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Posts Tagged ‘appropriations’

A crucial milestone was passed this week in the effort to get increased funding levels approved for global health programs, including PEPFAR, USAID and the Global Fund. The State and Foreign Operations Subcommittee of the House Appropriations Committee, led by Rep. Nita Lowey (D-NY), approved some increases for these programs relative to FY 2010, despite having less money overall to work with.

The Subcommittee divides up an overall amount of money that is only about 1.4% of the total US budget.   But, this total was $4 billion less than what President Obama requested, due to a cut imposed by the Chair of the Appropriations Committee, Rep. David Obey.  In fact, it was the international affairs account that bore the brunt of the cuts to the President’s budget proposal.

All of the global health programs in this bill were increased over FY 10 enacted levels.  Tuberculosis, family planning, and the Global Fund received increases above the President’s request.  Advocates had requested specific, higher levels and have sent a letter to both the House and Senate raising concern about HIV/AIDS funding.

These are the amounts approved for a few areas of interest, drawing on info from the Global Health Council:

The Global Fund — the Subcommittee rejected the Obama proposal to cut the US contribution below the FY 2010 level.  Instead, the Subcommittee approved $825 m,  a boost of  $75 million for the Fund above FY 2010. (President’s Request: $700 m; FY10: $750 m).  However, it remains to be seen whether the portion of the US contribution that comes through the Labor Health and Human Services budget will be provided in full.

Bilateral HIV/AIDS — the Subcommittee provided a boost of $91 million over the FY 2010 level, approving $5.050 b (President’s Request: $5.150 b; FY 10: $4.959b).  This is about half of what President Obama had requested.  Obama had proposed using half of his requested increase for PEPFAR to help finance technical and management assistance for the GHI Plus Countries, and we hear that the report language accompanying allows this.  That means  that about $50 m of the boost for PEPFAR will go to this purpose and only $41 m will be available to expand access to direct services, such as prevention, care and treatment.

USAID’s TB program —  The Subcommittee gave this program a boost of $15 m over the FY 2010 level, approving a total of $240 m (President’s request was $230 m; FY 10: $225 m)

In other decisions, the Subcommittee provided the full amount requested for the Peace Corps, giving it a boost of $46 m over 2010.  And it approved a $71 m increase for Embassy Security, Construction and Maintenance, $114m above the Obama request.

The panel considered an amendment offered by Rep. Rehberg that would have reduced most of the bill’s spending levels by 7.27 percent and reduced multilateral assistance by 31.85 percent.  But, this was voted down along party lines.

There are still many hurdles yet before the funding levels are finalized.  The Senate’s State and Foreign Operations Subcommittee is expected to consider the International Affairs budget sometime in July.  Then a conference committee would have to iron out any differences. Finally, the bill would have to be approved by the full Congress, which could be significantly delayed by the fall elections.

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The Center for Strategic and International Studies yesterday unveiled  a new “must-read” report for global health advocates, “Smart Global Health Policy.” While a panel at the Congressionally-chartered Institute of Medicine, made up primarily of scientists, issued recommendations on US global health policy last year, the CSIS panel is the first to involve high-level business leaders and sitting members of Congress.

The report drew on observations made during a study trip to Kenya, but it is unclear if consultation in developing countries went beyond that, for instance to include global representatives of affected communities and of developing country civil society, such as those on the boards of UNITAID and the Global Fund.

The report and the webcast of the launch event are available online.  Here are a few highlights:

The report makes a strong case that it is in the interest of the United States to continue and increase  our investment in global health and that the issue should matter to all Americans. It calls for keeping funding for AIDS, TB and malaria on a “consistent trajectory,” doubling spending on maternal and child health to $2 billion a year, forging a collaborative response to emerging heath threats, establishing strong coordination of global health policy across US agencies, and increasing support for multilateral efforts.

In 2009 there was a massive drop off in the expansion of treatment by US programs, and the report notes that AIDS advocates are “particularly anxious” at the slowing growth rate, a stalling that could also impact health systems.  The report suggests that funding is a concern for treatment advocates, yet, in fact, HIV prevention advocates have also been quite alarmed at the essentially flatline funding picture.

