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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?

(more…)

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Last week, the Center for Strategic and International Studies (CSIS) brought together a number of panelists from various administration agencies and NGOs at an event called “Linkages between Gender, AIDS, and Development – Implications for U.S. Policy.”  Panelists discussed the importance of placing women’s and girl’s health at the forefront of the Obama Administration’s global health efforts, and how policymakers and implementers can integrate programming that has already been proven to be effective, into the new Global Health Initiative. 

Ambassador Eric Goosby, the U.S. Global AIDS Coordinator, opened up the event by stating that women and girls are disproportionately impacted by the HIV/AIDS epidemic, and focusing on women and girls when implementing programs to fight HIV/AIDS will yield positive results for not only women and girls but entire communities. 

According to Goosby, 62 percent of individuals on PEPFAR-supported treatment are women.  PEPFAR will start new women-focused programs next year, such as a new gender-based violence initiative, and the PEPFAR Gender Challenge Fund, which makes an additional $8 million available for strengthening gender-based programs.

Ambassador Goosby explained that the Obama Administration’s new Global Health Initiative will build off existing programs to ensure that the necessary linkages are made to integrate family planning, reproductive health, and HIV/AIDS services.  He explained that women and girls should have access to a ‘one-stop-shop’ for services.  In addition to making more services available, Goosby underlined the importance of engaging in diplomatic dialogue with leaders to encourage them to address discriminatory laws and practices against women.

The resounding message of the day was the importance of integrating reproductive health services, family planning services, maternal and child health services, and HIV/AIDS services all in one synergistic package to ensure that women and girls in developing countries have all the tools they need to protect their wellbeing. 

Dr. Marsden Solomon of Family Health International (FHI) in Kenya explained the necessity of integrating such services by citing that 60 percent of their HIV/AIDS patients have unmet family planning needs.  He went on to explain that integrating HIV/AIDS and family planning services reduces unintended pregnancies, prevents vertical transmission, and improves maternal and child health overall.  FHI began integrating their HIV/AIDS and family planning services in 2001.  Their services include ARV and PMTCT treatment, STI treatment, pre and post-natal care, cervical cancer screening, and post-rape care, among others.

Amie Batson, Deputy Assistant Administrator for Global Health of the USAID, argued that women’s health should be promoted not just in health-related programs, but in economic growth programs, education initiatives, and in governance as well.  Health service accessibility should be expanded as well: commodities should be available at more locations, such as at kiosks or beauty salons.

A number of panelists emphasized the importance of integrating HIV/AIDS services and prevention techniques into economic development programs as a way to address both economic and health disparities.  Lufono Muvhango and Julia Kim described their successes in battling both HIV/AIDS and economic underdevelopment with the Image Program in South Africa.  The program not only provides microfinance loans to women in villages, but also implements gender training programs which aim to empower women to have the confidence needed to fight against sexual violence. 

In South Africa, it is estimated  that a quarter of women are living in abusive relationships.  Women involved in abusive relationships are 50 percent more likely to be infected with HIV/AIDS, compared to women who do not fall victim to intimate partner violence.  After reaching out to 12,000 women in 160 villages in South Africa, the Image Program has not only seen a significant increase in HIV/AIDS awareness, but has seen a 55 percent reduction in the risk of physical and sexual violence.

Pearl-Alice Marsh, the majority professional staff member for the House Committee on Foreign Affairs, stated that there are two major issues blocking progress in women’s health and HIV/AIDS concerns.  The first is funding: Marsh stressed that advocates must continue to pressure Congress to maintain their financial commitments, as well as help African nations get a handle on their budgeting so they can contribute more to the fight against HIV/AIDS and increase their ownership.  The second issue deals with global women’s health being a proxy for anti-abortion advocacy.  Marsh explained that letting ideology and politics get in the way of women’s health amounts to femicide, and more should be done to ensure that such rhetoric does not hinder progress in global women’s health.

