Posts Tagged ‘global AIDS’

Asia Russell, director of international policy for Health GAP, is currently in Uganda gathering first-hand accounts of the unfolding crisis in access to HIV treatment caused by stagnant funding for global AIDS programs, program realignment, the worldwide recession, and other problems. What follows is a sampling of what she has found so far, from a quick round of visits with implementers around Kampala. This information reinforces what Dr. Peter Mugyenyi, director of Uganda’s Joint Clinical Research Center, told US policymakers in a visit to Washington, D.C., last month.

 The Joint Clinical Research Centre (JCRC)

The experience has been that the ARV treatment program is being precipitiously transitioned to the Ministry of Health, which currently does not have the capacity to take it on.  Recently, JCRC referred 23 patients to government hospitals, but there was no treatment there. In some cases, some government treatment centers are providing week-to-week supplies of medicines to patients.  Reportedly, some clinics are reverting to use of d4T as well. Other clinic reports indicate that the sub optimal regimen of a single dose of nevirapine is still used for prevention of mother to child transmission—in order to keep costs down.

Before Dr. Mugyenyi’s recent testimony before Congress, OGAC indicated it would open up perhaps a few treatment slots for JCRC. But only on condition that the PEPFAR procurement partnership be used (the Partnership for Procurement and Supply Chain Management). Previously JCRC successfully procured and distributed drug supplies and had the flexibility to adjust treatment to the safest and most cost effective treatment according to advances in drug development.


Mildmay is definitely facing the current cutbacks as a crisis. The providers there are not recruiting new patients on treatment. They do not know the precise size of the waiting list, but they have moved from enrolling 260 patients on ARVs per month to about 25 to 30—enough to accommodate slots opening up due to patients currently on treatment who are transferred out, die, default, or are lost to follow up. Mildmay staff report that women and children will suffer the most as a result of these restrictions, because they are least able to afford to pay out of pocket for treatment.

There have been massive efforts to gain efficiencies through budget cuts, including grounding half of the vehicle fleet, cutting back on follow up to remotely located patients, not raising the salaries of staff for two years despite inflation–everything that is not an essential lifesaving intervention. 

At its main site, Mildmay used to do testing four out of five weekdays, regularly testing about 80 people per day, with about 25-30% of patients testing positive. Now they have reduced testing days to two per day, testing no more than 60 people. This has been the case for the last 5 months. Turning away people from testing will have a huge effect on prevention—and then there is nothing to give patients when they test positive. 

There is no way for the government health system to absorb these patients—perhaps slowly over time, but right now the capacity is not there—neither the health workers, nor the medicines, nor the motivation and training. 

Kiswa Health Center

Kiswa Health Center is very busy public facility serving the Kiswa neighborhood of Kampala. It is a Health Center III (HC III), meaning it provides basic preventive and curative care, although Kiswa is also providing ARV treatment through their HIV clinic four days per week. They have extremely limited staffing, with one doctor and one to two clinical officers, as is the case with other HC IIIs.

The major problems facing the facility include: lack of regular supplies of medicines and insufficient, poorly motivated, and/or absent health workers. The National Medical Stores (NMS—the medicines supplier for public sector facilities) cannot be depended upon to provide medicines in a timely fashion, despite correct and timely requests by facilities.

Several NGOs have been collaborating with Kiswa Health Center to provide HIV treatment and prevention and a range of other HIV services, including on-site HIV testing and counseling, ARV treatment, disease management, et cetera. According to health center staff, these PEPFAR NGOs have discontinued their services as of March 31. (There is a possibility there will be an extension until September, but this is unclear.)

This withdrawal has had a grave impact—the NGOs provided additional professional and non-professional health workers, essential medicines, reagents, and other crucial supplies and staff that were unavailable at Kiswa. These resources have now disappeared. At the same time, patients on waiting lists at other clinics, such as JCRC, are now coming to Kiswa to seek enrollment. These patients are being turned away. In addition, the public sector staff are now facing much higher workloads due to the discontinuation of services NGOs

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Okay, so funding for PEPFAR and TB programs did not get top billing in tonight’s State of the Union address. With the economy still sputtering, with voters anxious about the next paycheck and angry about spiraling deficits, global health wasn’t exactly a political winner in tonight’s speech.   

But President Obama still did squeeze in a mention of the issue, even specifically citing US efforts to combat HIV/AIDS, highlighting a “new initiative” against bioterrorism and infectious diseases, and articulating a commitment to strengthening “public health abroad.”  Obama’s quick rhetorical nod came amid deep worry among HIV experts and activists about this Administration’s commitment to maintaining scale-up of treatment for AIDS–anxiety that was only deepened today by some news out of South Africa.

Here’s what Obama said tonight about America’s role  in foreign aid in general and  global health in particular:

“That is the leadership that we are providing – engagement that advances the common security and prosperity of all people. We are working through the G-20 to sustain a lasting global recovery. We are working with Muslim communities around the world to promote science, education and innovation.

We have gone from a bystander to a leader in the fight against climate change. We are helping developing countries to feed themselves, and continuing the fight against HIV/AIDS. And we are launching a new initiative that will give us the capacity to respond faster and more effectively to bio-terrorism or an infectious disease – a plan that will counter threats at home, and strengthen public health abroad.

As we have for over sixty years, America takes these actions because our destiny is connected to those beyond our shores. But we also do it because it is right.” (For full text, click here.)

These few words were welcome, particularly coming on the heels of a disconcerting story about of South Africa today, in which a US official warned of deep cuts to US global AIDS funding. 

