Posts Tagged ‘Eric Goosby’

This Boston Globe story documents, for the first time, how U.S. government officials have told some PEPFAR-funded clinics to stop enrolling new HIV patients on lifesaving treatment.

“People are struggling to find resources to honor the commitments we have made,’’ Ambassador Eric Goosby, US global AIDS coordinator, told the Globe. “We’re not at a cap point yet. If it gets worse, we’ll have another discussion.’’

The story is a must-read for those concerned about the future of PEPFAR and the US commitment to fighting global AIDS. The paper reports that the decision “was prompted by tighter budgets as well as a debate over how limited global health care dollars can be spent most effectively, has sparked fears among AIDS advocates that the Obama administration is curtailing its commitment to a program that provides lifesaving drugs for 2.4 million people and that many view as President Bush’s most successful foreign policy legacy.” Click here for the full article.


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

Q: Roxana Rogers, USAID’s South Africa health team leader, said recently in South Africa that, “US government funding is going to come down dramatically over the next five years.” True?

A: No, it’s not true. Every year there’s been an overall increase in funding for PEPFAR, and we’ve also not been in a situation where we’ve had a decrease in any country, certainly not in South Africa. Our funding for South Africa is over a half billion dollars a year. Our resources that go into South Africa are having a huge impact, and I’m not understanding that (comment by Rogers).

We also committed to $120 million recently over two years to specifically address an unexpected shortage of funding for antiretroviral drugs in South Africa in nine provinces. The South African government asked us to be silent (about it during that time.) … It made a lot of sense for us to fund it for the simple reason that we not allow services to be interrupted and allow South Africa to respond to the increase in demand.

Roxana’s statement is based on the fact – I think – that she was used to PEPFAR funding that went up in huge increments every year — so much so they scrambled to find meaningful applications to use the funding for programs. Now we are in an economic crisis, with nowhere near the increase in funding like that, so on a relative level it may feel like a drop in funding.

Q: What happened in South Africa’s shortfall of funding for treatment?

A: PEPFAR has not run out of any antiretroviral drugs in any country, including South Africa. .. But for multiple times we’ve been asked to bail out a country for one or two months (because of drug shortages in the national program or funding shortages). South Africa had run out of resources to pay for the medication in nine provinces, starting in November. It was a significant outlay of resources for us and a real example of cooperation. In addition, we were able to work with the government to ensure their Treasury picks up the bill thereafter, so it doesn’t happen again.

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

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

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

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

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

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

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

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

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

Q: How does that strategy work?

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

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

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

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

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

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Despite a nearly flat budget, US Global AIDS Coordinator Eric Goosby today promised a “steep increase” in PEPFAR’s prevention activity, as the program pivots from an emergency US response to a broader long-term, country-driven endeavor. Indeed, Dr. Goosby signaled that PEPFAR will be as aggressive in scaling up prevention services in the next five years as it was in scaling up HIV treatment in the first five years.

Dr. Goosby spoke at a forum on US priorities in HIV prevention, hosted by the Center for Strategic and International Studies. In his opening remarks, Dr. Goosby described the huge challenge facing HIV prevention experts, noting for example, that for every 2 patients put on antiretroviral drugs, there are five who become newly infected. He also cited a National Intelligence Council estimate that by 2025, there could be as many 50 million HIV positive people living with HIV—25 to 30 million of whom would require treatment.

Dr. Eric Goosby Talks about PEPFAR's New Plans for HIV Prevention

PEPFAR’s efforts going forward will center on “combination prevention” models that deploy biomedical, behavioral and structural elements. Dr. Goosby said PEPFAR’s new effort to more accurate map the HIV/AIDS epidemic in high-burden countries will help program officials develop more effectively targeted strategies that move “from the demographics backward.” And he said PEPFAR would also try to better evaluate programs so they know what works and what doesn’t.

“We want to be nimble enough in our understanding of what we’re doing to identify efficacy and move the machine … when we see something that indeed does impact,” he said.  (Click here for more on PEPFAR’s five-year strategy.)

During a panel discussion afterwards, Dr. Goosby was asked how PEPFAR could achieve such ambitious prevention efforts with only minimal funding increases. He said the modest funding increases allocated so far, along with cost savings, such as anticipated decreases in treatment costs and eliminating funding that’s now directed to multiple groups to serve the same populations, would be sufficient to beef up prevention at time of constrained budgets.

He also said the US is pushing other wealthy countries to step up their commitment to combating the epidemic, so multilateral organizations, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, would be better funded. 

“The Global Fund is kind of the future,” he said. “We need to work hard to make it everything it needs to be.” He said discussions with other G8 leaders have already begun, but the effort will require leadership from President Obama and Secretary of State Hillary Clinton. (more…)

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In a 90 minute meeting with HIV advocates and implementers today, Ann Gavaghan spent almost as much time explaining what PEPFAR’s new five-year strategy does not mean as what it does mean.

The term “increased efficiencies” is not some code for budget cuts, Gavaghan promised, but rather a mandate to maximize the impact of PEPFAR programs. The phrases “country-led” and “country-driven” do not mean all PEPFAR funding will now flow to country governments and that “everyone else gets shut out,” she said. And the call for PEPFAR programs to address HIV/AIDS within a broader health and development context “does not mean HIV programs will be subsumed into development.”