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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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At a Congressional briefing today, AIDS experts expressed grave concern about a shift in the focus of the US President’s Emergency Plan for AIDS Relief, from providing HIV treatment to patients to providing technical assistance to developing country governments. The policy shift comes hand-in-hand with a pull-back from funding targets authorized in the Lantos-Hyde Act, which reauthorized PEPFAR.

These policies are leading to disturbing trends on the ground, including HIV-infected patients being denied access to lifesaving drugs in Uganda and elsewhere, emergency stock-outs of antiretroviral drugs, rising concerns about the emergence of HIV resistance,  and patients being “dumped” into the hands of ill-equipped government health facilities.

Much of the focus of the briefing, attended by key House staff members and a dozen or so HIV advocates, was on Uganda, which was featured prominently in a front-page New York Times story today about the devastating implications of stagnant funding for global AIDS programs.

“Uganda is the tip of the iceberg,” said Sharonann Lynch, of Doctors Without Borders. “You absolutely cannot ration care at this point… It’s throwing the last ten years of clinical practice out the window. What we’re seeing on the ground now is worse than six months ago. So what’s it going to be like six months for now?”

She said members of Congress need to ask the Obama Administration, including top officials at the Office of the Global AIDS Coordinator, pointed questions about their commitment to HIV treatment.

“How many new treatment slots will there be in 2010? How many new treatment slots will there be in 2011?” she asked.

Lynch noted that in several countries, such as the Democratic Republic of Congo, there are reports of PEPFAR redirecting money from treatment, i.e. purchasing ARVs, to providing training and technical assistance. That is devastating to developing country health systems, which are not equipped to take on the burden of AIDS treatment programs.

“It’s a radical shift in policy,” Lynch said. “PEPFAR had been filling the empty medicine cabinet, and technical assistance can only go so far. You can’t keep someone alive” if there are no drugs to treat their disease. She said there needs to be pressure on OGAC to get back to the business of saving lives and pursuing bold treatment targets.

Asia Russell, of Health GAP, said that OGAC officials initially told concerned activists that they could expand treatment, despite the limited funding, to more than 4 million people by finding cost savings in its current programs. But she learned on a recent trip to Uganda that implementers are being told that they cannot use any money saved through program efficiencies to add new treatment slots. She noted that creates a perverse disincentive to run efficient programs.

She said this policy seemed to be driven by the Office of Management and Budget, not OGAC. “They’re in the caboose,” she said of OGAC.

Russell said another problematic development in Uganda is that providers had once worked very closely with the public sector, sharing information and resources. But that’s not happening anymore, as treatment is being capped and patients are being steered toward ill-equipped government-run clinics.

Pearl-Alice Marsh, with the House Committee on Foreign Affairs, said she feared that the policy shift was intended to transfer programs to developing countries in a “very short period of time” and this new policy means less of a focus on bending the curve of the epidemic. But “we’re not out of the emergency phase” when it comes to AIDS.

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Last week, the Kaiser Family Foundation held a forum on the Obama Administration’s Global Health Initiative, sparking fresh debate over this significant shift in U.S. global health policy. In response to the presentations made by top U.S. government officials at that event, Shepherd Smith, a well-known AIDS advocate and program coordinator with considerable knowledge about the history and politics of PEPFAR, wrote this commentary about the Administration’s proposal for a six-year $63 billion GHI.

First and foremost, there is no one in the global HIV/AIDS community–clinicians, advocates, implementers, etc.—who disagrees conceptually with the intent of the Global Health Initiative (GHI).  In fact, the PEPFAR reauthorization legislation, known as the Lantos-Hyde Act, makes foundational the need to deal with a broad range of opportunistic infections, to strengthen healthcare systems, to train more healthcare workers, and to tackle a host of other activities in a more comprehensive manner than just addressing HIV, TB, and malaria. How and where that is done—and at what cost–is the issue at hand.

