Politics and Policy of HIV/AIDS

Just when it looked like PEPFAR would be reauthorized and that Congress would appropriate even more money than the president asked for, seven Senators, led by Tom Coburn of Oklahoma (along with Jim DeMint, Jeff Sessions, Saxby Chambliss, David Vitter, Jim Bunning, Richard Burr), have placed a hold on the bill, dramatically reducing the chances that it will pass this Congress. A hold is an obscure procedure in the U.S. Senate that enables any Senator to stop a bill that they do not like by preventing it from coming to the floor.

Michael Gerson, Bush’s former speechwriter, flagged this egregious action to set up an internal Republican dispute. As Gerson notes, Coburn objects that more of PEPFAR money is being spent on things other than treatment.

The seven, led by Coburn, complain that the reauthorization is too costly. They object to “mission creep” — the funding of “food, water, treatment of other infectious diseases, gender empowerment programs, poverty alleviation programs” — as though people surviving on AIDS treatment do not need to eat, work or get their TB treated.

They want 55% by law to be spent on treatment (which was how the first PEPFAR authorization worked) but this is stupid, as we’re not succeeding on prevention, meaning that more and more people are getting HIV and ultimately needing treatment. As Gerson writes:

Given that there are about 2.5 new HIV infections for every person starting on AIDS drugs, there is no way to control the pandemic through treatment alone. And because treatment is less expensive than it used to be, PEPFAR is meeting its treatment goal for less money. The 55 percent treatment floor would force the program to waste money in pursuit of an arbitrary, nonsensical spending target — the worst kind of congressional earmark.

You may want to give Coburn and company an earful about this nonsense. The ONE campaign has a letter to sign here. Direct contact info is available here.

UPDATE: Here is part of Coburn’s response where he rails against Gerson, touts his own credentials as a physician who has cared for AIDS patients and a consistent champion of HIV/AIDS programs. What he seems to be worried about is that the absence of a directive that 55% of PEPFAR money be spent on treatment will result in the program spending more money on consultants rather than services. I’m not sure if those funding directives are the best or only way to ensure that problem doesn’t occur.

Part of Gerson’s moral outrage is focused on my controversial stance that AIDS treatment dollars be spent on treatment. I want to preserve PEPFAR’s original formula that sends at least 55 percent of all dollars to AIDS treatment so widows and orphans and actual patients, not program officers and consultants, will be the primary beneficiaries of the program. This formula is made all the more important because the new authorization calls for a three-fold increase in funding from $15 billion over five years to $50 billion over five years. Moreover, this smart and well-designed policy, which Gerson once supported but now scorns, is a major reason why PEPFAR has been a Marshall Plan-like response, rather than a Katrina-like response, to the AIDS crisis in Africa.

Gerson’s determination to critique not just our policy concerns but our morality suggests that he is viewing this debate as proxy battle in the broader struggle in the Republican Party between what he views as “seedy” or “anti-government” conservatism and the “compassionate” conservatism he helped shape in the White House. That’s a broader debate that I welcome.

I don’t see a coherent answer to Gerson’s concern about prevention. I suppose that with an increased budget there would be enough money for treatment and prevention, even with the 55% limit, but 55% seems like an arbitrary Congressional mandate.

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Over at the CSIS Africa Policy Forum, I have a new op-ed on male circumcision and HIV prevention. Here are some excerpts:

In the past few years, clinical trials in Kenya, Uganda, and South Africa confirmed that male circumcision (MC) reduces the risk of transmission of HIV infection by approximately 60%.

In its Fourth Annual Report, the program [PEPFAR] announced that it had allocated $16 million in fiscal year 2007 for MC activities, up from $600,000 the year before. In FY 2008, funding may rise to $30 million.

The average cost to circumcise an individual has been estimated to be about $50. Thus, the $16 million for FY 2007 could be providing services to large numbers of people. Even assuming high start-up costs for training and administration, if only a quarter of these resources were dedicated to actual service delivery, that would still mean that more than 80,000 men could have received MC services by now. Unfortunately, while PEPFAR does a good job counting the number of individuals on anti-retroviral treatment, analogous data for circumcision services are not available. However, there is concern among experts and observers in the field that the number of people who have received MC services to date through PEPFAR is very, very low – probably fewer than 2,000.