Despite World TB Day (March 24) being just a few days away, no mention is made in the report of immediate tuberculosis funding concerns, lowered TB targets in the 6-year Global Health Initiative or USAID’s role in responding to TB.  Instead, the report includes TB within a much longer timeframe, stating that “we can accomplish great things in the next 15 years:  We can cut the rate of new HIV infections by two thirds, end the threat of drug-resistant tuberculosis, and eliminate malaria deaths.”

In terms of overall funding, the report calls for less spending in the near term than either the IOM panel or the Global Health Initiative coalition did; instead, the CSIS document endorses the President’s proposed funding of $63 billion by 2014.  While the IOM called for specific increased funding levels on AIDS, TB and malaria consistent with Lantos-Hyde, the CSIS report does not delve into specific funding levels, with the exception of maternal and child health.  Instead, taking the long view, it calls for $25 billion in annual spending by 2025.

One exciting aspect of the CSIS report is that it endorses innovative financing as a means of raising funds for global health.  The report does not touch on the concept of innovative taxation for health, recently championed by maternal health advocates at Family Care International and many other groups. However, it identifies some specific mechanisms, such as borrowing the money needed through an international finance facility, and it urges the US National Security Council to review the most promising ideas on innovative financing and develop a US position.

Admiral William J. Fallon kicked off the launch event, stating that global health is a “bipartisan enterprise… which can unite US citizens in collective action.”  He stated the importance of maintaining forward momentum, noting that “we do not want to coast or slide backward.”  Helene Gayle said that global health efforts are showcasing the American spirit of generosity and said “we need forward momentum even in a period of constrained resources.”

Jack Lew, the top State Department official developing the US Global Health Initiative, spoke about the Administration’s goals in developing the new strategy. He said that the Administration’s aim was to “challenge a way of doing business by moving beyond a primary focus on disease treatment.”  He said the goal was “not to do harm to existing programs.”

Advocates for effective HIV prevention have felt stymied in recent weeks by the lack of specific HIV/AIDS guidances from the Administration to the field and have noted that Kenya’s Partnership Framework with the US even appears to rule out family planning integration.  Family planning came up at the event when Dr. Michael Merson, of Duke University, criticized the Canadian government’s rejection of the inclusion of family planning as a part of its maternal health initiative.

But Lew’s presentation did not delve into details — and there was no opportunity at the event for questions from the floor.  He stated that program integration was crucial to meet the needs of women, and he commented on the importance of having family planning and HIV/AIDS services in one location.

The report is particularly noteworthy for the very strong focus on measurement for accountability in delivering services. Business leaders at the event decried the reporting burden on health programs and, along with Dr. Merson, called for a common set of impact indicators.

Rajeev Venkayya, Director of Global Health Delivery at the Bill and Gates Melinda Foundation, said that measurement matters because it allows us to maximize efficiency and stretch dollars while identifying what works and what doesn’t.  In addition, measurement allows us to hold accountable institutions, organizations, and even individuals, which in turn allows for greater project improvement.  Exxon Mobil Chairman and CEO Rex Tillerson agreed, and cited a Lancet article which said that evaluation must be a top priority for global health.

Robert Rubin, former US Treasury Secretary and former head of Citigroup and Goldman Sachs, told the audience that global health leaders “face wrenching choices” as a result of US fiscal problems.  He asked two members of Congress, Rep. Keith Ellison and Senator Jeanne Shaheen, whether global health is an issue that can “break through the mire” on Capitol Hill.

Senator Shaheen said that the issue can succeed, but it is crucial to explain to Americans that international affairs spending is only a tiny fraction of the US budget, much less than people realize.   She said it was cheaper to spend on global health than on war, noting Bill Clinton’s recent statement about the appreciation of PEPFAR expressed by Muslim residents of Tanzania.  She also said the current committee structure in Congress is an impediment and endorsed the recommendation included in the report for a consultative body that would work across committees.

Congressman Ellison also voiced strong support for greater US action on global health, stating that “infectious diseases know no borders.”  He said that while in Kenya, he made good progress in persuading Kenyan leaders of the necessity of stepping up their own contributions.  He suggested that by reducing US spending on outmoded weapons systems the US could improve its budget outlook and make global health spending easier.

Gayle Smith, the NSC official leading the development of the US Global health Initiative, was the concluding speaker at the event. She said global health was a bipartisan issue and that in fact President Obama specifically directed that the achievements of the previous Republican Administration be recognized.  She praised the CSIS report, and said that its ideas were remarkably congruent with those of the Administration.

