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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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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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Nearly 300 leading U.S. disease experts expressed serious concern about the White House’s inadequate budget request for global AIDS and TB programs, saying the proposed funding levels signal a retreat in the U.S. response to the twin epidemics of HIV and TB.

In a strongly-worded letter sent to members of Congress today, the physician-scientists said the consequences of a pullback in combating HIV and TB in the developing world would be devastating. HIV/AIDS experts, in particular, are concerned that insufficient funding requested by the White House could jeopardize the hard-won gains made in reducing HIV-related mortality, preventing new infections, and providing life-saving treatment and care to millions of HIV-positive patients through the President’s Emergency Plan for AIDS Relief (PEPFAR).

The letter comes amid an unfolding crisis in access to HIV treatment in southern Africa, a result of the economic downturn, stagnant funding for PEPFAR, and a shortfall in resources for the Global Fund to Fight AIDS, Tuberculosis, and Malaria. There are already disturbing reports from Uganda, Nigeria and Mozambique about limits on access to lifesaving drugs for new HIV patients, even for pregnant and breastfeeding women. These limits also put at risk U.S. investments in HIV testing campaigns launched across the developing world, because patients may now be reluctant to find out their status if they have no assurances of receiving treatment.

“We cannot retreat from the lifesaving mission we as a nation embraced in 2003 through the creation of the PEPFAR program,” the letter states. “Regrettably, the President’s FY 2011 budget reflects such a retreat by failing to request adequate resources to continue to scale-up HIV treatment or to respond to the twin epidemics of HIV and TB in southern Africa and elsewhere in the developing world.” Click here to see the House version of the missive: Global AIDS-TB Sign on Letter for House

Physician-scientists are also deeply worried about the U.S. commitment to fighting TB. The Obama Administration’s Global Health Initiative dramatically scales back treatment targets for tuberculosis, including lethal new strains of drug-resistant TB. The letter urges lawmakers to support full funding for the Lantos-Hyde Act, which calls for spending $48 billion over five years to address HIV/AIDS, TB and malaria.

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The full-court press is on for Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. With the Global Fund’s replenishment conference set for early October, “this must be an intensive period of advocacy of all of us,” he told a group of D.C.-based global health advocates on Wednesday.

One of the first—and most important—signals on the Global Fund’s prospects for a robust replenishment will come from Washington, when lawmakers in Congress set the U.S. contribution to the Fund in the FY2011 appropriations bills, he said. The Global Fund’s conference is set for Oct. 4 & 5 at the United Nations, and Kazatchkine urged advocates to push for Secretary of State Hillary Clinton to be there in person, instead of a lower-level U.S. representative.

“It would be extremely meaningful if Secretary Clinton could attend and come with a pledge for three years,” he said. “It’s essential for stability and planning,” he said of the three-year pledge, adding that he and others understand such a multi-year commitment would be contingent on congressional approval.

So how much money is he talking about? “Big money … but peanuts if we compare it to what the world could find in three weeks times to rescue the financial markets,” he said. “Money is political choice.”

Kazatchkine said the Global Fund has drafted three different potential funding scenarios, and he focused on the middle one in his talk on Wednesday. Under that scenario, the Global Fund could continue funding all its current programs and expand at the same pace as it did in Rounds 8 & 9. To do that, the Fund will need $17 billion over three years, with a $5.5 billion three-year contribution from the U.S., he said.

He acknowledged that the political climate for making this request is tough, but said advocates must stress that poor countries have been hit even harder by the economic crisis and much is at stake.

“All the gains we have achieved are fragile, and if we slow down on this, it can be very dangerous,” he said. If access to treatment for HIV, TB or malaria becomes more restricted, “we can lose drugs because of resistance,” he noted.

On the other hand, the potential gains are immense. He cited, for example, the Fund’s efforts to improve and expand access to prevention of mother-to-child HIV transmission. “It remains unacceptable that 400,000 children were infected with HIV in Africa last year, when in France it was 4,” he said.

If resources for the Fund are sustained and expanded, he said, the world could see virtual elimination of mother-to-child HIV transmission by 2015. “It would have not only a huge human impact, but also a huge symbolic impact,” he said. “I call it the beginning of the end.”

More broadly, the replenishment conference will go a long way to determining “where the world will be in 2015 in terms of global health,” he said.

In the video clip above, you can hear Kazatchkine’s response to a question about how advocates can answer questions from Capitol Hill about why robust funding is needed for both PEPFAR and the Global Fund, as opposed to one versus the other.

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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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This week, Dr. Peter Mugyenyi is visiting Washington from Uganda, where he directs the Joint Clinical Research Center, the largest PEPFAR implementer in East Africa. Dr. Mugyenyi was one of a half-dozen people in the room when PEPFAR was conceived back in 2003. As one of the program’s most eloquent supporters, Dr. Mugyenyi has recently begun voicing grave concern about the near flat-funding of PEPFAR’s budget. In this video interview, he talks about the on-the-ground consequences of a pullback from the fight against global AIDS. Dr. Mugyenyi will be testifying about this issue on Thursday at a hearing before a House Foreign Affairs subcommittee.

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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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