New GHI Resource from the Global Health Council

Many details of the Obama Administration’s Global Health Initiative are still murky, and it’s unclear just when we will learn more. In the meantime, the Global Health Council has launched a little Internet information hub about the GHI, with relevant documents, media coverage, and other related info. It’s at least a good starting point to sort out what we know, and what we don’t, about the six-year $63 billion plan. Check it out here.  You can also get another perspective on the GHI–and how it should be framed and funded–here.

Ambassador Goosby Discusses Budget, Partnership Frameworks, and New Role for AIDS Activists

Dr. Eric Goosby, the US global AIDS ambassador, spoke with John Donnelly about a number of issues surrounding PEPFAR and the Obama administration’s new Global Health Initiative, including how the administration hopes to ramp up treatment and prevention efforts with small increases in overall funding and how PEPFAR is constantly responding to emergencies in the field – including the move in December to give the South African government $120 million after the country had an unexpected funding shortfall in nine provinces.   

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.

Q: You have said, “Our commitment to universal coverage hasn’t wavered.” With the increase in demand for treatment and prevention around the world, how can you make that commitment with just a $141 million increase in your budget – and with some of that money earmarked for the Global Health Initiative?

A: We are committed to universal access. We are partnering with implementing countries to mount their response. Our expectation was never that we would be the sole source of funding to fight the epidemic. … PEPFAR or any other single funding line will not be able to successfully respond to the unmet need. … It’s not within one single program’s ability to mount that response.

I don’t know if PEPFAR ever presented itself that it was going to cover the entire need for prevention, care, and treatment for any country. We are definitely providing larger than the bulk of the funding – 50, 60, or 70 percent of it– in our focus countries already.

Q: You have talked in the past about finding savings in PEPFAR’s budget that would free up additional funds for treatment and prevention. What are you doing in finding these savings, including in trying to reduce the price of ARV medication?

A: We have been in long-term negotiations in every country we’re in to have the predominant purchasing (for drugs) occurring with generic manufacturers. We saw a shift two years ago, and now we’re in the high 80s, low 90 percent (of all drugs being generics) We have had discussions with South Africa … and they needed to move from  about a 65 percent brand dominance to somewhere down to 10-15 percent range, which they have started to do.

We are engaged with the Clinton Foundation to look at generic pricing arrangements, toward a commitment that creates and introduces a competitive component to generic pricing. After that initial deal is cut (in a country for generic drugs) competitive pressure from another generic manufacturer in that region will continue to drive that price down.

For other efficiencies, we have looked at the Clinton Foundation and Synergos (Institute in New York City) and other organizations that have a history of this type of work. We try to understand how we can use the experiences they have had with other countries, not with PEPFAR, to learn lessons that enable us to identify efficiencies for treatment and for prevention interventions.

Q: You are now helping to create partnership forums with countries on the HIV/AIDS response. How will you be able to ensure the representation of civil society groups in situations like the one unfolding in Uganda now – with the proposed law that would outlaw homosexuality?

A: PEPFAR has played a central role in being the dominant response in Uganda to the epidemic. We are now and always have been treating gay men in Uganda. Whether the country has admitted that or acknowledged that is a different issue — they never have. From day one, the Infectious Diseases Institute and TASO (The AIDS Support Organization) have been central in that response, and that will continue. In addition, PEPFAR is in a position to play a role in the partnership frameworks to engage in a substantial dialogue with country leadership about the public health impact from such a law. … With such a law, there is a fear that this will stop the flow of patients into testing and into treatment. We will always fight against that in the way our programs are implemented. PEPFAR also has an opportunity to identify – and fund – higher risk populations.

Q: How does that strategy work?

A: We could fund non-governmental organizations that do outreach, that create support groups. … Then there is a growing number of individuals who feel safe and who are willing to take those risks who coalesce in a group that can be funded as a separate NGO. In China now, there is an increasing number of NGOS created specifically for high-risk groups, especially men who have sex with men. … There is a need in creating these safe islands of safety so they can be tested and treated.

Q: For many years, you were on the outside of government, an activist, giving advice to those in power. What should activists be focusing on today?

A: Activists have played from the beginning of the epidemic a central role in reflecting a conscience for policymakers and for governments to understand their responsibility in orchestrating an effective response to this epidemic.