Gavaghan is a top policy official with the Office of the US Global AIDS Coordinator, and her remarks came at a meeting of the Global AIDS Roundtable in Washington. The room was jammed with more than 50 advocates looking for translation and elaboration of the strategy documents OGAC released last month on World AIDS Day. Those documents spell out, in broad brush, a vision for transitioning PEPFAR over the next five years from an emergency response to a more durable, integrated initiative, but they’ve sparked a wave of questions about PEPFAR’s focus and its commitment to continued treatment scale-up. 

On the latter point, Gavaghan was adamant in rebutting the notion that PEPFAR is pulling back on treatment. “We are continuing to support scale up of treatment,” she said. ”Let me repeat that.” And she did.

In the five-year plan, PEPFAR set a treatment target of reaching more than 4 million people with antiretroviral drugs. Advocates say this is a low-ball figure; the program already serves more than 2.4 million, so the new figure suggests that expansion of AIDS treatment over the next five years will be only about 1.6 million people, a significant slowing of the initiative’s growth and far short of the need.  Disease experts and advocates have said that PEPFAR can and should reach 7 million people with ARVs by 2014. (more…)

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The Center for Global Health Policy’s director, Christine Lubinski, is quoted in this recent NPR story that examines the Obama Administration’s approach to combating global AIDS.

The piece, which also includes an interview with US Global AIDS Coordinator Eric Goosby, delves into the Administration’s plans for building developing-country capacity (and responsibility) for AIDS programs and for integrating US global AIDS efforts with other global health programs. Some details of the Administration’s approach were released on World AIDS Day in these five-year strategy documents.

In the NPR story, Goosby says the current trajectory of US support for combating global AIDS is not sustainable in the long term.

“We are constantly increasing the number of individuals that are alive and continuing to use services,” Goosby tells NPR. “And it is a growing crescendo kind of economic burden that the United States and the countries are learning how to accommodate.”

An AIDS program that is “completely dependent on offshore resources and not embedded in the public system of the country runs the risk of being ephemeral and dependent on how steady and reliable those resources remain,” Goosby adds.

Lubinski, who is also vice president for global health at the Infectious Diseases Society of America, highlights the continuing need for treatment scale up and says that Goosby has been put in a very difficult position.

Goosby is “a man who’s been an amazing advocate and provider of HIV treatment, and now may be faced with telling all of these countries they need to do more with less,” she says. “At the same time, you know, tens of thousands of very sick people are knocking on the door asking for treatment.”

Click here to listen to the whole segment or read the transcript.

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Federal officials today celebrated the approval of the 100th antiretroviral drug authorized under an expedited regulatory framework created five years ago, as a way to fast-track the delivery of cheap HIV drugs to the developing world through the PEPFAR program. A panel discussion, held at the Pan American Health Organization Headquarters to mark the milestone, featured FDA Commissioner Margaret Hamburg, OGAC Director Ambassador Eric Goosby and ambassadors from Haiti and Tanzania.

The FDA process was launched in May 2004, in response to a call from activists, clinicians and members of Congress to use the WHO’s pre-certification drug list to make purchases of generic medications for PEPFAR-funded programs. Instead, a process was devised to allow the FDA to certify generic antiretrovirals (ARVs) for PEPFAR purchase, even if the branded drug was still protected by U.S. patent laws.

According to the first speaker, Dr. Mirta Roses Periago, director of the Pan American Health Organization, more than 4 million people now have access to lifesaving HIV medications, including 455,000 in Latin America and the Caribbean region. Periago noted that these numbers reflect only 42 percent of those who need ARVs and commented on the urgent need to bring down prices and increase availability of second-line treatments. (more…)

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As Obama’s new global AIDS coordinator, Dr. Eric Goosby has no shortage of burning issues on his plate—from reports of ARV stock-outs in the developing world to questions about the long-term sustainability of PEPFAR. At a 1 ½ hour community meeting at the State Department Friday, the unassuming California doctor tried to reassure the global AIDS community that he has his eye on both the immediate and the far-reaching.

So even as he’s pushing aggressively forward to develop country ownership and building capacity for taking over AIDS programs, Dr. Goosby said he’s also urgently aware of the need to scale up prevention of mother to child transmission, to find ways to expand ARV treatment in a tight budget climate, and to meet new PEPFAR mandates, including recruiting 140,000 new health care workers.

In a wide-ranging session with more than 100 advocates and experts, Dr. Goosby said his overarching goal as head of PEPFAR is to build an enduring program that will be there to serve the sick and poor in developing nations for decades. “We are at an exciting point in PEPFAR’s evolution,” he said from the dais of an auditorium in the State Department. “Our charge now is to make sure that contribution is realized into the future, not for five years but for 25.”  

“… The economic downturn has created an urgency to this discussion that wasn’t there before,” Dr. Goosby said. But he acknowledged the country-ownership effort will take a decade or longer to achieve.

“No country is in a position to take over” these PEPFAR programs, but US and other leaders need to start the dialogue now, he said. (more…)

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