A large part of the problem is that there are simply not a sufficient number of trained professionals nor properly equipped facilities to safely carry out the circumcision surgery for the large numbers of people who might request it. More worrisome still is the concern that MC funds are not being dedicated to organizations with the most experience and/or capacity to train people to carry out the procedure. In some cases, funds may be targeted to social marketing of the procedure and to encouraging local populations to support MC, without sufficient investment in the actual capacity and infrastructure necessary to meet that demand.

Male circumcision offers the same sort of compounded benefit that most effective vaccines offer to populations – herd immunity. As more men are circumcised, not only is their own risk of acquiring HIV reduced, but their current and future partners and their partners’ partners also are at lower risk.

While concerns about cultural acceptance should inform where and when MC services are provided, the main problem holding back the wider availability of such services appears to be supply, not demand. If training and infrastructure are the primary barriers to more expansive rollout of MC services, then it is incumbent on PEPFAR, now undergoing reauthorization before Congress, as well as on other donors, to respond. They need to do a better job channeling funding to those purposes and to implementing organizations that can translate support into effective service provision. To miss the potential of MC through squandered resources, oversensitivity to cultural concerns , and ineffective programming will only prolong the tragedy of HIV/AIDS in Africa.

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From the KaiserNetwork.org

A pharmaceutical plant in Uganda this week will begin production of generic antiretroviral drugs following an order from the Ugandan
government for drugs worth 17 billion Ugandan shillings, or about $10 million, the East African Business Week reports (Etyang, East African Business Week, 1/28).

Ugandan President Yoweri Museveni in October 2007 commissioned the 15-acre pharmaceutical plant, which will produce triple-therapy combination antiretroviral and first-line malaria treatments. Ugandan pharmaceutical importer Quality Chemical Industries and Indian
pharmaceutical company Cipla will produce the drugs. The factory will manufacture the antiretroviral combination therapy Triomune, which contains lamivudine, stavudine and nevirapine. In addition, the factory will produce the first-line antimalarial combination treatment Lumartem, which contains artemisinin and lumefantrin (Kaiser Daily HIV/AIDS Report, 11/26/07)…

…According to the Business Week, about 100,000 Ugandans currently have access to no-cost antiretroviral treatment, but about
238,000 people in the country are expected to need the drugs by 2012. In 2005, about 42% of people in need of antiretrovirals had access to them, according to statistics (East African Business Week, 1/28).

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Amy Patterson has a post on a new CSIS online Africa Policy forum.

Here is my comment on her piece.

Amy Patterson makes a number of important points. I generally agree that greater civil society mobilization would likely foster country ownership of HIV/AIDS programs, but what would that look like? How would that alter what donors are already doing? And, given the opportunity costs of focusing on civil society mobilization compared to other possible priorities, is a greater focus on participation by community organizations the most pressing need in the fight against HIV/AIDS?

Patterson notes that HIV/AIDS is not seen as a top priority in Afrobarometer polling. Does that not suggest that there may be difficulties in mobilizing civil society in Africa for this cause? The basic supposition in this piece is that the failures to date have been in part failures of insufficient engagement at the local level.

That may be true, but it also could be difficult for well-meaning outsiders to engender this kind of mobilization in the absence of top-level support by African leaders. We have witnessed the difference in the aggressive approach by President Museveni of Uganda in contrast to South Africa’s Thabo Mbeki whose support for AIDS denialists is well-known. Can or should external donors empower local groups in the face of state opposition? In the case of South Africa where the Treatment Action Campaign was already active, external support has been important. But, what if civil society is not especially active, the country’s executive is hostile, and the health system is decrepit? Where are resources best spent?