She said the Administration’s commitment to fighting global HIV/AIDS was “absolute” and, she added, “this will grow over the life of the initiative.” She said the Administration’s plans for the Global Health Initiative “include an ambitions set of targets in terms of outcomes.”

She did not respond to concerns submitted to the Administration by the Global Center, TAG, the Global Health Council, and the GHI Working Group that the Administration’s targets regarding tuberculosis contradict a directive from Congress approved in 2008 as a part of Lantos-Hyde.  In fact, it was surprising that the event unfolded without  reference  to the consultative process which numerous NGOs have engaged in regarding the US Global Health Initiative or to the detailed analyses these groups have submitted to the Administration.

There were a range of reactions from health NGOs to the event.  Eric Friedman at Physicians for Human Rights noted the “surprisingly little attention in the report to human resources for health and health systems, and no mention of including civil society in the development of country compacts.” He praised the report for “proposing that the Administration develop a long-term, 15-year framework for making progress in and committing the United States to improving global health, a good idea so long as it does not set the stage for underambition, and is flexible to respond to changes in the years ahead. ” He also would have liked to see “a recommendation that the United States should deliberately integrate a right to health approach throughout U.S. global health programs, including the consistent focus on equality, accountability, and participation that this entails.”

Matt Kavanagh at Health GAP praised what he heard from the report, which included an emphasis on keeping up the fight against HIV/AIDS, especially important for the health of African women. But he noted with concern that “some of the Administration comments that seemed to favor prioritizing ‘cheap’ interventions that do not work in the long term, such as single dose nevirapine instead of treatment for HIV positive mothers, an approach abandoned long ago as ineffective in wealthy nations.”

The American Medical Students Association’s Farheen A. Qurashi said that the report “takes a bold, but necessary, approach to U.S. global health planning by insisting upon a 15-year comprehensive plan.”  She said, “Unfortunately, the Commission’s report does not appear to specify the need for scaling-up of PEPFAR investments versus the dangers of flat-funding, and instead uses language that suggests that a continuation of current levels of funding without annual growth is sufficient.”

On health systems, she said that “though integration and health systems strengthening is mentioned in general terms, and the need for training and retention of health care workers is noted, there is no detailed analysis of the measures, funding, and support necessary to establish and retain adequate numbers of health professionals and other health care workers.”

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Evaristo Marowa, UNAIDS Country Coordinator for Botswana, said today that major opportunities to prevent HIV, and save billions of dollars in the long run, will be missed if the US and the international community fail to increase AIDS funding for Botswana and other countries in southern and eastern Africa. 

He made his comments in a presentation at the Global Health Council, where he also provided a powerpoint:  Botswana HIV epi and responses.  Dr. Marowa’s presentation comes as global AIDS advocates anxiously await next week’s release of President Obama’s budget proposal.  His urgent warning about the danger of donors adopting a flat or near-flat funding approach provided an interesting counterpoint to last week’s CSIS publication on HIV prevention, which did not mention the need to increase funding in its recommendations to the US government.

Dr. Marowa is a physician with a specialty in dermatology and sexually transmitted infections (STIs). He trained at Universities in Harare, Kinshasa, Liverpool and London.  Since September 2006, he has been the UNAIDS country coordinator in Botswana, and previously he worked in Tanzania, Zimbabwe, and Bangladesh.

HIV prevalence in Botswana has fallen in recent years from 38% to 24%, with declines seen particularly in young people. The country has had strong leadership on the issue at the highest levels, which Marowa called “visionary and committed.” Prevention of mother-to-child transmission has been “an astounding success,” with a transmission rate of about 4%.  A large proportion of people have been tested for HIV, about 60 to 70%, and access to antiretroviral medications is also high at about 85%.  PEPFAR has been a major support to these programs, providing about $90 million a year.

However, he said that a high degree of internal mobility in the population, multiple concurrent partnerships, low rates of male circumcision, low condom use, and high rates of gender-based violence, which form the basis for an ongoing HIV/AIDS crisis.  Marowa also cited alcohol abuse as a contributing factor, an issue on which he said the current president was very active. (more…)

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Lawmakers have finalized the fiscal year 2010 budget for foreign assistance, setting funding for key programs to fight global HIV and TB and reaching a landmark deal to revise the needle-exchange ban.

