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Posts Tagged ‘funding’

The Kaiser Family Foundation (KFF) and the Center for Strategic International Studies (CSIS) held a panel discussion Wednesday to assess the global health outcomes of the G8 and G20 summits held in Canada last month, where world leaders pledged to reduce maternal and child mortality through the Muskoka Initiative for Maternal and Child Health.

Participants discussed the financial commitments made by G8 nations to reach Millennium Development Goals (MDG) 4 and 5, which deal with reducing child mortality and improving maternal health, respectively. HIV/AIDS was not addressed. Panelists included Jennifer Kates of the Kaiser Family Foundation and J. Stephen Morrison of CSIS. They were joined by Leonard Edwards, the Canadian Prime Minister’s Personal Representative to the G8 and G20 summits, and by Mark Abdoo, Director for Global Health and Food Security on the White House National Security staff.

G8 members committed to contributing an additional $5 billion for the next five years, which will be used to strengthen country-led national health systems in developing countries. Funding will enable delivery on key interventions along the continuum of care, from pre-pregnancy to early childhood.

G8 leaders anticipate that the Muskoka Initiative will mobilize more than $10 billion over the next five years. Already the governments of the Netherlands, New Zealand, Norway, the Republic of Korea, Spain, and Switzerland have collectively pledged $800,000, while the Bill and Melinda Gates Foundation has pledged $1.5 billion over the next five years.

In the past, the global health focus of the G8 has been on reducing the prevalence of HIV/AIDS. However, G8 members have fallen way short of their commitments. In 2005, G8 nations pledged to achieve full universal access to HIV/AIDS treatment by 2010, and pledged to expand HIV/AIDS budgets by $50 million by this year. Jeffrey Sachs, special advisor to the UN Secretary General on the MDG, reports that G8 nations have fallen $30 million short on their pledge.

In 2007 in Norway, G8 leaders pledged $1.8 billion to achieve universal access for children to HIV/AIDS treatment by 2010. UNICEF estimates that an additional $649 million is needed to meet their pledge.

HIV/AIDS is the leading killer of women of reproductive age worldwide. The G8 pledged to reduce the number of maternal deaths by 64,000 in the next five years. However, that goal cannot be achieved without integrating HIV/AIDS care into maternal health frameworks. HIV/AIDS prevention and treatment must be included in all discussions of improving maternal and child health, or else the goals set out will not be achieved and the G8 will continue to fail to meet their commitments.

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The strongest scientific-journal rebuttal yet to the Obama Administration’s proposal to shift resources to maternal and child health at the expense of HIV/AIDS treatment scale up comes from two medical students, who in a commentary just published in AIDS make a clear and convincing case that such a move would actually undermine the health of women and children around the globe, not improve it.

“While we welcome the Mother and Child Campaign in a diverse portfolio of global health strategies funded by the United States, we are troubled by the ‘either/or’ mentality that places HIV/AIDS funding in direct opposition to initiatives to improve MCH,” write Sarah Leeper and Anand Reddi, who are studying medicine at Brown University and the University of Colorado respectively.

Referring to a JAMA article by Colleen Denny and Ezekiel Emmanuel that first outlined this proposal, they write: “We do not accept the premise by Denny and Emmanuel that the proportion of child deaths due to AIDS is ‘small,’ nor do we support the characterization of highly active antiretroviral therapy (HAART) as ‘new, complex, and expensive.’ We would argue that policies based on misrepresentations such as these threaten to undermine rather than support MCH worldwide.”

Leeper and Reddi take apart the Denny-Emmanuel argument piece by piece. For starters, they note that in the five countries with the highest HIV adult prevalence, HIV is the No. 1 cause of mortality for children under 5 years old. “One-thousand children were born with HIV everyday in 2007, due in part to the fact that <25% of all HIV-positive women worldwide have access to prevention of mother-to-child transmission,” they write.

