PHR Library

July 31, 2003

FOR IMMEDIATE RELEASE

A Health Action AIDS Briefing Paper

Administration Claims that $3 Billion Cannot Be Effectively Used to Fight Global HIV/AIDS Are Mistaken

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Media Contacts:
Nathaniel Raymond nraymond@phrusa.org Tel: (617) 301-4232 Cell: (617) 413-6407

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Physicians for Human Rights has close ties to the United States' leading specialists in HIV/AIDS prevention, care, and treatment, many of whom are engaged in overseas programs. Drawing on their experiences and those of others intimately involved with HIV/AIDS in Africa, we respectfully but adamantly disagree with the Bush Administration's belief that more than $2 billion cannot be effectively spent to combat global HIV/AIDS in the coming year. We urge Congress to support $3 billion in appropriations for fiscal year 2004 to combat global HIV/AIDS.

Dr. Joseph O'Neill, the Director of the Office of National AIDS Policy, has stated that Congress should not appropriate more than $2 billion because even though treatment is central to the AIDS initiative, treating HIV/AIDS patients is very complex and requires the United States to build much more infrastructure, including training health care workers.[1] Dr. O'Neill similarly referred to infrastructure and capacity needs in a letter to Senator Frist opposing more than $2 billion this year. In that letter, Dr. O'Neill stated the Administration's “sound judgment that funds in excess of [$2 billion] could not be [spent] effectively in this first year.” Dr. O'Neill also stated that “the United States is responsible for over 40% of all contributions made to the Global Fund.”[2]

The Administration's position misrepresents the degree of infrastructure investment required to make widespread AIDS treatment possible in Africa, overlooks the importance of frontloading the infrastructure investments that are required, neglects tremendous needs beyond treatment, and distorts the level of other nations' contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Infrastructure costs must be frontloaded

The solution to Dr. O'Neill's concern about inadequate infrastructure is to invest immediately in that infrastructure to ensure that widespread treatment, prevention, and care begin as soon as possible. It would be illogical to recognize infrastructure needs but then deny funding for that infrastructure. The sooner infrastructure is strengthened, the faster the number of people on AIDS medication can increase, the more lives will be saved. These investments must not be delayed.

Health care workers must be trained in administering and monitoring anti-retroviral therapy. Training does not take long. In Rwanda, for example, the training time for a cohort of doctors, nurses, lab technicians, and social workers needed for a treatment program is about two weeks.[3] In Haiti, training sessions lasting less than one week prepared villagers to become community health workers able to monitor the use of both anti-retroviral drugs and tuberculosis medications.[4] Even as more health care workers are being trained, those who have been trained can begin providing patients anti-retroviral therapy; they do not need to wait for fiscal year 2005 to arrive.

In many countries, where few people have access to voluntary counseling and testing (VCT) services, significant investment is needed so that people know their HIV-status and can, if they are positive, seek treatment. One key to Uganda's ability to provide anti-retroviral therapy to 10,000 people is its network of VCT sites.[5] VCT sites, the entry point for not only treatment, but also care and prevention services, require significant investment in year one of the American AIDS initiative.

For those Africans who do not have access to functional basic health infrastructure, more significant infrastructure investments will be needed before treatment will be possible. These investments include rehabilitating health facilities, ensuring phone service or satellite communications and consistent supplies of clean water and electricity for all health facilities, strengthening supply chains, increasing laboratory capacity, enhancing management systems, and building new health facilities to ensure access to all.

Modest infrastructure improvement can make treatment widespread

Stephen Lewis, UN Secretary-General Kofi Annan's Special Envoy on HIV/AIDS: “Even with things in the shape they now are, and assuming some incremental improvement in capacity and infrastructure, you could prolong and save millions of lives. There is no excuse for using capacity as a bar to saving and prolonging millions of lives. There's just no question that you could.”[6]

Dr. Paul Farmer of Partners In Health and his colleagues operate a clinic in rural Haiti that provides anti-retroviral therapy to more than 500 people.[7] Based on his experiences, Dr. Farmer has observed that the method of treatment he employed in Haiti, where community health care workers directly observe people taking their medication, requires only “basic laboratory data available in most rural clinics.”[8] If this approach “can be implemented in the devastated Central Plateau of Haiti[,] it can be implanted anywhere.”[9] The experience in Haiti has also demonstrated the symbiotic relationship between anti-retroviral therapy and infrastructure. Introducing an integrated program of prevention, care, and treatment, including anti-retroviral therapy, led to improved tuberculosis detection and care, better women's health programs, and improved primary health care.[10] Treatment can help build infrastructure.

