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Posts Tagged ‘Goosby’

Ezekiel J. Emanuel, center, White House global health advisor

Ezekiel J. Emanuel, head of the Department of Bioethics at The Clinical Center of the National Institutes of Health and a breast oncologist, is on extended detail as a special advisor for health policy to the director of the White House Office of Management and Budget.

But that doesn’t speak to his impact. He is one of the architects of the Obama administration’s Global Health Initiative, and he has been a lightning rod of criticism for activists who want a much more vigorous global AIDS response from the administration.

Emanuel spoke to John Donnelly on Saturday about how the Obama administration now needs better ideas for making global health programs more efficient, and how he won’t shy away from taking on AIDS activists. “I have two brothers and all we do is disagree,’’ he said.

Q: You haven’t been shy in pushing back on criticism from AIDS activists about the Obama administration’s smaller increases in the global AIDS budgets than under the Bush administration. What really upsets you?

A: We can have disagreements about the right policy, which way we are going forward, but we can’t have a disagreement about the facts – the facts of the budget. A number of advocates are saying we are cutting the PEPFAR budget. The fact is funding for HIV and our work on PEPFAR is going up – in 2009 2010 and 2011. That is matter of fact. You may not like the allocation we have made, or not like the pot we are putting it in, but (saying we are) cutting the budget is wrong.

The second thing is [the notion] that somehow I am `anti-HIV,’ or `anti-work-we-are-doing-on-HIV,’ is absolutely wrong. This development of the [Global Health Initiative (GHI)] is building on everything we have done, using what our work in HIV and malaria has shown us. One of the things that we have shown is that you can take complicated medical interventions, get them working in rural areas — including sophisticated techniques like measuring T cell and viral loads — and monitor people. A lot of what we have put into the GHI is built on the foundation of PEPFAR. We want to broaden it.

And (another thing) is that we have a moral obligation to the people we are trying to help that if we are spending money on things that are not efficient, we have to be more efficient. There is a moral obligation from the community (working in AIDS issues) not to just ask for more money, but to say, `We have this pot of money, how are we going to do the most with it?’

We’re not doing this because we are green-eyeshade, no-morals people. It’s because we want to save lives and spend money most efficiently.

Q: Still, Ambassador Eric Goosby told Science Speaks this week that even with efficiencies, there will be a `mismatch’ between funds and the need.

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Dr. Eric Goosby, US Global AIDS Coordinator

Global AIDS: `An inevitable mismatch of resources and need’

Ambassador Eric Goosby, MD, the US global AIDS coordinator who assumed his position a little more than a year ago, will be a significant presence at the International AIDS Conference in Vienna, which kicks off Sunday night. John Donnelly interviewed him Wednesday about his expectations for the conference, what was behind the Uganda problem with shortages of AIDS medicine, and whether The New York Times was right when it reported in May that the Ugandan drug shortfall was “the first example … of how the war on AIDS is falling apart.’’


Q: You just wrote an article on the State Department blog on how you traveled to Uganda in June to address drug shortages, detailing how the Global Fund suspension of funding had a spillover effect on all AIDS treatment there. Why did you feel the need to go to Uganda to sort it out?

A: The reason was that I wasn’t getting a clear picture of what the problem was and why we were finding ourselves in a situation where seven of our clinics were saturating (reaching the limit of number of patients). Attempts to work through the PEPFAR team in country resulted in explanations … patients came, we saw them, that’s what happened. It wasn’t that they were withholding their explanation of the domino-effect of the Global Fund sites. The truth was, they weren’t aware of it. So when we went we interviewed every provider, and looked at all the records, and saw an abrupt increase in enrollment that had not been budgeted for in PEPFAR. I asked the question, `Why did that occur?’ I found out that 11 Global Fund supported public clinics in the course of 18 months or so had gone from stuttering to stopping. Their Global Fund grant stopped. There was no formal closing of these clinics. They quietly closed. Patients who went to those clinics just showed up at our door.

Q: So is this an isolated problem based in one country with one large grant? Was The New York Times wrong in reporting from Uganda in May that “Uganda is the first and most obvious example of how the war on global AIDS is falling apart,’’ or was there some truth to it?

