Today’s White House news conference on the Obama Administration’s global HIV/AIDS efforts did not, in fact, provide all that much news.

The main announcement came from Secretary Hillary Clinton, who said the International AIDS Society would host its 2012 conference in Washington, D.C., a step made possible by the Administration’s repeal of the HIV entry ban. That two-decades-old ban barred HIV-positive individuals from coming to the U.S., a discriminatory rule that had no basis in public health.

Its demise “is a significant victory for public health and human rights,” Dr. Elly Katabira, associate dean for AIDS research at Makerere University and president-elect of IAS, said at the White House event. To be sure, it’s great that for the first time in 22 years the IAS meeting will be held in the U.S.–in D.C. no less, a city that, as Dr. Katabira noted, has been heavily affected by the HIV epidemic.

Clinton said that PEPFAR would serve as “the cornerstone of our Global Health Initiative,” the White House proposal, first unveiled in May, which called for spending $63 billion over six years on a new global health strategy. And Jeffrey Crowley, director of the White House Office of National AIDS Policy, said that Obama would build on PEPFAR’s success by “doubling PEPFAR funding over the next six years” as part of the GHI proposal. But Crowley didn’t elaborate, and the math behind that statement was unclear.

For now, we know that Ambassador Eric Goosby, MD, the Administration’s global AIDS coordinator, has predicted PEPFAR may be flat-funded, or nearly so, for fiscal years 2010 and 2011. And with key details of the Administration’s GHI remain under wraps, there’s still growing concern the administration will pull back from global AIDS scale up.

At today’s event, Dr. Goosby, said he would outline the five-year US global AIDS strategy later this week. The Office of the US Global AIDS Coordinator will also release some “annexes” later this week that provide more detail about the Administration’s plans to transition PEPFAR from an emergency response to a more sustainable “country-owned, country-driven” program, as Dr. Goosby put it.

“PEPFAR’s five-year strategy will focus on sustainability, programs that are country-owned and country-driven … programs that build upon our success and incorporate efficiencies,” Dr. Goosby said. 

So perhaps we’ll get some of the nitty-gritty details later this week. For now, on the eve of World AIDS Day, many critical questions about the Administration’s vision for PEPFAR and its commitment to scaling up the global AIDS initiative remain unanswered. What about funding levels? What about treatment targets? What about new evidence-based policies on needle exchange?

A new issue brief released today by the Center for Global Health Policy and amfAR, The Foundation for AIDS Research, highlights the transformative success of the global AIDS response in changing the trajectory of the epidemic and improving health outcomes beyond AIDS.

The issue brief details the diverse impacts of the intensive response to the AIDS pandemic, including reduced mortality; benefits in addressing other diseases, such as tuberculosis and malaria; in strengthening health systems; and building a strong emphasis on accountability and outcomes in global health initiatives. A sidebar addresses flaws in current arguments for shifting global health priorities based on cost-effectiveness considerations. 

The report’s recommendations include keeping U.S. commitments on the global AIDS response by expanding investment in AIDS and other global health initiatives, and using PEPFAR programming and principles as a foundation for broader health service delivery.

The full report, titled, “Smart Investments in AIDS and Global Health: Building on What Works,” is available at www.idsaglobalhealth.org or http://www.amfar.org/hill/article.aspx?id=8222.

In a long anticipated move, the World Health Organization released new recommendations on the treatment and prevention of HIV/AIDS today. The WHO announced that it is now recommending antiretroviral therapy (ART) be initiated at a CD4 threshold of 350 cells/mm3 for “all HIV-positive patients, including pregnant women, regardless of symptoms.”

The WHO called for prolonged use of antiretroviral (ARVs) drugs among pregnant women to reduce the risk of mother-to-child transmission of HIV and said HIV-positive mothers and their babies should take ARVs during breastfeeding. The WHO also said countries should phase out the use of Stavudine, or d4T, “because of its long-term, irreversible side-effects,” according to a news release from the WHO.