The article also notes that all children born to HIV-positive mothers, whether they have HIV themselves or not, are at a much higher risk of death if maternal HIV is not treated. Leeper and Reddi point to a study of 3,468 children of HIV-positive mothers in Africa found that uninfected children with HIV positive mothers who gave birth “at an advanced disease stage” were at significantly higher risk of death. “This may be attributable in part to the fact that children with HIV-positive caregivers reside in food-insecure households more often than their unaffected peers, putting them at higher risk for malnutrition and death from diarrhea and acute respiratory infection,” they write.

Leeper and Reddi detail how HIV therapy is a cost-effective intervention and highlight the opportunities to build on PEPFAR and other global AIDS initiatives to improve maternal and child health, rather than doing the latter at the expense of the former. They note that clinical studies in Rwanda and Haiti have shown how PEPFAR has led to better maternal and child health outcomes.

“Confronting illness in isolation–whether by funding PEPFAR at the expense of programs that target MCH or vice versa–cannot be our way forward. Integrated health service delivery models that address the well-being of both HIV-positive and HIV-negative families, without prioritizing one at the expense of the other must be developed, funded, and implemented,” they conclude. “The complex and interrelated challenges of MCH against the devastating global backdrop of HIV require comprehensive models of care that combine HIV/AIDS and MCH initiatives.”

You can find their article here. It has been published online ahead of print.

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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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The New York Times today ran a powerful set of stories on the consequences of stagnant funding for global AIDS programs. The main article documents a sharp turnabout in the war on AIDS, as new patients in Uganda are being denied access to treatment because of inadequate funding.

 “Uganda is the first country where major clinics routinely turn people away, but it will not be the last,” the Times reports. “In Kenya next door, grants to keep 200,000 on drugs will expire soon. An American-run program in Mozambique has been told to stop opening clinics. There have been drug shortages in Nigeria and Swaziland. Tanzania and Botswana are trimming treatment slots, according to a report by the medical charity Doctors Without Borders.”

US Global AIDS Coordinator Eric Goosby tells the Times: “I’m worried we’ll be in a ‘Kampala situation’ in other countries soon.”

Here are links to this comprehensive look at the crisis in global AIDS:

At Front Lines, AIDS War Is Falling Apart http://www.nytimes.com/2010/05/10/world/africa/10aids.html?ref=africa

As the Need Grows, the Money for AIDS Runs Far Short

http://www.nytimes.com/2010/05/10/world/africa/10aidsmoney.html

After Long Scientific Search, Still No Cure for AIDS

http://www.nytimes.com/2010/05/10/world/africa/10aidsscience.html?ref=africa

Cultural Attitudes and Rumors Are Lasting Obstacles to Safe Sex

http://www.nytimes.com/2010/05/10/world/africa/10aidscondom.html?ref=africa

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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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There were plenty of frightening statistics and unsettling trends highlighted at today’s World TB Day briefing on Capitol Hill. But one photo captured the true scope of the problem in scaling up diagnosis and treatment of the global TB epidemic.

Celine Gounder, MD, an IDSA member and TB/HIV specialist at Johns Hopkins University, described a recent trip to Malawi, where she saw shopkeepers volunteering to collect sputum samples from customers with chronic coughs. The accompanying photo: a man transporting the sputum samples to a laboratory in a small wooden box balanced on the back of his bicycle.

Dr. Celine Gounder discusses the TB epidemic at a Senate briefing

As Dr. Gounder noted, this small community had overcome one of the hurdles in getting suspected TB patients access to proper care. But many others remain. For starters, those specimens so carefully balanced on the bike would be examined using sputum smear microscopy, the only widely available diagnostic test for TB in Malawi. But Malawi has one of the highest HIV prevalence rates in the world, and the vast majority of HIV-related TB cases will be missed by sputum smear microscopy. A more accurate TB test, culture, is not available in the country because of lack of funding. So many of the patients will get false negative results, and continue to transmit the TB bug.

Her presentation provided compelling evidence of the need for more resources devoted to increased laboratory capacity and better diagnostics for TB. But she noted the gap between rhetoric and reality when it comes to TB funding. See Dr. Gounder’s power point here: CGounder_US Senate Briefing_20100324 and below is a video of her presentation.