The agreement—expected to pass the House before the end of this week and the Senate before the end of next week—includes some modest increases for bilateral HIV and TB, as well as for the Global Fund to Fight AIDS, Tuberculosis and Malaria. But the funding levels still fall far short of what’s needed to combat these twin epidemics and of what was authorized in the Lantos-Hyde Act passed by Congress last summer.

The deal, for example, would allocate $5.359 billion for global AIDS, $1.05 billion for the Global Fund, and $225 million for TB. It also includes a slight boost for NIH. The gloal AIDS figure does not include bilateral HIV/AIDS funds for USAID or the CDC’s Global AIDS Program; with those pots of money tallied, the total US bilateral AIDS funding for 2010 stands at $5.828 billion. (See chart below for more details on how this comparies to last year, etc.)

The real headline, though, is this: Key congressional negotiators agreed to ease the ban on federal funding for needle exchange programs. This is a long-overdue move that will remove an unnecessary and harmful barrier to effective HIV prevention efforts. It’s also a big surprise.

Earlier this year, the House approved lifting the ban, but included so many restrictions as to make federal funding for such programs essentially unfeasible (i.e., not near any schools, parks, arcades, etc.). The Senate voted to keep the ban in place.

The new agreement revises the ban so it would only prohibit the use of federal funds for needle exchange programs in a location “that local public health or law enforcement agencies determine to be inappropriate.”

Here’s the chart, which lays out the approved spending levels for FY2009, the funding levels authorized in the PEPFAR II, the President’s request for FY2010, and last night’s Congressional agreement.

Dollars in millions

  FY09 PEPFAR II Obama FY 10 Final
Global AIDS $5.159bil $6.5bil $5.259bil $5.359bil
Global Fund $600 $2bil $600 $1.05 bil
Tuberculosis $163 $650 $173 $225
NIH $30.566 N/A $30.758 $31.008

 

Notes:  The reauthorization bill did not contain specified year by year funding levels with the exception of the Global Fund which was authorized at $2 billion.   The amounts listed under PEPFAR II for bilateral Global AIDS and TB are extrapolated from the overall five-year funding levels authorized in the bill. In addition, as noted above, the global AIDS figure does not include money directed to USAID or CDC for their bilateral HIV programs.

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How could the world dramatically lower the incidence of tuberculosis and save millions of lives? 

An effective TB vaccine would revolutionize the response to TB, which kills about 5000 people each day, and eliminate the need for lengthy and often difficult drug treatment.   

An effective vaccine would be of tremendous benefit all over the world, including in the United States, where there were 13,299 cases of active TB reported in 2007 and about 11 million people with latent TB. 

Of course, there’s no question that much more can be done to prevent TB using existing methods, notably the Three I’s.  But, imagine what an effective vaccine could do.  Vaccination of newborns with a successful TB vaccine could decrease global TB incidence by 39 percent to 52 percent by 2050, and mass vaccination could result in a nearly 80 percent decrease of TB by 2050, according to a recent estimate. 

What’s exciting is that the effort to develop such a vaccine is proceeding rapidly and could produce results in just a few years — that is, if the United States government and other donors provide the funding necessary for large-scale clinical trials. 

Right now, that’s a very big “if.”

A vineyard near Worcester, on the road to Barrydale

A vineyard near Worcester, on the road to Barrydale

South Africa is a leader in TB vaccine research, and I recently had the opportunity to visit a tuberculosis vaccine facility in Worcester, 120 km northwest of Cape Town, and to take some photos.  The facility has the strong support of the US-based Aeras Global TB Vaccine Foundation, and it is a terrific example of capacity building and international cooperation.

In fact, Aeras is supporting this kind of capacity building and healthcare infrastructure strengthening (including laboratories and disease detection) not only in South Africa but at partner sites in Kenya, Mozambique, Uganda, Cambodia and India as well.

The area called the Boland, where facility is located, is one of the most beautiful places I have ever visited.  It is the source of world-class wine as well as those delicious Ceres fruit juices you can find in supermarkets in the US and other countries.

Unfortunately, this rural area also has one of the highest rates of TB in the world.

TB incidence in the research area is about 100 times that which we have in the United States. The level of TB incidence in this area is at 1400 cases per 100,000 people, even higher than the overall South Africa rate of 900 per 100,000.  