These decisions—coming on the eve of World AIDS Day–are very significant, even if widely expected. For starters, they add fuel to the argument that more money is urgently needed for global AIDS programs; with these new recommendations, more HIV-positive patients in poor countries will become eligible for HIV therapy, and treating those patients will become more expensive if the low-cost Stavudine is not an option.

“These new recommendations are based on the most up to date, available data,” said Dr Hiroki Nakatani, Assistant Director General for HIV/AIDS, TB, Malaria and Neglected Tropical Diseases at the WHO.  ”Their widespread adoption will enable many more people in high-burden areas to live longer and healthier lives.”

The WHO’s decisions also come just before top Obama Administration officials are set to discuss its vision for the US global AIDS program, PEPFAR. At 2:30 today, Secretary of State Hillary Clinton, Global AIDS Coordinator Eric P. Goosby, MD, and others will discuss the Administration’s efforts on HIV, domestically and internationally.

It’s unclear just how much news Clinton, Dr. Goosby, and others will make. No funding levels are expected to be announced, but there may be a few new policy tidbits.

One key question is how Dr. Goosby will react to the WHO news. During a presentation at the IDSA Annual Meeting last month, Dr. Goosby estimated that a change in the WHO treatment threshold would mean 2.5 to 3 times as many people eligible for treatment. At that session, he advocated access to ARVs at 350 for pregnant women and for those who are HIV-TB co-infected.

And in a recent Q&A posted on the Global Health Council’s blog, Goosby said: “I think that if countries go to 350 (CD4 count), there will have to be rationing because they do not have enough resources to cover people below 200 or people below 150. If they now say anybody 350 and down are eligible, they are going to have to figure out a way responsibly to put those people who are most ill on drugs first.”

 Another key barometer for Monday’s news conference is whether the Administration announces a new treatment target for PEPFAR. If Goosby and other officials do not articulate a clear treatment goal, that could be a signal of wavering commitment to robust scale up of US efforts to combat the HIV/AIDS pandemic. (The White House event can be viewed live at www.whitehouse.gov/live.)

The WHO, in its news release, noted that its decisions are based on well-established scientific evidence showing that earlier initiation of ART “reduces rates of death and disease.”

“An earlier start to antiretroviral treatment boosts the immune system and reduces the risks of HIV-related death and disease. It also lowers the risk of HIV and TB transmission,” the release says.

The WHO acknowledged that the new recommendations would increase the number of patients needing treatment. But “the associated costs of earlier treatment may be offset by decreased hospital costs, increased productivity due to fewer sick days, fewer children orphaned by AIDS and a drop in HIV infections,” the WHO noted.

The new UNAIDS report out today—an epidemic update—highlights key strides made in HIV prevention.

New HIV infections have been reduced by 17% over the past eight years, the new UNAIDS data shows, including declines in sub-Saharan Africa, East Asia and elsewhere. The report also says that the number of AIDS-related deaths has dropped by more than 10 percent in the last five years and estimates some 2.9 million lives have been saved by global HIV treatment initiatives.

“We cannot let this momentum wane,” said Dr Margaret Chan, Director General of WHO, according to a press release accompanying the report. “Now is the time to redouble our efforts, and save many more lives.”

Despite these gains, the document says prevention efforts are lagging behind changes in the epidemic, failing to reach key populations, including sex workers and injecting drug users. Read the full report here or the press release here.

As World AIDS Day approaches, leading physician‐scientists called on the White House and Congress to continue the scale‐up of HIV prevention and treatment services in the developing world and to preserve U.S. leadership in the battle against this deadly epidemic.

The Obama Administration is expected to release its five‐year global AIDS strategy on Dec. 1—World AIDS Day. In a Global Center press release, HIV/AIDS doctors and researchers said the Administration’s new plan should set bold new treatment targets for PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, and include robust funding levels to fulfill promises made in the landmark Lantos‐Hyde legislation, which calls for spending $48 billion over five years on global AIDS, tuberculosis and malaria.

