Feeds:
Posts
Comments

Posts Tagged ‘prevention’

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…)

Advertisements

Read Full Post »

Here at the Microbicides 2010 conference in Pittsburgh I got a chance to talk with Dr. Gita Ramjee, one of the top researchers in the field, about the most exciting scientific challenges being discussed at the meeting.  Dr Ramjee is the Director of the HIV Prevention Research Unit at the South African Medical Research Council.  She also explains in the interview why development of an effective microbicide for rectal use is so crucial, for both men and women in Africa, in particular given higher than expected rates of reported anal sex in several countries, as well as in many other regions of the world including the United States.

Read Full Post »

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.

Read Full Post »

The Center for Strategic and International Studies yesterday unveiled  a new “must-read” report for global health advocates, “Smart Global Health Policy.” While a panel at the Congressionally-chartered Institute of Medicine, made up primarily of scientists, issued recommendations on US global health policy last year, the CSIS panel is the first to involve high-level business leaders and sitting members of Congress.

The report drew on observations made during a study trip to Kenya, but it is unclear if consultation in developing countries went beyond that, for instance to include global representatives of affected communities and of developing country civil society, such as those on the boards of UNITAID and the Global Fund.

The report and the webcast of the launch event are available online.  Here are a few highlights:

The report makes a strong case that it is in the interest of the United States to continue and increase  our investment in global health and that the issue should matter to all Americans. It calls for keeping funding for AIDS, TB and malaria on a “consistent trajectory,” doubling spending on maternal and child health to $2 billion a year, forging a collaborative response to emerging heath threats, establishing strong coordination of global health policy across US agencies, and increasing support for multilateral efforts.

In 2009 there was a massive drop off in the expansion of treatment by US programs, and the report notes that AIDS advocates are “particularly anxious” at the slowing growth rate, a stalling that could also impact health systems.  The report suggests that funding is a concern for treatment advocates, yet, in fact, HIV prevention advocates have also been quite alarmed at the essentially flatline funding picture.

Despite World TB Day (March 24) being just a few days away, no mention is made in the report of immediate tuberculosis funding concerns, lowered TB targets in the 6-year Global Health Initiative or USAID’s role in responding to TB.  Instead, the report includes TB within a much longer timeframe, stating that “we can accomplish great things in the next 15 years:  We can cut the rate of new HIV infections by two thirds, end the threat of drug-resistant tuberculosis, and eliminate malaria deaths.”

In terms of overall funding, the report calls for less spending in the near term than either the IOM panel or the Global Health Initiative coalition did; instead, the CSIS document endorses the President’s proposed funding of $63 billion by 2014.  While the IOM called for specific increased funding levels on AIDS, TB and malaria consistent with Lantos-Hyde, the CSIS report does not delve into specific funding levels, with the exception of maternal and child health.  Instead, taking the long view, it calls for $25 billion in annual spending by 2025.

One exciting aspect of the CSIS report is that it endorses innovative financing as a means of raising funds for global health.  The report does not touch on the concept of innovative taxation for health, recently championed by maternal health advocates at Family Care International and many other groups. However, it identifies some specific mechanisms, such as borrowing the money needed through an international finance facility, and it urges the US National Security Council to review the most promising ideas on innovative financing and develop a US position.

Admiral William J. Fallon kicked off the launch event, stating that global health is a “bipartisan enterprise… which can unite US citizens in collective action.”  He stated the importance of maintaining forward momentum, noting that “we do not want to coast or slide backward.”  Helene Gayle said that global health efforts are showcasing the American spirit of generosity and said “we need forward momentum even in a period of constrained resources.”

Jack Lew, the top State Department official developing the US Global Health Initiative, spoke about the Administration’s goals in developing the new strategy. He said that the Administration’s aim was to “challenge a way of doing business by moving beyond a primary focus on disease treatment.”  He said the goal was “not to do harm to existing programs.”

Advocates for effective HIV prevention have felt stymied in recent weeks by the lack of specific HIV/AIDS guidances from the Administration to the field and have noted that Kenya’s Partnership Framework with the US even appears to rule out family planning integration.  Family planning came up at the event when Dr. Michael Merson, of Duke University, criticized the Canadian government’s rejection of the inclusion of family planning as a part of its maternal health initiative.