This is the view directly oppostite the SATVI research facility.

This is the view directly oppostite the SATVI research facility.

The situation in South Africa is aggravated by unemployment, poor housing conditions (cramped and with inadequate air circulation), extreme inequity in access to medical care, and HIV/AIDS. 

As we explored in Deadly Synergy, TB is having an enormous and deadly impact on people who are living with HIV/AIDS.  Since 2007, HIV and TB co-infection has been the most significant cause of premature death in the province of Western Cape. 

However, it is also worth noting that, globally, most people with TB disease are not HIV positive. 

The woman on the left runs a local saloon, in Gugulethu, where people drink beer made from corn.  TB can spread in such enclosed spaces.

The woman on the left runs a local saloon, in Gugulethu, where people drink beer made from corn. TB can spread in such enclosed spaces.

In fact, in the Western Cape, HIV prevalence is less than the overall rate in South Africa as a whole.  Hassan Mahomed, the SATVI Clinical Director, told us that there are other factors in addition to HIV which are driving the TB problem in the area, which predates the escalation of HIV. 

He told us that the long, cold and rainy winters in the area lead people to staying indoors where they can become infected by TB.  He said poverty and alcoholism were also major factors, with many of the people receiving low wages for seasonal work on the many farms in the area.  

Many people live in cramped quarters, as in this photo from Gugulethu, near Cape Town

Many people live in cramped quarters, as in this photo from Gugulethu, near Cape Town

Children can suffer terrible forms of TB disease, such as TB meningitis, which can lead to severe brain damage and paralysis. 

While children in South Africa receive some protection from the BCG vaccine, developed about 90 years ago, this does not protect them against pulmonary TB and the protection does not last into adulthood.

But research is advancing rapidly.  There are now 10 new TB vaccine candidates in clinical trials worldwide, and four of them are being tested in Worcester, at the field site of the South African Tuberculosis Vaccine Initiative (SATVI).

We happened to arrive at the site on a day when mothers were bringing in their babies to receive an already-proven vaccine against pneumococcal disease.  Children in the TB vaccine study area are provided with other vaccinations free of charge, whether or not their parents choose to enroll them in the study. 

This mother of three had brought her daughter in for the free pneumococcal vaccination.  She said her uncle had suffered from TB.

This mother of three had brought her daughter in for the free pneumococcal vaccination. She said her uncle had suffered from TB.

I asked one of the mothers if the 150 Rand (about $19 USD) payment she receives for each clinic visit was a help to her, and she said yes but the even more important benefit was that as a study participant her baby also receives regular medical check-ups.

On our visit to the site, I got a chance to meet four month old Janenique Pienaar of Worcester.  Her mother was beaming, clearly delighted that her daughter is making history as the first baby in 80 years to be vaccinated in a proof-of-concept efficacy trial (Phase IIb) of a candidate TB vaccine. 

Child receiving his pneumococcal vaccine.

Child receiving his pneumococcal vaccine.

This vaccine candidate, called MVA85A/AERAS-485, would be a booster to the BCG vaccine, and it has already been shown to be safe in a number of Phase I and Phase II clinical trials. 

 To study this vaccine candidate, SATVI is enrolling 2783 healthy, already BCG vaccinated, babies, at about 4 months of age to participate in the trial. Half the babies will be given the new vaccine, and the other half a placebo. 

The children will then be monitored for two years to compare the incidence of TB in the two groups. If successful, the vaccine would proceed to a much larger, and more costly, Phase III clinical trial in 2011. 

A sleepy-eyed baby Janenique, with Dr. Michele Tameris, clinical manager of the South African Tuberculosis Vaccine Initiative

A sleepy-eyed baby Janenique, with Dr. Michele Tameris, clinical manager of the South African Tuberculosis Vaccine Initiative

This vaccine could be ready for wide-scale use by 2016, if the trials are successful.  Unfortunately, funding for later stage clinical trials for TB vaccines is at present very much in doubt, and the funding shortfall could significantly delay progress.

While the NIH and CDC have funded some early stage TB vaccine research and epidemiology studies, funding for the kind of late-stage trials conducted in South Africa is authorized under the PEPFAR law (Lantos-Hyde) to come through USAID. 

USAID is already investing significantly in AIDS and malaria vaccine research, but unfortunately it has not provided funding for TB vaccine research, whether through Aeras or another program.