“US government funding is going to come down dramatically over the next five years,” warned Dr Roxana Rogers, USAID South Africa Health Team leader last week, according to this story. “There is not a friendly feeling in the US towards more funding for HIV/AIDS,” Rogers told a meeting in Cape Town on the future of US assistance for HIV/AIDS, hosted by the US-based Council on Foreign Relations. Here’s a link to that full story.

US officials tried to quickly to “correct the record” by issuing this statement, which says the US is “fully committed to the multi-party effort led by the Government of South Africa to fight HIV and AIDS in South Africa” and adding these funding figures: “In South Africa, PEPFAR support from 2004-2009 has totaled over $2 billion (R15 billion), representing the largest contribution from PEPFAR to any country.  In 2010, PEPFAR will add $559 million (R4.2 billion) to the cause in South Africa. “

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Five key House lawmakers—including the chair of the Congressional Black Caucus—have called on the Obama Administration to step up its commitment to combating global AIDS.

In a letter to the president, Rep. Barbara Lee, D-Calif., and other House members expressed concerned that “continued rapid roll out of AIDS treatment is endangered in Africa” and said the White House needed to dramatically ramp up funding in the Fiscal Year 2011 budget. A similar letter, from a bipartisan group of U.S. senators, is expected to go to the White House later this week.

Despite broad support in Congress for expanding the President’s Emergency Plan for AIDS Relief (PEPFAR), demonstrated in last year’s reauthorization of that program as the Lantos-Hyde Act, “we will fail to meet its promise if the current funding trends continue,” the lawmakers wrote. In addition to Lee, the House letter was signed by Reps. Henry Waxman, Donald Payne, John Conyers, and Eliot Engel.

“Without expanded funding beyond these 2-3 percent rate increases, it will be incredibly difficult to substantially expand access to treatment, roll out promising prevention programs, train new health workers, or care for the millions of orphans,” as the Lantos-Hyde Act mandates, the letter states. “In order to get back on track with the authorization levels in Lantos-Hyde, we urge you to commit $7.5 billion for bilateral AIDS programs and $1.75 billion for the Global Fund in your fiscal year 2011 budget request.” The letter also calls on Obama to provide $650 million for bilateral tuberculosis programs and $924 million for malaria. (more…)

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This post is by Center Director Christine Lubinski, who attended today’s meeting at the NIH of the Consortium of Universities for Global Health.

When Dr. Eric Goosby, Ambassador at large and the US global AIDS coordinator, addressed academic leaders of global health programs at a gathering outside Washington today, he spent most of his short talk underscoring two concepts that dominate this Administration’s discussions of global health: sustainability and integration.

He also spoke about the Obama Administration’s Global Health Initiative (GHI) as a “seed for a broad discussion moving  from bilateral to multilateral actions.” Dr. Goosby, in addressing the Consortium of Universities for Global Health, stated that a bilateral effort is not sustainable—by which he presumably meant PEPFAR. He went on to say: “There is not a will for that on the Hill and there is an interest in partnerships and a shared burden with the global community—for both caring for HIV-infected individuals as well as other conditions.”

Dr. Goosby spoke about the challenge of working to transfer the leadership for development and implementing systems of care to PEPFAR countries’ public health systems. PEPFAR has shown that there is the ability to respond, and now the technical expertise can be moved to the local government, he said. Dr. Goosby noted that PEPFAR staff are working with governments to develop national, provincial and local systems of care to assess unmet needs and to find resources to make allocation decisions based on the prioritization of unmet needs.

Integration became his theme as he spoke about expanding treatment capacity in terms of developing  a continuum of treatment and prevention services that would include identifying and treating a variety of primary care conditions, such as hypertension, immunizations, referral to family planning and reproductive health services. Integration would begin with patients already engaged in PEPFAR-financed systems of care, but he also mentioned special outreach to women.  If governments are not willing to engage, Dr. Goosby said, he and his team will look to  work with NGOs  and faith-based organizations to develop care systems.  (more…)

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Many policymakers and program implementers agree that PEPFAR is at a key turning point; the biggest challenge going forward is to transform this successful global AIDS initiative from an emergency response in the face of a worldwide epidemic into a sustainable chronic disease program.

The Obama Administration’s plans for that transformation have been the subject of much debate (and the source of some anxiety), since the president has said little about global AIDS since taking office. But we got a few hints about the Administration’s vision this week when a letter surfaced from Obama’s Global AIDS Coordinator, Dr. Eric Goosby, to US ambassadors in PEPFAR countries.

The letter, and a four-page accompanying blueprint for moving PEPFAR forward (both pasted below), focus heavily on sustainability, country ownership, and technical assistance.

“The landscape around us is changing, with the need to balance a broad portfolio of global challenges at a time of financial crisis,” Dr. Goosby wrote in the Aug. 7 missive. “As a result, we need to plan for the next stage of PEPFAR’s development in this context and cannot assume the dramatic funding growth of PEPFAR’s early years will be repeated.” (more…)

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For anyone concerned about a pullback in funding for global AIDS programs, this commentary in The Lancet Infectious Diseases is a must read. It addresses the apparent wavering commitment of donor countries amid the economic downturn and touches on the unfolding debate about the merits of disease-specific initiatives, such as PEPFAR, versus efforts to efforts to strengthen health systems. Here’s what the editorial has to say on that point:

“Although programmes that focus on single diseases are under increasing criticism as being too narrow in focus to bring about sustainable changes to health, efforts funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, and the US President’s Emergency Plan for AIDS Relief have not only enabled countries to start tackling their HIV/AIDS problems over the past 9 years, but also helped to strengthen health systems generally. These initiatives also have the potential to help tackle the problems of malnutrition and gender and social inequality.” (more…)

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