In Uganda, where anti-retroviral drugs are available for about $360 per year, about 10,000 people living with HIV/AIDS are on anti-retroviral therapy, out of about 120,000 people in urgent need of the treatment.[11] The 10,000 Ugandans who are on anti-retroviral therapy do not have access to special infrastructure that other Ugandans cannot access. What they do have is more money than most Ugandans, which enables them to afford the drugs.

A study conducted in 2000 by McKinsey and Company estimated that if anti-retroviral costs were reduced to about $600 — they are now about half this sum — treatment in Uganda could be rapidly expanded to reach 50,000 people (about 42% of those in immediate need) with only limited infrastructure investments in nine regional hospitals in Uganda.[12] That is the about the same number of people now being treatment in all of Africa.

If Uganda's health infrastructure is typical for Africa, then treatment could be expanded to reach about 1,875,000 Africans of the 4.5 million Africans in immediate need of treatment with only limited infrastructure investments.[13] While a crude measurement — health infrastructure in Africa varies from country to country, as well as within countries — this figure is strongly suggests the possibility for widespread treatment in the very near future.

In 2002, WHO set the goal of having 3 million people living with HIV/AIDS on anti-retroviral therapy by 2005. WHO set this goal because of their belief that 3 million people live in areas with access to health services that have the potential to provide treatment in the near future. Although the past year has seen little progress towards this goal because the necessary resources have not been made available, the new Director-General of the WHO believes that this goal remains feasible. In July 2003, Director-General Dr. Jong-Woo Lee recommitted WHO to achieving this treatment goal. The world's leading health authority continues to believe 3 million people in developing countries can be treated in just two years, and does not believe that a slow ramping up is necessary before widespread treatment becomes possible. By December 1, 2003 — World AIDS Day —WHO will unveil a plan for achieving this goal. It will require resources. The United States should have sufficient money appropriated to pay its share.

Considerable capacity already exists

When introducing treatment protocols, the United States will be building on experience, and even success. A growing number of countries are developing and beginning to implement treatment plans. Through the first two rounds of the Global Fund, the Fund's technical review panel and Board approved proposals that will enable 500,000 people to be treated over the next five years. As of late 2002, at least 40 African countries had national HIV/AIDS strategies, 26 of which (65%) either incorporated anti-retroviral therapy into their plans or set anti-retroviral therapy coverage targets.[14] Even some countries that did not include anti-retroviral therapy in their plans have since begun to take steps to introduce and scale-up anti-retroviral therapy programs.[15]

A promising treatment strategy is DOT-HAART, the directly observed therapy approach that Dr. Farmer is using in Haiti. DOT is the gold-standard for tuberculosis treatment. It is widespread in many African countries. In countries including Botswana, Burkina Faso, Congo, Ghana, Kenya, Lesotho, Malawi, Mozambique, Rwanda, Uganda, Tanzania, and Zimbabwe, DOT for tuberculosis is available in every district.[16] Six of these countries have been designated part of the American AIDS initiative. Not only is DOT widely available; it is also frequently successful. In cases registered in 2000 where tuberculosis was detected and people received treatment, WHO reports a successful outcome in 77% of cases in Botswana, 80% in Ethiopia, 80% in Kenya, 75% in Mozambique, 79% in Nigeria, and 79% in Tanzania.[17] These countries are all part of the American AIDS initiative.

Widespread treatment is possible using existing health infrastructure. AIDS treatment can be integrated into existing tuberculosis control infrastructure. Health systems have multiple other entry points where AIDS treatment can be introduced, including hospitals and health clinics, tuberculosis services, sexually transmitted infections clinics, anti-natal care clinics, and child health services.[18]

Treatment is becoming increasingly less complex

Treatment is becoming increasingly less complex, both for the person with HIV/AIDS and the health care provider. The number of pills that people need is decreasing, with regimens developed that require people to take two pills three times per day, with efforts ongoing to further reduce the pill burden. The job of the health care provider is being simplified as well. In April 2002, the World Health Organization produced a set of treatment guidelines, which enable national policymakers to develop standardized treatment regimes, and enable health care providers to use basic blood tests and clinical observations to monitor patients. WHO's then-Director-General Dr. Gro Harlem Brundtland, stated, upon releasing the guidelines, “[f]or the first time we now have the chance to apply a simplified, easy-to-follow public health approach to AIDS treatment rather than complex individual treatment regimes.”[19]

Numerous other AIDS-related needs exist: prevention, care, and support

Treatment is not the only gaping need in the battle against AIDS. The medical and scientific communities have reached a consensus on the importance of both prevention and treatment. Based on UNAIDS and WHO estimates, close to $5 billion is needed for prevention efforts alone in 2004,[20] an American share of about $1.6 billion. UNAIDS has estimated that a dozen key prevention interventions can reduce the number of new adult infections from 4 million to 1.5 million once they are implemented.[21]

In many instances significant improvements in providing people treatment for opportunistic infections will be possible with simple but highly effective investments in health infrastructure, including in communications equipment, more ambulances, more training, and improved information management systems. One of the most critical care interventions is perhaps the simplest — ensuring that people living with HIV/AIDS are adequately nourished.