I am sympathetic to Patterson’s argument, but those of us who worry about public health and HIV/AIDS in sub-Saharan Africa need to flesh out what our specific policy recommendations would look like. The closest we gets in terms of specifics come in terms of the need for more simplified and harmonized reporting requirements by donors and finanicial support for civil society groups to hire and train bookkeepers, community organizers, and grant writers. All of that sounds reasonable, but I do not know how transformative efforts like that would be, if they were implemented.

It appears that bilateral programs like PEPFAR have focused on getting anti-retroviral drugs to needy populations in short order, which may have come at the cost of building local capacity in the health sector. Other donors like the Global Fund may have had more success in coordinating with local groups, yet they too have imperatives of getting money out the door and people on treatment. Alex de Waal’s 2006 book presciently warned of this potential outcome of focusing on short-term exigencies over long-term capacity.

In recent months, the debate about whether or not HIV/AIDS funding is coming at the cost of other health care priorities taps into this anxiety that people are getting treated for AIDS, but two problems are not being addressed as they should 1) other health care needs (and implicitly local health care capacity) and 2) prevention programs.

As I understand it, donors are increasingly seeking funds not just for HIV but for broader health systems capacity. Moreover, the ABC agenda seems to have run aground; changing sexual behavior is hard and political disagreements in the West have made it difficult to implement a coherent strategy.

As a consequence, the prevention discussion has turned towards male circumcision as a powerful strategy to reduce new infections. If this is where the discussion at the policy level is headed, how would or could civil society mobilization enhance the success of those programmatic efforts?

In the 1980s and 1990s, donors chose to go around the state because of fears about corruption and lack of capacity, but the argument has turned. Donors now know that long-run success depends on capable governance by recipient countries (as well as efficient markets). The political imperative of getting HIV/AIDS funds spent quickly and effectively has cut against this broader recognition of the importance of state and market capacity in health systems.

I worry that focusing so much effort on civil society mobilization could come at the cost of state capacity and development of markets for health care. There certainly is an important role for community groups in this process, particularly in terms of holding governments and service providers accountable. To the extent Patterson and other scholars can draw out the implications of this line of critique, I think the discussion will be richer for it.

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This from the Kaiser Family Foundation reports:

HIV/AIDS Treatment Programs Will Not Keep Pace Unless Number of New Cases Decreases, Experts Say at PEPFAR Reauthorization Hearing
[Dec 12, 2007]
HIV/AIDS treatment programs in Africa will not be able to keep pace unless the number of new cases significantly decreases, experts said Tuesday at a Senate Health, Education, Labor and Pensions Committee hearing to reauthorize the President’s Emergency Plan for AIDS Relief, the Boston Globe reports (Donnelly, Boston Globe, 12/12).

I agree with the critics that Congress’ mandated spending requirements on prevention money are insane, but I disagree with those who think that if we just dump all our prevention money into condoms that will solve things. If you are married woman in the developing world, what chance do you have of forcing your husband to always use a condom? He may have a long-term girlfriend on the side which increases the risk to him and you, but asking your husband to use a condom potentially puts woman at great personal risk of abuse.

Here, one expert suggests that condoms are not the main answer and that abstinence and faithfulness policies have a role to play as part of prevention.

Experts at the hearing testified that the “most important battle” in curbing HIV/AIDS is stopping HIV transmission but disagreed on how to stop the spread of the virus, the Globe reports. Some witnesses at the hearing debated the effectiveness of a PEPFAR requirement that one-third of HIV prevention funds focus countries receive through the program be used for abstinence-until-marriage and fidelity programs (Boston Globe, 12/12).

Norman Hearst, a professor at the University of California-San Francisco School of Medicine, said that encouraging married men to be faithful to their wives and delaying the onset of sexual intercourse are the two main ways to stop the spread of HIV in Africa (Walker, CQ HealthBeat, 12/11).

According to Hearst, programs that focus on promoting condom use have “never worked” in areas where HIV is generalized (Boston Globe, 12/12). “It’s easier to change sexual behavior than getting the people to use an imported sexual device all of the time,” Hearst said (CQ HealthBeat, 12/11).

At the end of the day, it still seems that people are grasping for answers on prevention. Hence, the interest in male circumcision.

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