will achieve all the goals that President Obama and Secretary of State Clinton referred to,” Goosby said in an interview in his Washington office recently. “We will hit a home run here.”

He wouldn’t say exactly how the goals will be reached. Advocates say the details of the administration’s plans are critical at a time when they see a turning point in the US response to the AIDS epidemic: Either America is turning away from the earlier ambitious focus on AIDS and focusing on more broadly based health care goals, or it’s turning toward the fight against AIDS with a sense of heightened purpose and renewed energy.

But with so much of the Obama administration’s emphasis on its Global Health Initiative, which includes the AIDS fight and has struggled to show results in its three years of existence, few see the AIDS fight taking off toward an AIDS-free generation.

“There is not a huge commitment to global health in this US administration,” Gonsalves said. “Global health is sliding out of the limelight.”

Goosby said that PEPFAR country coordinators have set goals on treatment, circumcision, and preventing newborn infections, and that some funding to scale up the efforts is coming from new savings from cheaper drugs and other efficiencies. In addition, he said, new revenue will be coming from increased contributions from developing countries.

The new approach to funding AIDS, according to Goosby: Building up two other large pots of money — from both developing countries and the Global Fund, which is supported by a wide array of donors, including the US — while keeping the third pot, PEPFAR funding, strong.

“That has been a profound change in countries actually realizing that these are their populations, they are ministries of health, they are the ones responsible for people’s care, and us realizing that an unrealistically fat system of care in place is not helping,” he said. “We’ve created a dynamic now to give the country an opportunity to address the unmet need fully with our pot, the Global Fund pot, and their pot. But we are going to demand (that developing countries) are going to oversee it and that they contribute to it monetarily and increase that contribution as resources allow them to.”

Wanted: More country contributions

Goosby said this sharing of financial responsibility is a “big change” from the start of PEPFAR, and “it moves us closer to being able to ensure these programs will be there for the next 30 years.”

In 2010, international donors disbursed $6.9 billion to fight AIDS in developing countries, down from the $7.6 billion that the wealthiest countries gave in 2009. That marked the first time in a decade that there has been a major cut in funding.

Of that $6.9 billion in 2010, the US contributed 54 percent, according to one study. When all contributions are considered, including large amounts spent by developing countries, the US portion decreases to 24 percent of all AIDS funding, which nearly matches its 23 percent portion of the global GDP.

Some developing countries have pledged to contribute more money in light of the global fiscal turbulence. Nigeria, which has 500,000 people on AIDS treatment, pledged last year that it would fund 50 percent of the cost of universal access to AIDS treatment by 2015. Other countries contributing more include Zambia, an extraordinarily poor country, which paid $5 million for antiretroviral drugs last year. Kenya agreed to a 40 percent increase in its health budget and set a goal of putting 1 million people on treatment, up from 460,000 currently. South Africa also committed to use more funds to fight AIDS.

Nigeria pledging to pay more

“Nigeria is stepping up,” said Dr. John Idoko, director general of the Nigeria’s National Agency for the Control of AIDS. “We have been concerned because of the global economic crisis, and we realize that we have to take more responsibility to set priorities and fund our programs.”

Many activists remain concerned that the fiscal crisis, though, will cause cuts so deep that more contributions from developing countries won’t make up the difference.

“I actually feel fairly positive with the ways things have been going, but the financial crunch genuinely imperils the momentum that has been created,” said Stephen Lewis, the former United Nations special envoy for HIV/AIDS in Africa and co-founder and co-director of AIDS-Free World, an advocacy group.

But other issues concern activists as well.

The first is whether the Obama administration will reach the target of supporting 6 million people on treatment. One source of doubt is whether the United States is poised to start taking credit for putting people on treatment even if it has done little to help them.

For instance, a memo written by a team of PEPFAR officials earlier this year recommended that the US claim it is supporting 277,000 people on treatment in the southeastern African country of Malawi. The United States has never claimed credit in Malawi before because the vast majority of AIDS funding in Malawi is from the Global Fund.

The PEPFAR document claims the US could claim credit for several reasons, including that it funds quarterly visits to check in on treatment sites and that it helped “prepare” the first edition of the “Malawi Integrated Guidelines for Clinical Management of HIV in Children and Adults.”

“They are trying to go from zero people treated to 277,000 treated without a single additional dollar to Malawi and without giving a single pill to anyone,” Davis said. “It’s ridiculous.”

A second concern is the disclosure the US government has had trouble spending its money in some African countries, running up a $1.5 billion pipeline of funding that has been stalled in the US Treasury for 18 months or more. Many activists had heard rumblings about the backlog of funds, but did nothing about it until the GlobalPost broke the story in April.

In the last six weeks, Goosby and his senior team have met with staff members in Congressional offices and activists in Washington and Nairobi to explain the predicament. Many fear that the disclosure could lessen support in Congress for AIDS programs. Others believe the administration should have been more forthright in acknowledging the rising backlog of unspent money, which was first identified internally two years ago.

“It’s an absolute failure of the activists,” Gonsalves said. “We should have been screaming bloody murder a year ago about this when we first heard something about it. We should have made it much more visible.”

A third issue is building up health services.

“The public health systems are still very weak — not as weak as pre-PEPFAR or Global Fund, but still weak,” said Dr. Paul Farmer, co-founder of Partners in Health, the quarter-century-old NGO based in Cambridge that provides health care for the poor in six countries. “You need to put the supplies and drugs into the hands of the right people, from the community health workers to the physicians. It requires going that final mile.”

Rwanda provides good example

Farmer explained further that Rwanda was a good example of improving the system, including the training of community health workers. In 2004, the country had almost no one on AIDS medication. Today it has more than 9,000, and it is one of two countries in Africa (Botswana is the other) regarded as securing treatment for 95 percent of those who are eligible.

Inside the US Office of the Global AIDS Coordinator office, which is housed in a nondescript brick building five blocks west of the White House on Pennsylvania Avenue, senior officials are looking for ways to find savings in many programs as well as deciding where to ramp up funding in order to try to dramatically reduce the number of new HIV infections.

But activists say they have long heard about how efficiencies are saving money and new prevention schemes will be ramped up, but they don’t see evidence of either. They also don’t see a long-term strategic plan.

“What’s the goal for 2015? Or 2020?” said Paul Zeitz, vice president for policy at Act V, an advocacy group that brings in celebrities to push the AIDS fight. “What’s the long-term US strategy? I don’t think they’ve figured that out yet.”

Caroline Ryan, the director of technical leadership in the global AIDS office, said the office feels “pressure” from all sides.

“We have a lot of pressure from the Hill (Congress) and OMB (Office of Management and Budget) that we can get more impact for the same amount of dollars,” said Ryan, who has been the office’s chief scientific adviser for the last eight years, nearly since PEPFAR’s inception. “We also have pressure from the countries not to slow down. The only way to do that is to get efficiencies and to be very analytical on how you get impact.”

Ryan and others in the office express hope that countries will start seeing results once these new prevention strategies are ramped up.

“It’s sort of like it all came together at the right time,” Ryan said. “Now we have results (from clinical trials) and it’s up to the programs to do the implementation. How do you take the discoveries from the bench desk to the bedside? That’s the exciting part of PEPFAR. It’s a living lab for bedside science.”

But how does PEPFAR do it?

That’s the key question. But their answer, for now, remains a secret.

Officials in the global AIDS office refused requests from GlobalPost to turn over its country-by-country roadmap of the HIV prevention strategy ahead. Their reason: The numbers are constantly changing.