“Less than a decade ago, some questioned the viability of providing HIV treatment to poor patients in the developing world. Today, we have extraordinary evidence of PEPFAR’s success ‐more than 2 million people in resource‐poor countries have avoided severe diseases and untimely deaths through access to antiretroviral drugs,” said Kenneth Mayer, MD, co‐chair of Global Center’s scientific advisory committee and a professor at Brown University, where he directs the AIDS Program.

But Dr. Mayer noted that the majority of people who need lifesaving antiretroviral therapy still do not have access to it. “Without continued scale up of HIV treatment, millions of people in the developing world are likely to succumb to this chronic, treatable disease—with devastating consequences for their families and their communities,” he said.

Read the full press release on the Global Center’s website.

HIV is not to blame for the ills, figuratively or literally, of developing world health systems, and funding for AIDS programs can’t take a hit in favor of other health threats.

That’s the take-home message of a statement issued last week from 87 civil society, research and other health groups from more than two dozen groups around the world. The statement condemns the notion that donor countries should siphon funding from global HIV programs to address other health problems in resource-poor countries.

“The neglect of health systems in general, and particular health challenges such as tuberculosis and diarrhea, is not a recent phenomenon and certainly cannot be attributed to one disease that is obsessively touted as the culprit-namely, HIV,” the statement reads.

The proclamation—titled “HIV is not over-funded: Health is under-funded”—rejects the notion that other health threats can or should be addressed by pitting AIDS funding against other needs, such as child and maternal health.

“This competition is completely irrational,” Paula Akugizbwe, of the AIDS and Rights Alliance for Southern Africa, said at a press conference in Cape Town last week.

“We cannot keep shuffling our scanty resources from one disease to another and expect to see lasting change,” said Akugizbwe, a key player in organizing the statement. “Health, a vital requirement for stable societies and socio-economic development, needs to be prioritized and funded appropriately. But this cannot be at the expense of HIV, which underpins so many other health challenges.”

As the statement says: “More resources for health overall are desperately needed – not only for the humanitarian and health systems benefit, but also to lessen the destabilizing impact of poor public health on socio-economic progress, particularly in low-income countries.”

It continues: “Shifting funding from HIV will not fill the yawning gaps in resources for health – this move is a cheap diversionary tactic that offers no genuine or long-lasting solutions for health systems. What is required is a shift in political will to prioritize and invest vigorously in health. Until this happens, neglect and dysfunction will continue to pervade health systems irrespective of what specific health needs we focus upon.”

 Read the full statement and see the list of endorsers by clicking below.

HIV Is Not Over-Funded Health Is Under-Funded_19 11 09

Leading academic, scientific, and public health leaders from around the world sent a letter to President Obama last night, urging him to maintain robust scale up of AIDS services as part of his Global Health Initiative.

“It is imperative that we save lives, families and communities, as well as stabilize developing nations, through continued scale-up of HIV prevention and treatment services,” the letter says. “U.S. global health policy now has an opportunity to leverage the success of the AIDS response by using accelerated scale-up of HIV prevention and treatment as a platform on which to build broader and more sustainable healthcare capacity in low-and middle-income countries.”

The signatories on the letter include a broad array of leading medical and health experts—Jim Yong Kim, president of Dartmouth College; Martin Blaser, chair of the Department of Medicine at New York University, David M. Serwadda, dean of the School of Public Health at Makerere University, and Paul Farmer, chair of the Department of Global Health and Social Medicine at Harvard University, to name a few.

The missive to Obama comes as the Administration hones a new approach to global health. Top government officials are putting the finishing touches on a new global AIDS strategy, which is set to be released on Dec. 1—World AIDS Day. But right now, signals from the White House indicate lukewarm support for the US global AIDS program. Dr. Eric Goosby, Obama’s global AIDS coordinator, recently said the Administration would flat-fund PEPFAR for at least the next two years, possibly longer

The White House is also crafting details of its all-important Global Health Initiative, which could come out in the next few months. And there’s the nomination—finally—of Dr. Rajiv Shah to head USAID.