What I think is most needed today is for advocates to look at the larger picture of responsibility, i.e., who is responsible for the response, and to start to talk about it as a shared responsibility, not just dependent on any one country to model a response, but (about the US) playing an appropriate needed role as a world power, an economic power, a political power.

Also, the advocacy originally in the US was by those most impacted by the disease. There needs to be advocacy now coming from the infected and affected communities in countries where we’re most engaged.

Letter to Clinton: Preserve PEPFAR’s Autonomy, Keep it at State

Although Administration officials have said PEPFAR would be the “cornerstone” of its Global Health Initiative, HIV advocates and experts are worried that PEPFAR and the Office of the U.S. Global AIDS Coordinator could actually have less visibility and authority under the GHI.

The Administration has not yet detailed what the GHI’s governance will look like, but there’s apparently some discussion about moving PEPFAR to USAID, instead of keeping at the State Department. Advocates worry this would be disruptive for a program that has been so successful, in part because of its streamlined, singular focus.

The Global Center and other groups sent a letter to Secretary of State Hillary Clinton today asking her to “preserve the autonomy” of PEPFAR by keeping at State and reporting to her.

“Subsuming OGAC and the administration of the PEPFAR program within a new GHI organizational structure could set back the Administration’s global agenda,” the letter states. “OGAC and PEPFAR’s success are a testimony to what streamlined processes and a nimble structure can accomplish.  Its programs are lauded around the world for making a difference while respecting countries’ autonomy.  We must not disrupt or undermine the program’s operation, including its important leadership and coordination role among the agencies that now implement programs, and within countries where continuity of leadership and funding sustains life-saving programs.”

Click here to read the full document. Letter to Sec Clinton re PEPFAR within GHI (2)

PACHA’s New Leadership Includes Domestic and Global HIV/AIDS Stars

Under new leadership appointed by the White House, the Presidential Advisory Council on HIV/AIDS (PACHA) convened its first session yesterday under the Obama Administration.

Michael Horberg, an HIVMA board member, introduced himself at yesterday's PACHA meeting

Health and Human Services Secretary Kathleen Sebelius announced 24 new members to the Council earlier this week, including Michael Horberg, MD, a member of the HIV Medicine Association’s board of directors.

The council has focused mostly on providing advice and recommendations to the President on domestic AIDS policy, and this year, a key role for the PACHA will be to advise in the development and implementation of the National HIV/AIDS Strategy. But PACHA also has a role in counseling the White House on global AIDS policy. And several of the PACHA appointees have a strong global focus, starting with its chair, Dr. Helene Gayle, the CEO of CARE USA, who also worked on HIV issues at the CDC and the Bill and Melinda Gates Foundation.

In addition to Gayle, other globally-oriented members include Jim Kim, M.D., Ph.D., who is president of Dartmouth College and a co-founder with Paul Farmer of Partners in Health, and Ernest Darkoh, MD, MPH, who is chairman of BroadReach Healthcare and an expert in HIV treatment program implementation and health system strengthening.

Kathleen Sebelius, Helene Gayle, and other newly appointed members of PACHA at the council's first session

Blueprint for Global Health Initiative Raises Fresh Questions About Funding

The Obama Administration has finally lifted the curtain, if only for a preview, on its proposed $63 billion six-year Global Health Initiative (GHI), which the President first unveiled almost a year ago with a broad-brush call for a more integrated comprehensive approach to funding global health. 

Amid much anticipation, the White House yesterday released a 21-page “consultation document” on the GHI. You can read the full GHI document here. The Administration is seeking comments and input on the plan by Feb. 22^nd. To offer your perspective, send an email to ghi_comments@state.gov.

Perhaps the biggest news in the document—and the element that raises the most questions—relates to funding. Although there aren’t many new details about how the $63 billion would be spent over the six year timeline, the consultation does outline plans to set up a “GHI Strategic Fund Reserve.”

For FY 2011, this new GHI Fund will have $200 million to support a review of country health plans, to scale up “proven cost-effective interventions” for maternal and child health and infectious diseases, and to begin integration interventions, according to GHI document. In addition, in FY 2011 and 2012, the GHI fund will be tapped to help 10 “GHI Plus” countries with additional technical, management, and financial resources to implement integrated programs and make investments across health conditions. The list of GHI Plus countries will be expanded to 20 in later years.

