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Former US President Bill Clinton speaks to the International AIDS Conference

Filed by Meredith Mazzotta from Vienna

“This is only the end of the beginning,” former President Bill Clinton said at the Monday morning plenary session of the International AIDS Conference in Vienna. “We have to transition now from what has essentially been a ‘make-it-up-as-you-go’ initial response to a calculated, long-term response.“

Part of that response, he said, is recruiting more well-trained health care workers. “Specifically, we need people who can do good work at a lower cost over a wider geographic range than doctors can do alone in poor countries, or that doctors and nurses can do alone.” Clinton also spoke about fighting the idea that there is a dichotomy between investing in HIV/AIDS treatment and prevention and investing in health care systems. Part of that involves showing that we are spending the money we do have effectively and wisely.

A few other recommendations he mentioned: challenging African nations to spend more on health, educating as well as advocating on the economic benefits of HIV treatment and prevention, cutting the cost of service delivery, and spending a higher percentage of donor aid on in-country services managed by local government or nongovernmental organizations.

At the Sunday evening opening ceremony, protesters marched into the session room and onto the stage with posters, flags and horns, chanting about keeping promises for AIDS funding. This was in response to recent budget proposals for FY2011 that indicate a retreat from the Obama administration’s promise to fund global AIDS at $50 billion over the next five years.

In response to the protesters, Clinton offered this advice, “You have two options here. You can demonstrate and call the president names, or we can go get some more votes in Congress to get some more money. My experience is that the second choice is the far better one and more likely to pay off,” Clinton said, adding, “There is no way the White House will veto an increase in spending for AIDS.”

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Five Republican U.S. senators recently sent a pointed letter to US Global AIDS Ambassador Eric Goosby, MD, asking for a clear response to reports that patients are being denied HIV therapy in Uganda and that clinicians elsewhere are “being forced to ration lifesaving treatment.”

The letter, signed by Sens. Michael Enzi of Wyoming, Tom Coburn of Oklahoma, and others, says the lawmakers are increasing concerned “that these reports signal a troubling direction of the current PEPFAR strategy.”

“…We acknowledge that prevention efforts are an important component of the highly successful PEPFAR program, but the clear innovation of PEPFAR is its focus on treatment,” the senators write. “After all, treatment is prevention. Reductions in viral loads reduce the likelihood of individuals spreading the disease. Treatment also reduces transmission among partners, diminishes mother-to-child transmission, and keeps those with HIV in the medical system where they can receive proper counseling. The availability of treatment is integral to promoting HIV/AIDS testing and early diagnosis. After all, how can we continue to promote testing when the program is not able to provide treatment?”

Click here to read a U.S. government memo directing Ugandan implementers not to add new patients unless a treatment slot opens due to a patient’s death or loss to follow up: Memo-Oct-Halt Treatment Scaleup

The GOP senators also note that in the reauthorization of PEPFAR, Congress specifically mandated that more than half of bilateral AIDS money be spent on lifesaving medical care for HIV positive patients and said they were concerned that the Office of the Global AIDS Coordinator might not be “taking adequate steps to meet these statutory requirements.”

They ask Dr. Goosby to answer a half-dozen or questions, including the total number of people expected to receive treatment in 2010; the treatment allocation, as a percentage of PEPFAR’s budget, in FY2009; and an explanation of PEPFAR’s policy on whether savings achieved in treatment programs can be used to further expand treatment slots.

That last item is particularly worrisome among some advocates who have heard that implementers are being told any cost-efficiencies they find in their treatment programs cannot be used to add patients to the rolls.

Another letter sent this week, from HIV advocates in the U.S. and Uganda to Secretary of State Hillary Clinton, also raises these issues.

“Hundreds of people each month are already going from clinic to clinic searching for treatment,” states that missive, from a coalition of advocacy groups including Physicians for Human Rights, Health GAP, and others. “Families are being forced to choose between dangerous resistance‐inducing sharing of drugs and letting family members die. Tens of thousands waiting in line for others to die are not ‘new’ patients, per se, but were tested and put into care through PEPFAR support with the promise that treatment would be available when clinically needed. Now they are instead being turned away. We note that while some implementers are enrolling new patients the extremely limited treatment slots available are far outstripped by demand.”

To read the letter for GOP Senators, click here: PEPFAR Treatment Letter

To read the advocates letter, click here: Clinton–UGANDA CS letter

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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)

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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?

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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.

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Secretary of State Hillary Clinton presided over the swearing in of Eric Goosby, MD, as Ambassador at large and US Global AIDS Coordinator last night in an emotional ceremony that included numerous Goosby family members, including his wife, his two children and his mother. Sitting with Dr. Goosby’s family were Ambassador Mark Dybul, MD, and UNAIDS Director Michel Sidebe, both of whom Clinton recognized in her remarks. Among the several hundred guests were at least four senior government officials, including Director of the White House Office on AIDS Policy Jeff Crowley; Deputy Secretary of State Jack Lew; Deputy Secretary of Health Bill Corr; and NIAID Director Tony Fauci.

 Secretary Clinton’s remarks clearly underscored the personal and collegial relationship she shares with Ambassador Goosby. He is a “great doctor, and a really good human being,” Clinton said. 

Secretary of State Hillary Clinton presides over Dr. Eric Goosby's swearing in as US global AIDS coordinator

Secretary of State Hillary Clinton presides over Dr. Eric Goosby's swearing in as US global AIDS coordinator

She spoke about their recent trip to South Africa and a visit to an HIV clinic, where she said Goosby connected with the clinic workers in a way that demonstrated his understanding of building and nurturing partnerships. Clinton also commented on the long road South Africa has traveled to come to grips with the HIV epidemic and the importance of the new government leadership in the face of the tremendous burden of HIV. She also spoke of PEPFAR as a platform for President Obama’s Global Health Initiative.

Dr. Goosby thanked his family for supporting him, as he uprooted his life to take this job. He said he wanted to serve in this role because of the strong commitment that both Secretary Clinton and President Obama have to the battle against AIDS. He noted that his involvement in treating HIV/AIDS began 25 years ago, but that the epidemic is still a crisis today, with massive unmet needs for prevention, treatment and care services. He said stigma and discrimination still fuel the epidemic, and he identified the urgent need for honest discussion and appropriate evidence-based interventions to respond to men who have sex with men, injection drug users, and the culturally-driven heightened vulnerability of women and girls.

Dr. Goosby concluded his remarks by describing the history of PEPFAR to date as the great work that can be achieved “when we dare to think big.”

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From the implementation of so-called “smart power” diplomacy to the future of PEPFAR, there are many unanswered questions about the Obama administration’s approach to foreign aid. For starters, who will head USAID, which oversees many US global health programs as well as other development assistance?

The buzz so far has centered on health-care pioneer Paul Farmer, a doctor who has a wealth of experience in HIV and TB. The speculation about Farmer continued today—albeit with scant new information—with this story by the Associated Press, in which Clinton bemoaned a burdensome vetting process.

Despite that vacancy, some other global health policy blanks may be filled in, or at least partially shaded, in the coming days. Tomorrow, for example, Secretary of State Hillary Clinton will give a “major policy address” (so billed by the State Department’s communications office) at the Council on Foreign Relations.  And next week, Dr. Eric Goosby, US Global AIDS Coordinator, will be among those headlining an event at the International AIDS Society conference in South Africa, where Goosby is expected to discuss the future of PEPFAR. (We will be blogging from the IAS meeting next week, so check back for posts detailing the goings-on in Cape Town.) (more…)

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