But Lew’s presentation did not delve into details — and there was no opportunity at the event for questions from the floor.  He stated that program integration was crucial to meet the needs of women, and he commented on the importance of having family planning and HIV/AIDS services in one location.

The report is particularly noteworthy for the very strong focus on measurement for accountability in delivering services. Business leaders at the event decried the reporting burden on health programs and, along with Dr. Merson, called for a common set of impact indicators.

Rajeev Venkayya, Director of Global Health Delivery at the Bill and Gates Melinda Foundation, said that measurement matters because it allows us to maximize efficiency and stretch dollars while identifying what works and what doesn’t.  In addition, measurement allows us to hold accountable institutions, organizations, and even individuals, which in turn allows for greater project improvement.  Exxon Mobil Chairman and CEO Rex Tillerson agreed, and cited a Lancet article which said that evaluation must be a top priority for global health.

Robert Rubin, former US Treasury Secretary and former head of Citigroup and Goldman Sachs, told the audience that global health leaders “face wrenching choices” as a result of US fiscal problems.  He asked two members of Congress, Rep. Keith Ellison and Senator Jeanne Shaheen, whether global health is an issue that can “break through the mire” on Capitol Hill.

Senator Shaheen said that the issue can succeed, but it is crucial to explain to Americans that international affairs spending is only a tiny fraction of the US budget, much less than people realize.   She said it was cheaper to spend on global health than on war, noting Bill Clinton’s recent statement about the appreciation of PEPFAR expressed by Muslim residents of Tanzania.  She also said the current committee structure in Congress is an impediment and endorsed the recommendation included in the report for a consultative body that would work across committees.

Congressman Ellison also voiced strong support for greater US action on global health, stating that “infectious diseases know no borders.”  He said that while in Kenya, he made good progress in persuading Kenyan leaders of the necessity of stepping up their own contributions.  He suggested that by reducing US spending on outmoded weapons systems the US could improve its budget outlook and make global health spending easier.

Gayle Smith, the NSC official leading the development of the US Global health Initiative, was the concluding speaker at the event. She said global health was a bipartisan issue and that in fact President Obama specifically directed that the achievements of the previous Republican Administration be recognized.  She praised the CSIS report, and said that its ideas were remarkably congruent with those of the Administration.

She said the Administration’s commitment to fighting global HIV/AIDS was “absolute” and, she added, “this will grow over the life of the initiative.” She said the Administration’s plans for the Global Health Initiative “include an ambitions set of targets in terms of outcomes.”

She did not respond to concerns submitted to the Administration by the Global Center, TAG, the Global Health Council, and the GHI Working Group that the Administration’s targets regarding tuberculosis contradict a directive from Congress approved in 2008 as a part of Lantos-Hyde.  In fact, it was surprising that the event unfolded without  reference  to the consultative process which numerous NGOs have engaged in regarding the US Global Health Initiative or to the detailed analyses these groups have submitted to the Administration.

There were a range of reactions from health NGOs to the event.  Eric Friedman at Physicians for Human Rights noted the “surprisingly little attention in the report to human resources for health and health systems, and no mention of including civil society in the development of country compacts.” He praised the report for “proposing that the Administration develop a long-term, 15-year framework for making progress in and committing the United States to improving global health, a good idea so long as it does not set the stage for underambition, and is flexible to respond to changes in the years ahead. ” He also would have liked to see “a recommendation that the United States should deliberately integrate a right to health approach throughout U.S. global health programs, including the consistent focus on equality, accountability, and participation that this entails.”

Matt Kavanagh at Health GAP praised what he heard from the report, which included an emphasis on keeping up the fight against HIV/AIDS, especially important for the health of African women. But he noted with concern that “some of the Administration comments that seemed to favor prioritizing ‘cheap’ interventions that do not work in the long term, such as single dose nevirapine instead of treatment for HIV positive mothers, an approach abandoned long ago as ineffective in wealthy nations.”

The American Medical Students Association’s Farheen A. Qurashi said that the report “takes a bold, but necessary, approach to U.S. global health planning by insisting upon a 15-year comprehensive plan.”  She said, “Unfortunately, the Commission’s report does not appear to specify the need for scaling-up of PEPFAR investments versus the dangers of flat-funding, and instead uses language that suggests that a continuation of current levels of funding without annual growth is sufficient.”