Along with more standard interventions, other forms of prevention, care, and support interventions are needed. Among them: judicial and legal infrastructure in many countries must be strengthened to protect the rights of women; children orphaned or otherwise affected for HIV/AIDS must receive support for education; economic opportunities must be created for people left destitute by HIV/AIDS; interventions are needed to prevention HIV transmission through unsafe medical injections, and; a concerted effort is needed to stop the spread of tuberculosis, which is being driven by HIV/AIDS.

The proposals coming into the Global Fund to Fight AIDS, Tuberculosis and Malaria demonstrate that countries have plans to spend resources. In the latest round of proposals to the Global Fund, countries submitted what are expected to be about $1 billion worth of technically sound proposals that are consistent with internationally accepted best practices in fighting the diseases, although only about $400 million in uncommitted contributions is currently available for this round. Countries have sound plans. They lack resources.

The Global Fund needs the full $1 billion authorized by Congress

The Global Fund, whose Board is chaired by Secretary Tommy Thompson, is already proving its efficiency at quickly and effectively distributing funds based on an innovative, country-driven process that ensures the participation of civil society and best scientific practices and is reinforced by multiple layers of accountability. In its first 18 months, the Fund committed $1.5 billion to more than 150 programs in 92 countries.[22] The Fund is facing a shortfall of $3 billion over the next year,[23] making a U.S. contribution of $1 billion critical for the Fund's continued success. The Administration believes that $1.8 billion can effectively be spent through bilateral assistance. Together with $1 billion to the Fund, even accepting the Administration's beliefs about the difficultly of spending more than $1.8 billion in bilateral assistance in fiscal year 2004 — with which we decidedly disagree — we find it difficult to understand the basis for the assertion that there would be any difficulty effectively spending any less than $2.8 billion.

Through its contributions to the Global Fund, the United States could help respond to the AIDS emergency in countries and regions of the world not covered by the bilateral AIDS initiative. These countries include India. Official statistics report 4.58 million people living with HIV/AIDS in India,[24] but the U.S. National Intelligence Council reports that some experts believe 5-8 million Indians are already living with HIV/AIDS, a number that could grow to 20-25 million by 2010[25] — or at least two-thirds of the number of people currently living with HIV/AIDS in all of Africa. A responsible AIDS emergency plan must help address the burgeoning AIDS crisis in India.

Other countries are supporting the Global Fund

Dr. O'Neill's statement that the United States is currently contributing more than 40% to the Fund reflects the fact that the United States has been commendably prompt in its payments to the Global Fund, not that its contributions to the Fund have been disproportionately large. As of mid-July 2003, although the United States has actually paid 41.7% of the total contributions to the Fund, U.S. pledges through 2003 are 32.7% of the Fund's total[26] — almost precisely the ratio of one American dollar to two international dollars that Congress supported in the AIDS authorization bill. If the United States contributes $1 billion of the $3 billion that the Fund needs in 2004, the United States will continue to be almost perfectly in line with this ratio.

The leverage that Congress sought is working. At the July 16 donors meeting in Paris, European Commission President Romano Prodi personally guaranteed a $1 billion contribution from Europe for 2004.[27] If the United States uses the AIDS authorization bill to leverage money for the Global Fund, but then fails to contribute the funds that other countries are anticipating, it would severely harm the United States' future ability to leverage contributions to the Global Fund.

Conclusion

The full $3 billion authorized for fiscal year 2004 is needed, can be well spent, and if appropriated, will be well spent. As the disease tears at the fabric of AIDS-burdened societies, building capacity will only become more difficult the longer the United States waits before devoting our best efforts to stopping the scourge. Congress must act now. We encourage you to support efforts to appropriate $3 billion for fiscal year to fight global HIV/AIDS. 

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Physicians for Human Rights (PHR) mobilizes the health professions to advance the health and dignity of all people by protecting human rights. As a founding member of the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Peace Prize.