The Obama Administration supported a tiny increase of only $10 million for USAID’s TB program in 2010.  Congress is now on course to provide a larger increase for 2010, but it will be roughly a $150 million increase at best — far less than the increase of about $500 million we and other advocates had sought for implementation of TB programs and research.  

The Aeras Global TB Vaccine Foundation needs over $30 million per year in additional funding to support a late stage clinical trial of a TB vaccine candidate.

Proud mom, with baby Janenique, the first baby to receive the candidate vaccine in this trial

Proud mom, with baby Janenique, the first baby to receive the candidate vaccine in this trial

We hope that the Administration proposes a substantial increase for TB in its 2011 budget proposal, yet the signs so far are not good. 

TB is not just any disease.  It’s the third leading cause of morbidity and mortality combined in women of reproductive age in developing countries. India’s national TB program estimates that some 100,000 women in India alone are rejected by their families every year because of TB.

Yet, the Administration’s draft, 6-year strategy on TB omits any reference to the TB funding levels “authorized” last year in the Lantos-Hyde bill, now US law. 

That bill specified $4 billion over 5 years for TB, or $800 million per year, including for vaccine development.  But, to become a reality, this funding level needs annual support from Administration and from the Budget Chairmen and Appropriators in Congress. 

What we have heard from government insiders is that the Administration feels the amount of TB funding now provided through PEPFAR, which directs some of its funding to addressing TB-HIV coinfection, in effect addresses the TB funding need.  Would that were the case!

President Obama just awarded the Presidential Medal of Freedom to Archbishop Emeritus Desmond Tutu.  He, like Nelson Mandela, is a TB survivor, and both have called for bold action to confront TB.  Tutu has appealed for funding for TB and HIV programs, even in these difficult times.

South African Archbishop Emeritus Desmond Tutu

South African Archbishop Emeritus Desmond Tutu

We must heed their call to action. TB is estimated to deplete the incomes of the world’s poorest communities by $12 billion per year. South Africa has made progress in the fight against TB, but there is still much to do.  As Tutu has stated, “As we have overcome apartheid, so we shall defeat TB and HIV/AIDS, these ungodly twin killers.”

— David Bryden, Senior Program Policy Officer, Center for Global Health Policy 

The floor of the District Six Museum in Cape Town has this quote from Langston Hughes

The floor of the District Six Museum in Cape Town has this quote from Langston Hughes

 

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A key House subcommittee has called for lifting the ban on funding for needle-exchange programs, a significant step forward in the hard-fought battle for evidence-based treatment of HIV/AIDS.

Disease experts, particularly those who specialize in treating HIV/AIDS, have long argued that the ban on needle exchange unnecessarily impeded HIV/AIDS prevention efforts. Rep. David Obey, D-Wis., chairman of the House Appropriations Committee, noted as much in a statement today announcing the proposed change in policy.

“Scientific studies have documented that needle exchange programs, when implemented as part of a comprehensive prevention strategy, are an effective public health intervention for reducing HIV/AIDS infectious and do not promote drug use,” Obey said in this statement. (more…)

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From Capitol Hill to sub-Saharan Africa, the subject of spending on global health is likely to take center stage this week, or at least a more prominent place than usual. But the increased attention may not result in more robust resources for the deadly epidemics of HIV/AIDS and tuberculosis.

In Washington, the Senate Appropriations Committee is scheduled to take up its foreign affairs spending bill this week, determining crucial funding levels for global AIDS and TB programs. The House has already marked-up its version of the bill; click here to read our earlier blog post on the modest increases approved in that chamber for PEPFAR and bilateral TB.

Meanwhile, world leaders will gather in Italy on Wednesday for the G8 Summit; there’s deep concern that global health will get short-shrift at the session, as government officials seek to backtrack from earlier commitments amid the economic crisis. This Huffington Post piece provides a good sense of the landscape, and we’ll try to provide updates as the summit gets underway.

Finally, at the end of the week, President Barack Obama will travel to Ghana, his first trip to sub-Saharan Africa as president. It is a chance for global health advocates to highlight the immense needs in that region, but even that milestone visit isn’t likely to drum up much new support for global HIV funding. The White House choose Ghana because to showcase a stable democracy on the continent, as the New York Times reported in this story a while back. And Obama is set to talk about food aid there, not disease epidemics.

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