But there’s concern about where that $200 million will come from. White House officials have made it clear that some of that money will come from PEPFAR and other global health programs. What’s not clear is how much of PEPFAR’s budget, for example, will flow into the GHI Fund. Nor is it clear how those PEPFAR/GHI funds will be spent, i.e. will global AIDS money be used to finance nutrition or child health programs or will it be used for AIDS-related services?

If it’s the former, that could be devastating for efforts to combat HIV and TB, which need every penny available in this era of tiny budget increases. PEPFAR is slated to get a $141 million increase under the Obama budget blueprint, a welcome boost but too small to match the scope of the epidemic. If $100 million of that flows to the GHI Fund, that does not leave much to scale up treatment and prevention as the Administration has promised. As for TB, it would only see a $5 million increase over FY 2010 levels under the White House plan, a bump up that leaves little to spare for other causes. Click here to read more about the Obama budget for global health.

White House Budget Falls Short on Global HIV & TB

Although some details are still murky, a first-blush analysis of  Obama Administration’s fiscal year 2011 budget doesn’t look good for US efforts to combat the HIV and tuberculosis epidemics. From treatment to prevention, these global health threats could get short-changed under the White House plan.

Let’s start with PEPFAR, the President’s Emergency Plan for AIDS Relief. For the second year in a row, the Administration has called for a single-digit increase for this program, about 2.6 percent, or $141 million. That small increase comes despite lofty campaign promises, congressional mandates, plus a pledge that PEPFAR would serve as the “cornerstone” of the Administration’s new Global Health Initiative (more on the GHI later).

The White House’s PEPFAR budget is not adequate to preserve vital momentum in HIV treatment scale-up, nor is it enough to fund important new HIV prevention innovations in the developing world.

The numbers for TB are even more disheartening. The Administration only requested a $5 million increase over 2010 funding, a paltry amount for a disease that last year killed more than 1.8 million people, including 500,000 women. Moreover, the Centers for Disease Control’s TB program, with its critical clinical trials network, would be cut by more than $1 million, further undermining US capacity to evaluate new diagnostic, treatment and prevention tools for TB. This comes in the face of evidence that drug-resistant TB is a growing threat and if left unchecked, could spiral into a broader global health catastrophe.

Here’s a more detailed analysis of all global health funding from the Global Health Council:  GHC FY11 CBJ GH Funding Chart (Draft). The Kaiser Family Foundation also has this helpful breakdown. The Global Center, the GHC, and other groups will continue to analyze the budget as more details come out.

One bright spot in the Administration’s request was in biomedical research at the National Institutes of Health, which would see a $1 billion boost under today’s plan, including $98 million for HIV/AIDS research at NIH, a significant increase at a time of constrained resources.

There’s no question the U.S. faces tough choices amid spiraling deficits and a difficult economy, but underfunding much needed global health programs, which account for a fraction of the federal budget, is not the answer to America’s fiscal woes. Investment in these programs will reap immense dividends down the line–in financial, diplomatic, and public health arenas alike.

A New Weapon in the Fight against HIV/TB Co-Infection

New results from a tuberculosis vaccine trial indicate that the Mycobacterium vaccae (MV) was effective in preventing TB among people with HIV. Given that TB is the No. 1 killer of people with HIV in the developing world, this could be a major advance in the battle against these synergistic scourges.

In the seven-year study in Tanzania, researchers with Dartmouth University and other partner institutions found that immunization with MV reduced the rate of TB by 39 percent. Now, they said, the focus needs to turn to manufacturing larger amounts of the vaccine for additional studies and possible clinical use.

Click here to read the Dartmouth press release and here to read a news story about the trial findings.

WSJ Story: HIV Patients Turned Away in Uganda Amid Reduced Treatment Scale Up

The headline in today’s Wall Street Journal article is chilling enough: ”War on AIDS Hangs in Balance as U.S. Curbs Help for Africa.”

Then come gripping details of a mother desperate to get access to needed medications, so she will not infect her new baby with HIV. And the fears expressed by health care providers that Uganda’s successful efforts to combat AIDS is in serious jeopardy.

“Unless the promised funding is forthcoming soon we will see an absolute disaster in the next year or so,” says Shepherd Smith, a longtime Christian activist for HIV issues in Africa. “The human tragedy that is nearly upon us is significant and I believe will be a huge disservice to the people of the United States because we will be unable to keep humanitarian commitments we have made.”