On health systems, she said that “though integration and health systems strengthening is mentioned in general terms, and the need for training and retention of health care workers is noted, there is no detailed analysis of the measures, funding, and support necessary to establish and retain adequate numbers of health professionals and other health care workers.”

Read Full Post »

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

It’s been almost 3 years since the World Health Organization developed its recommendations and goals for male circumcision. As Kim Dickson, MD, an AIDS expert with the WHO, outlined in a presentation at CROI today, scale-up has not been speedy or simple.

In her talk, Dickson noted that the WHO identified 13 priority countries for scale up, especially those with high prevalence, generalized heterosexual epidemics, and low levels of circumcision.  All of the countries are in eastern and southern Africa. The goal: reach 80 percent of adult males and newborns by 2015 in the target countries. 

This intervention could prevent more than 4 million adult HIV infections over 15 years, but millions of circumcisions would have to be performed during this time period. The approximate cost of the procedure in these settings is $50. 

 Advocacy has been vibrant at all levels, and there have been multi-stakeholder consultations in all countries including various groups. A number of funding agencies have made money available for male circumcision-related activities, including PEPFAR, the Global Fund, and the Bill & Melinda Gates Foundation.  Male circumcision policies have been developed in Lesotho, Namibia, South Africa, Swaziland, Uganda and Zimbabwe. Kenya has developed actual guidelines.  Most countries are focused on so-called “catch-up” strategies to reach adult men, but longer term neonatal strategies are under consideration in Botswana, Swaziland and Zambia.  Provider training programs have been implemented in almost all 13 countries.

The bottom line question, however, is how many circumcisions have been done?  (more…)

Read Full Post »

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.

Read Full Post »

Nearly 1,500 physicians, scientists, and other global health leaders from the U.S. and around the world today called on Ugandan President Yoweri Museveni to stop the Anti-Homosexuality Bill before his country’s Parliament.

In a petition that drew signatures from clinicians, professors, researchers and students at leading US and international institutions, these experts said the Ugandan legislation would violate human rights and undermine public health, posing a particular threat to Uganda’s successful HIV/AIDS programs.

The bill would impose life imprisonment, or even death, for same-gender consensual sex acts and threatens imprisonment of individuals who do not report suspected homosexual acts to the police. The proposed law has sparked international condemnation, and there is growing pressure from world leaders on President Museveni to kill the bill.

HIV experts are very concerned the legislation would deter an already vulnerable at-risk population from seeking HIV services out of fear that it could land them on death row, as well as intimidating the health care workers who serve these populations.

“This legislation will violate Ugandans’ human rights and will impede successful efforts in HIV prevention by promoting misinformation suggesting that HIV transmission in Uganda is primarily due to male homosexual behavior. It will also create a chilling effect on patients’ willingness to seek HIV testing and prevention services and jeopardizes the fragile gains Uganda has made in combating the AIDS epidemic,” Kenneth Mayer, MD, co-chair of the Center for Global Health Policy’s Scientific Advisory Committee and professor at Brown University, where he directs the AIDS program, said in this news release highlighting the petition.

“This proposal would needlessly undermine public health in Uganda by further stigmatizing people with HIV or at risk of infection and by severely compromising the patient-health provider relationship,” said Michael Saag, MD, chairman of the HIV Medicine Association’s board and a chief of infectious diseases at the University of Alabama at Birmingham. (HIVMA and the Global Center helped spearhead the petition effort.)

Here’s the full letter to Uganda’s president: Petition_Opposing_Harmful_Uganda_Legislation[1]

The missive to President Museveni comes as Congress prepares to delve into this growing international controversy. On Thursday, Jan. 21, the Tom Lantos Human Rights Commission will hold a hearing on Uganda’s anti-gay bill, probing the foreign policy, public health, and human rights implications of the legislation. The hearing will be held from 2 to 3:30 p.m., in Room 2172 of the Rayburn House Office Building. 

Lawmakers will hear testimony on these issues from the Global Center’s Director, Christine Lubinski, along with a State Department official, a Ugandan human rights expert, and others.

It also comes amid reports that David Bahati, the sponsor of Uganda’s Anti-Homosexuality Bill, plans to come to Washington, D.C. to attend the National Prayer Breakfast on February 4. Click here to read more about his planned trip.

Read Full Post »

Older Posts »