The announcement of the GHI in May of 2009 shed little detail on what this new $63 billion program might look like, leading many to believe little thought had gone into the initiative.  Nearly a year later, we are beginning to see the outlines of this plan. Clearly, it is a work in progress that needs further discussion and a broader airing. We now know, for example, that the $63  billion is not really new money, but rather the $48 billion authorized over five years in the Lantos-Hyde Act, with a sixth year tacked on at the end.  There is, perhaps, over that six-year period possibly two or three billion dollars of “new” money. So what does that mean for the core PEPFAR program? And how can a new global initiative be successful with so few new dollars?

PEPFAR concentrated on the countries hardest hit by HIV/AIDS, while this new initiative appears designed to be inclusive of all the developing nations in the world.  In order to gain the resources to do this without any significant additional funding, there has to be some deconstruction of the highly successful PEPFAR program. Furthermore, building an entirely new GHI program, which still has not been entirely fleshed out, will take time and some trial-and-error efforts before we get it right.  That takes a lot of energy and a lot of money.  By lessening the emphasis on the core PEPFAR focus to develop a global program with limited funding may well result in the failure of not just one initiative, but both. This then is a high-risk venture.

It would be helpful to publish any risk analysis that has been done on GHI in respect to its impact on PEPFAR if future funding is flat-lined or reduced. For example, the HIV-positive patients now in care under PEPFAR fully expect to be put on antiretroviral therapy once their CD4 count falls below two hundred.  Is this still a realistic expectation? And if not, how is that explained to host countries and to those who will suffer and die if they don’t get access to treatment?

The credibility of the United States is at stake in this significant and sudden program change.  We have made commitments and established excellent working relationships with the countries that have benefited from PEPFAR.  If we don’t meet those commitments, there will be legitimate criticisms of the U.S.  Many of these countries have very limited resources and will now be asked to shift funding and emphasis. They will have to wonder if a subsequent administration will require them to change everything yet again.   

One particular concern is how GHI will interact with the faith community, which delivers 30 % to 70 % of all health care needs in developing countries, according to World Health Organization estimates. The short GHI narrative nearly overlooks the important role the faith community plays, as well as services other NGOs provide. If failures arise in the core PEPFAR program that negate the commitments these faith entities have made to their patients and congregants, then they will naturally shy away from future participation in U.S. government sponsored health programs.  This aspect alone should cause us to be certain the commitments we made under PEPFAR are met–before moving forward with the GHI.  Already, there have been media reports that some clinics in PEPFAR countries are being forced to turn away new patients seeking HIV treatment because of flat funding.  If such scenarios continue, there will be needless suffering that will not cast a positive light on the GHI.

Another concern is the Administration’s statement, in the GHI consultation document, that “the GHI Fund is expected to increase in FY 2012 and beyond.” That may be wishful thinking of the highest order at this particular time in our nation’s history. It’s almost as if those writing this haven’t watched the news in several years. The American people are saying we need to stop or reduce federal spending, and that needs to be factored into the funding equation for this new program. If spending goes down instead of up, there needs to be a contingency plan for the core PEPFAR program, which so much of this seems to be dependent on for success.

The uncertainty now building around both PEPFAR and GHI is not healthy, and it can only be resolved through Congressional hearings that promote a greater understanding of the issues surrounding this significant shift in policy. Without a strong bipartisan political commitment to this initiative (as there was to the reauthorization of PEPFAR), there is serious potential for failure of not just GHI, but PEPFAR as well. The GHI’s success is dependent on an increase in funding, which at this point may or may not happen. Without that guarantee, we may do more harm than good in embarking down this new road.

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At the start of a forum today on the Obama Administration’s Global Health Initiative, Jen Kates, the Kaiser Family Foundation’s director of global health policy and HIV, laid out eight major questions about the proposal—queries that will go a long way toward determining whether the initiative is a success or not.

