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Posts Tagged ‘PEPFAR’

The Obama administration today released a government-wide strategy on a subject that previously had drawn little high-level attention from Washington – the Millennium Development Goals, or MDGs.

Much like National Security Strategy documents put together by a succession of U.S. administrations, Obama’s MDG strategy serves as more of a framework of principles, rather than giving specific details on how the U.S. government will help developing countries reach the goals by 2015.

Some of the most prominent MDGs are eradicating extreme poverty and hunger, reducing child mortality, and improving maternal health.

“We just think it’s a tremendous opportunity to have the US engage proactively in the MDG dialogue with some fresh ideas,’’ said Ben Hubbard, deputy chief of staff at the U.S. Agency for International Development, in an interview with Science Speaks. “We are 10 years in, and five to go. We looked at the data, and asked ourselves what is needed to get to the finish line and what the U.S. can uniquely contribute.’’

The strategy, which was released today in an invitation-only gathering in Washington with no press coverage, comes two months before the United Nations will hold meetings on MDG progress.

It lists significant achievements as well as miserable failings in countries. (more…)

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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.

(more…)

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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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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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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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