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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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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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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.

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“Sustainability” is the catchphrase increasingly tossed around in discussions about fighting the global HIV/AIDS epidemic. Now, a new opinion piece in the journal AIDS explores what it would take to achieve meaningful sustainability—outlining some key steps necessary to foster strong, enduring treatment programs in resource-poor settings.

As a backdrop, the authors, including Edward J. Mills, MD, of the University of Ottawa, and Julio Montaner, president of the International AIDS Society, note that the current international financial crisis has put HIV funding streams in jeopardy and report on decreased treatment targets, drug stock-outs, and other developments that threaten the recent gains in transforming HIV from a death sentence to a chronic management disease.

“Under dire circumstances, plans should be in place to ensure that we do not slide back to a time of little hope,” the authors write in AIDS. With indications that foreign policy priorities are shifting in the U.S. and elsewhere, the authors say that it’s time to examine “how to build a long-term response to HIV/AIDS that is less dependent on the vagaries of external support.”

They outline four arenas that merit intense focus for any such effort:

*Increasing human resources in a way that builds domestic production of health workers in Africa;

*Developing training capacity using regional expertise and a “university without borders” to provide training throughout Africa;

*Supporting regional drug production with keen attention to patent pools and related issues; and

*Building research capacity in a way that will increase career opportunities and bolster retention of African researchers.

Executing these steps will require more funding in the short term, the authors concede, “but donors must move beyond taking a 3-year perspective on a lifelong disease.”

Here’s the cite for the piece:

Ensuring sustainable antiretroviral provision during economic crises.
AIDS. 2009 Dec 17;
Authors: Mills EJ, Ford N, Nabiryo C, Cooper C, Montaner J

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PEPFAR today released three “annexes” to its five-year global AIDS strategy, offering some additional details and context for the plan issued last week on World AIDS Day.

The first annex, which can be found here, addresses PEPFAR’s prevention, care, and treatment plans for the next five years. “Prevention remains the paramount challenge of the HIV epidemic,” the document notes, emphasizing that prevention efforts will be a key priority for PEPFAR as the program transitions from an emergency response to a more long-term effort. 

A top prevention goal, the annex says, will be to help countries better map their HIV epidemic and reassess their prevention efforts based on that new data. There will be an emphasis on “combination” prevention strategies that include behavioral, biomedical and structural components.

On treatment, the document points to the recent decision by the WHO to change its treatment guidelines (calling for antiretroviral treatment to begin at a CD4 cell count of 350 rather than 200) as evidence of the growing challenge in meeting global treatment needs. The five-year global AIDS strategy PEPFAR released last week included a treatment goal of reaching more than 4 million people over the next five years, a major disappointment to advocates who had called for a much bolder target. In the annex, PEPFAR says that it will focus on reaching the sickest people first, as well as pregnant women and patients co-infected with HIV & TB. (more…)

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Physician-scientists working on the frontlines of the HIV/AIDS epidemic today urged the White House to set bold new HIV treatment targets for PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief.

The Center for Global Health Policy joined with a coalition of other organizations—including HealthGAP, amfAR (the Foundation for AIDS Research), the Treatment Action Group, and The AIDS Institute—in calling for PEPFAR to reach 6 million people with antiretroviral drugs by 2013 and 7 million by 2014.

The Global Center and these other organizations, part of the Global AIDS Roundtable Treatment Working Group, detailed this HIV treatment imperative in a recent memo to US Global AIDS Coordinator Eric Goosby, MD.

The memo comes as the Administration crafts two related policy positions. First, the Administration is now preparing its Congressionally-mandated five-year global AIDS strategy, including treatment goals and funding levels for fiscal year 2011. And second, in the coming months, the White House is expected to release the details of its Global Health Initiative, which some fear will outline a shift away from AIDS toward other global health priorities.

HIV/AIDS experts say new attention to child and maternal health is welcome and necessary, but it cannot come at the expensive of continued scale up to combat the AIDS epidemic. For one thing, HIV/AIDS in inextricably linked to child and maternal health. In Sub‐Saharan Africa, antiretroviral drugs are critical to addressing maternal and child mortality, and robust scale-up of ARVs will mean millions of women’s lives saved from HIV and tuberculosis. It will mean fewer AIDS orphans and fewer HIV-positive babies.

“HIV remains the largest cause of maternal mortality in some countries and community‐wide coverage of ART is increasingly being shown to decrease non‐HIV infant mortality, poverty, and deaths from diseases like TB,” the memo to Dr. Goosby says. “It is also important to note that Lantos‐Hyde prioritizes scale‐up of PMTCT programs and expansion of ART treatment for HIV‐infected children—priorities that will not be realized in the absence of increased investment in ARV treatment and ambitious treatment targets.” (more…)

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