After a 90-minute discussion, most of those key questions—such as how much funding the GHI will get, how the money will be divvied up, and how its goals will be measured—remained unanswered. But we did learn a few things from the U.S. government panelists who are developing and overseeing the implementation of the GHI, the White House’s controversial initiative calling for a more integrated, comprehensive approach to funding global health.

Amie Batson, the deputy assistant administrator for global health at USAID, had the most news to share. On governance of the GHI, she said a “strategic council” had been established, and it would serve as a forum for pulling together all the government agencies that have expertise in achieving the GHI’s goals. The group has partners from a gamut of federal agencies—from the departments of the Treasury and Defense to NIH and CDC.

At the more operational level, she said, there was a “trifecta” of leaders– USAID Administrator Rajiv Shah, CDC director Thomas Frieden, and Global AIDS Coordinator Eric Goosby—charged with developing and executing the GHI. “They are tasked with defining a shared or joint operational plan,” she said, and each of them has a deputy charged with delivering on that plan.

Batson also said the Administration would release a final GHI plan by early summer. And by the end of this month, officials would announce the first ten “GHI Plus” countries; those countries will then get additional technical, management, and financial resources to implement integrated programs and make investments across health conditions. (The list of GHI Plus countries will be expanded to 20 in later years.)

“We’re now engaging very actively with the countries,” she said. The GHI Plus countries will offer a sort of field test “where we have an intensified learning effort.”

Today’s forum, hosted by the Kaiser Family Foundation and available online here, was the most extensive public discussion yet of the GHI, a $63 billion six-year plan announced by President Obama nearly one year ago.  It has been the subject of much debate because, while the plan includes many lofty and significant goals, some advocates fear it will not be adequately funded and that it may shift focus away from critical programs, such as PEPFAR. Key officials crafting the plan say the U.S. needs to turn its attention to other health problems, such as child and maternal health, but they do not seem to fully grasp or acknowledge the links between specific diseases, such as HIV and TB, and women’s health.

The shift could have serious repercussions on the ground in the developing world. For example, the GHI’s goals on TB represent a significant step back from more aggressive targets laid out in the Lantos-Hyde Act that reauthorized PEPFAR, even though TB claims 1.8 million lives a year.

At today’s forum, Ann Gavaghan, chief of staff in the Office of the U.S. Global AIDS Coordinator, said the GHI should be viewed as an opportunity to build on the stunning successes achieved in fighting global AIDS and other diseases over the last decade, not as a step back from those efforts. “The GHI is not designed to take away from any of those successes but to say let’s recognize what’s been done … and let’s figure out a way to really build those best practices,” she said.

But wide-ranging questions from the audience signaled there is still deep concern about the initiative and how it will be implemented and funded. Several attendees asked about why TB, for example, appeared to be getting short shrift in funding and focus. Gavaghan and Deborah Birx, director of CDC’s Global AIDS Program, both tried to assure advocates that the Administration was committed to combating TB and understood how much of a threat it presents, but neither one specifically addressed the underfunding or weak targets.

Another advocate asked about the apparent contradiction between the Administration’s rhetoric about wanting more international collaboration and its proposed cut to the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. Gavaghan said the White House had made a robust request for the Global Fund and remained fully committed to its success, including active U.S. participation on the organization’s board and in country-level coordination.

Several attendees asked about how the GHI would deal with the severe health care workforce shortage in the developing world, noting that the GHI blueprint issued in February did not offer very many details about that critical piece of health system strengthening.

Batson said that’s because the solution to that problem is country-specific and will have to be dealt with in a focused way in each place. “Many of the governments have put this as No. 1 on their lists, so I think you will see a lot of innovation,” she said.

To learn more about the GHI, read our earlier blog posts here and here analyzing the GHI’s consultation document. In addition, Kaiser has this nice analysis/overview—including the 8 outstanding questions—of the GHI.

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