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Last Monday’s New York Times stories, detailing the consequences of the faltering battle against global AIDS, has triggered an outpouring of reaction.

For starters, there was this May 13 editorial by the Times itself, which noted that the war against AIDS, spearheaded by the US, had “racked up enormous successes over the past decade.” The editorial says that part of the current problem stem’s from the Obama Administration’s decision to shift its attention to improving child and maternal health and to push countries “to improve their medical delivery systems, manage their own AIDS programs and contribute more of their own funds.”

“Those are good goals,” the paper’s editorial board wrote. “But the AIDS pandemic is still spreading. And the goal of universal access to treatment remains a distant dream.”

In addition, there have been at least eight letters to the editor, representing a broad range of views about the stories and issues they raised. One notable response came from Dr. Eric Goosby, Obama’s US Global AIDS Coordinator, who defended the Administration. Goosby said the stories painted “an unjustifiably negative picture of the global AIDS fight and America’s role in it.

“…While challenges remain,” Goosby write, “we are building on and expanding our successes, not walking away from them. This is a global responsibility, and we are using this success story to invite other governments and donors to join us in meeting it.”

Here are links to all the letters.

The first four: http://www.nytimes.com/2010/05/15/opinion/l15aids.html

 Another four published on the web: http://www.nytimes.com/2010/05/16/opinion/lweb16aids.html?ref=opinion

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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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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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This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.

The opening day of CROI included a session on the future of PEPFAR, featuring the US lead on global AIDS, Ambassador Eric Goosby, MD, as well as the health minister of Namibia and the UNAIDS deputy director.  Kevin De Cock, MD, recently named the head of global health at the CDC, moderated the session.

Goosby opened his talk by assuring this HIV scientific audience that the Obama Administration is focused on “maintaining, extending and increasing” the US response to global AIDS and described the President’s FY 11  $7 billion for PEPFAR, the largest request to date.  (Presumably, this $7 billion figure includes bilateral global TB activities as well as the Administration’s request for the Global Fund—which actually reflects a net  reduction from the amount that was appropriated for the current fiscal year.) Goosby talked about using key lessons learned to build the future of PEPFAR. He catalogued those lessons as follows:

*The HIV response has benefited both health systems and health status with, for example, reductions in hospitalization, coinfection, and  stigma

*Goals and targets help to drive programs and need to be modified as programs mature

*Prevention programs require targeted, data-driven responses

*Emergency response mechanisms must be supplanted with efforts to build country capacity to develop and coordinate a response to the epidemic

*The US must be able to demonstrate the impact of every dollar we spend.

Goosby then highlighted some of the major components of the new 5-year PEPFAR strategy, released in December:

  • Promotion of sustainable country programs
  • Strengthening partner government capacity
  • Expansion of prevention, care, and treatment in both concentrated and generalized epidemics
  • Integration and coordination of  HIV programs with broader global health and development programs
  • Investments in innovation and operations research.

Ambassador Goosby told the audience that his office was actively engaged in dialogue with the Global Fund , other bilateral programs, and foundations about ways to effectively converge resources and to identify efficiencies and savings.   As he has frequently done in other public statements, he spoke about the need for country ownership, but he explicitly described this as ownership by country and civil society.  This inclusion of civil society will no doubt be reassuring to some, but so far, civil society participation in the development of the 5-year partnership frameworks that the Office of the Global AIDS Coordinator is working on with a number of countries has been extremely variable and quite limited in some contexts.  He also pointed out that in most cases, in the near term, country ownership was more about control in identifying priorities and administering programs than actually providing the financing.  In particular, he highlighted transitioning to local partners as the dominant source for service delivery.

He noted that he thought that PEPFAR could make an important contribution to the global evidence base around effective prevention and described prevention as a combination of biomedical interventions, behavioral interventions, and structural/policy and social changes.

In regard to HIV treatment, Goosby said that expanding treatment and ensuring quality would continue to be a priority as the program moved from providing treatment access to 2.4 million to the “mid 4 millions.”  PEPFAR would also continue to provide technical support around treatment guidelines, ensuring retention adherence, and monitoring drug resistance.   PEPFAR is also committed to maximizing the use of pooled procurement for drugs and laboratory commodities and the use of generic ARVs , which is currently 89 percent. (more…)

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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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