“Despite the clear need for a heightened response to the global TB problem, funding that has been appropriated for these activities falls short of what was authorized by the Lantos-Hyde Act and what is needed to make decisive progress,” she said. “USAID, which is the primary US agency conducting global TB activities, received only $225 million in FY 2010 of the $650 million dollars authorized.”

She noted in particular that the White House’s Global Health Initiative includes TB treatment targets that are much lower than those set out in the Lantos-Hyde Act, which reauthorized PEPFAR. And she said HIV/TB co-infection was getting particularly short-shrift.

“Little more than lip service has been paid to delivery of TB-related interventions by HIV programs,” Gounder said.  “Only 16% of all TB patients were tested for HIV in 2007. Only 2.2% of HIV patients were screened for TB. And only 30,000 of HIV patients, 2% of the target, received isoniazid preventive therapy, which has been proven to reduce the risk of TB and mortality by one-third to two-thirds.”

Gounder’s remarks came at a Senate briefing on the global TB epidemic, which included a special focus on drug-resistant TB. The event, entitled “Bringing Methods to Scale: New Perspectives in the Changing World of TB,” also featured a presentation by Ernesto Jaramillo, team leader for MDR-TB for the World Health Organization’s Stop TB Department, who detailed the WHO’s newest data on drug-resistant TB. (more…)

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This posting is by Rabita Aziz, Program Associate at the IDSA/HIVMA Global Center

The new report by the Center for Strategic and International Studies (CSIS) Commission on Smart Global Health Policy  calls for the U.S. to double contributions to better maternal and child health, to $2 billion a year.  Such investments should be focused on a few core countries in Africa and South Asia where there is a clear need, where partner governments are willingly engaged, and where concrete health gains can be made along with increasing a country’s capacities.

The report demonstrates that maternal mortality is a profound problem by offering this data: a woman’s risk of dying in pregnancy or childbirth is 1 in 7,300 in the industrialized world, 1 in 120 in Asia, and 1 in 22 in sub-Saharan Africa.  Although there are clear preventative solutions in many of these cases, accessing such measures is problematic.

The report states that improving maternal mortality requires an interlinked set of interventions that are supported and sustained over time, including heightened efforts to improve local transport.  In addition to addressing maternal mortality, it is imperative that efforts to end child and infant mortality are undertaken.  The report states that it is estimated that a package of 16 simple and cost-effective measures could prevent nearly 3 million of the estimated 4 million deaths in the first month of life.  Additionally, expanding access to immunizations can save the lives of 2 million children under the age of five.

Although the report clearly states that maintaining America’s commitment to fighting against HIV/AIDS is one element in a global health strategy, it fails to integrate this commitment within the framework of strengthening maternal and child health.

Globally, HIV/AIDS is the leading cause of death among women of reproductive age.  When half of the 31.3 million people living with HIV worldwide are women, and 98 percent of them reside in developing countries, the importance of envisioning HIV/AIDS as a maternal and child health issue is clear.  Integrating HIV/AIDS efforts within efforts to improve maternal and child health, and scaling them up, is key to a rights-based approach to health.

Among pregnant women in Johannesburg, South Africa’s most populous city, HIV is the main cause of death, according to a five-year study of maternal mortality at one of the city’s largest public hospitals

It is also important to recognize that HIV-negative children born to HIV-positive mothers still face high mortality risks as long as their mothers are not receiving treatment.   A Ugandan study found that not only is there a 95% reduction in mortality among HIV infected adults after 16 weeks of antiretroviral treatment, but there is an 81% reduction in mortality in their uninfected children younger than 10, and an estimated 93% reduction in orphan hood.[1]

Unfortunately, there is no mention in the report of undertaking initiatives to reduce the prevalence of HIV/AIDS among women and ensure access to treatment as a key maternal health strategy, even though it is clear that taking such measures will greatly strengthen families and communities.  Prevention of mother to child transmission of HIV is imperative, as well as ensuring access to ongoing treatment for the mother.


[1] Mermin et al (2008) Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study Lancet 371: 752-759.

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