Here’s s link to the full story: http://online.wsj.com/article/SB10001424052748703906204575027442437944112.html?mod=WSJ_hpp_sections_world

Ugandan Doctor Describes US Role in Fueling Homophobia & Deadly Implications

Dr. Paul Semugoma, a Ugandan physician, just published this poignant perspective on the anti-gay movement in his native country, the US role in fostering that hostile climate, and the repercussions on efforts to fight HIV/AIDS and reach out to the vulnerable at-risk populations if the tide is not reversed.

“Uganda is undergoing a crisis of homophobia,” he writes. “In the 1990s, the country had an effective HIV/AIDS prevention program. Broad-based partnerships and targeted public education campaigns meant that the number of people living with HIV actually declined dramatically. That’s over. In this decade, ideology and prejudice shouldered aside science to drive Uganda’s anti-AIDS campaign.

“The US bears much of the blame. The US President’s Emergency Program for AIDS Relief (PEPFAR) surrendered to homophobia and reinforced the invisibility of gay men. It preached “abstinence until marriage;” since gays can’t marry, they were excluded from HIV outreach. The US Agency for International Development, responding to Congressional pressure, barred use of the term “men who have sex with men.” In Uganda, these programs funded faith-based organizations — many with no experience working on HIV prevention or treatment, many openly spreading hatred of lesbians and gay men.”

This has now culminated in a frightening debate over the Anti-Homosexuality Bill pending in the Ugandan Parliament and inspired, at least in part, by some conservative US religious leaders. That legislation would impose life imprisonment, or even death, for same-gender consensual sex acts and threatens imprisonment of individuals who do not report suspected homosexual acts to the police.

“The Obama administration has a chance to turn things around — but it must act fast,” Semugoma writes. “It must press Uganda’s government to bring science and human rights back into HIV prevention. Otherwise, my patient, and thousands like him, will die from the deadliest diseases: silence and fear.”

 It’s worth reading the whole commentary: 

http://www.huffingtonpost.com/dr-paul-semugoma/puritanism-is-deadly-poli_b_440858.html

Obama’s SOTU: Jobs, Jobs, and …. Global Health?

Okay, so funding for PEPFAR and TB programs did not get top billing in tonight’s State of the Union address. With the economy still sputtering, with voters anxious about the next paycheck and angry about spiraling deficits, global health wasn’t exactly a political winner in tonight’s speech.   

But President Obama still did squeeze in a mention of the issue, even specifically citing US efforts to combat HIV/AIDS, highlighting a “new initiative” against bioterrorism and infectious diseases, and articulating a commitment to strengthening “public health abroad.”  Obama’s quick rhetorical nod came amid deep worry among HIV experts and activists about this Administration’s commitment to maintaining scale-up of treatment for AIDS–anxiety that was only deepened today by some news out of South Africa.

Here’s what Obama said tonight about America’s role  in foreign aid in general and  global health in particular:

“That is the leadership that we are providing – engagement that advances the common security and prosperity of all people. We are working through the G-20 to sustain a lasting global recovery. We are working with Muslim communities around the world to promote science, education and innovation.

We have gone from a bystander to a leader in the fight against climate change. We are helping developing countries to feed themselves, and continuing the fight against HIV/AIDS. And we are launching a new initiative that will give us the capacity to respond faster and more effectively to bio-terrorism or an infectious disease – a plan that will counter threats at home, and strengthen public health abroad.

As we have for over sixty years, America takes these actions because our destiny is connected to those beyond our shores. But we also do it because it is right.” (For full text, click here.)

These few words were welcome, particularly coming on the heels of a disconcerting story about of South Africa today, in which a US official warned of deep cuts to US global AIDS funding. 

“US government funding is going to come down dramatically over the next five years,” warned Dr Roxana Rogers, USAID South Africa Health Team leader last week, according to this story. ”There is not a friendly feeling in the US towards more funding for HIV/AIDS,” Rogers told a meeting in Cape Town on the future of US assistance for HIV/AIDS, hosted by the US-based Council on Foreign Relations. Here’s a link to that full story.

US officials tried to quickly to “correct the record” by issuing this statement, which says the US is “fully committed to the multi-party effort led by the Government of South Africa to fight HIV and AIDS in South Africa” and adding these funding figures: ”In South Africa, PEPFAR support from 2004-2009 has totaled over $2 billion (R15 billion), representing the largest contribution from PEPFAR to any country.  In 2010, PEPFAR will add $559 million (R4.2 billion) to the cause in South Africa. “