Given all that activity, the focus on AIDS could not come at a more crucial moment, particularly as the Administration appears to be shifting its attention to other health problems, such as child and maternal health, without an apparent acknowledgement of the link between AIDS and the health of mothers and children.

As the letter notes, HIV/AIDS is the No. 1 cause of death among women aged 15-44, the virus remains a leading cause of maternal mortality in sub-Saharan Africa. “Globally, only one-third of pregnant women have access to antiretroviral drugs that can virtually eliminate the risk of perinatal transmission,” the signers note. “Twelve million children have lost one or both parents to AIDS and the number of orphans continues to rise.”

The letter argues we cannot effectively address other health threats by pitting AIDS funding against other health needs, as some in Washington seem to be advocating.

“Today, some argue that we cannot increase the so-called “treatment mortgage” or that HIV resources should be shifted to other health care priorities,” the letter says. “We reject the notion that urgent health conditions should be pitted against one another. Narrow conceptions of cost–effectiveness, or the cost of a given intervention in isolation, cannot become the litmus test to compare interventions for different diseases or to prioritize U.S. global health funding.”

Click here to read the full text and see a complete list of signatories or below for a PDF.

Final_Letter to President on AIDS scale up 11 18 09 (2)

Sen. Sherrod Brown, D-Ohio, has asked the White House to make tuberculosis a focal point of its Global Health Initiative.

As the Obama Administration works to flesh out the all-important details of its six-year $63 billion GHI plan, Brown sent a letter to the White House saying it is “imperative” that TB be part of the strategy to combat diseases around the world.

“TB kills nearly 2 million people each year and is the leading killer of people with HIV/AIDS,” Brown wrote in the Nov. 17 missive. “In many cases, AIDS patients receiving drugs thanks to American aid die for lack of TB treatment.”

Brown also pointed out the role an aggressive U.S. TB strategy could have in shoring up key American allies and in strengthening maternal health, a cornerstone of the GHI.

“Global aids for TB control and prevention will also advance women’s rights, which I know is a priority for your administration,” Brown says. “TB is the leading curable infectious killer of women, claiming even more women’s lives than maternal mortality.”

The Administration first announced its Global Health Initiative in May, but crucial details have yet to be released. The White House is reportedly crafting those detals now but it’s unclear when the full plan will be released publicly.

Here is a link to Brown’s letter.

111709 TB Letter to the President

The latest HIV clinical care information is now available in a compendium of the year’s HIV-related articles from Clinical Infectious Diseases and The Journal of Infectious Diseases.

The publication, 2009 Clinical Issues in HIV Medicine: Recent Advances & Challenges, was edited by Kenneth Mayer, MD, Miriam Hospital, Brown University and Daniel Kuritzkes, MD, Brigham and Women’s Hospital, Harvard Medical School. It includes a wide range of HIV-related articles, including a piece on when to start HIV therapy, race and sex differences in ART use and mortality among HIV-positive persons, and the NIAID’s research agenda on drug-resistant TB.

Click here to see this important publication put out by the HIV Medicine Association.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, delivered a forceful message on the need for a “storm” of attention and resources devoted to developing new TB treatment and prevention efforts.

“It is imperative that we transform the way we diagnose, treat, prevent, and control TB — through biomedical research and public health measures — to the same extent that we have done and will continue to do with HIV/AIDS,” Fauci writes in this commentary on MSNBC’s website today. “We are beginning to see the winds of change, but what we really need is a storm.”

In an echo of the speech he delivered this summer at the Pacific Health Summit in Seattle, Fauci, a powerful leader in infectious disease research, outlined the need for a robust new TB research agenda. “The TB research effort will require a sustained and long-term commitment from government, academia, industry and philanthropy.”

Click here to read the whole piece and here to read our earlier post on Fauci’s remarks in Seattle.