Only Stronger U.S. Leadership Can End the AIDS Epidemic
Existing treatment and prevention techniques could prevent millions of new HIV infections and deaths from AIDS—but only if Obama sustains funding.
by Mark Harrington
This article was first published on 24 July 2012 in theAtlantic.com.
Four years ago, President Obama's election generated hope for new American leadership in the fight against AIDS here at home and around the world. On that day, South Africa's Treatment Action Campaign -- the movement which combined massive demonstrations with sophisticated insider legal cases and science-based activism to force South Africa to create the world's largest HIV treatment program -- recalled his visit to their offices in the township of Khayelitsha, Western Cape, in August of 2006, and how it had urged him to run for president to have a chance to fulfill his commitment to addressing AIDS.
"Obama took a strong position on preventing and treating HIV/AIDS," the group recalled in 2008, "and was critical of President Mbeki and the South African government's response to the epidemic," then expressed through a deadly form of HIV denialism.
Since becoming president, Obama has continued to talk the talk, promising last December on World AIDS Day to lead the way towards an AIDS-free generation, and to increase U.S. support for global HIV treatment to cover antiretroviral therapy (ART) for six million people around the world by the end of 2013. That makes his silence this week, during the first International AIDS Conference to be held on American soil since the 1990 gathering during the George H.W. Bush administration, all the more striking.
Obama simply hasn't walked the walk when it comes to funding for AIDS. In fact, earlier this year, he proposed a shocking cut of $550 million to the President's Emergency Plan for AIDS Relief (PEPFAR), the most successful U.S.-funded global health program in history.
At first, the administration failed to provide any explanation for such drastic cuts, which could put the lives of thousands who depend on the United States to pay for treatment at risk. Later, in response to pressure from the Treatment Action Group and its activist colleagues, administration officials claimed that they had been so successful in reducing costs that they could reach the target of getting medicines to 6 million during 2013 even with dramatically reduced funding.
It's true that costs have gone down. Earlier this week, the Clinton Health Access Initiative released data showing that the cost of providing HIV care and treatment has dramatically fallen in the past two years due to increased use of generic medications and overall program efficiencies. The annual cost of HIV care in Ethiopia, Malawi, Rwanda, and Zambia -- including drugs, lab costs, and health worker salaries -- is now just $200, while in more developed South Africa it is $682. In her speech to the International AIDS Conference on Monday, Secretary of State Hillary Clinton indicated that these economies of scale enabled PEPFAR-supported programs to enroll 600,000 people in the last six months, compared with 700,000 in the past fiscal year.
With these successes in hand, the Obama administration could easily have proposed a more rapid scale-up towards unmet HIV prevention and treatment needs, rather than slashing PEPFAR. There are plenty of global health needs to which the funds saved on "efficiencies" could have been applied -- expanding TB testing in mothers and children, purchasing GeneXpert TB test kits, which can diagnose the disease and its most common drug-resistance patterns in two hours rather than the two weeks or more traditional TB culture takes -- as well as expanding ART treatment slots and growing maternal and child health programs. All these would have been steps forward towards the making administration's AIDS-free generation promise a reality.
Instead, the administration decided to pocket the savings, leaving millions of people out in the cold.
Some people even wonder if the president's lack of enthusiasm for PEPFAR heralds the program's demise next year, when it is due to be reauthorized by Congress. PEPFAR was launched in 2003 by President George W. Bush and, along with the Global Fund to Fight AIDS, Tuberculosis and Malaria, has channeled $39 billion in U.S. aid towards HIV treatment and prevention efforts (as well as the fights against TB and malaria) around the world, making the United States the single largest source of dollars addressing the global HIV pandemic. Four-and-a-half million people today are receiving life-saving HIV treatment through PEPFAR in low and middle-income countries in Africa, Asia, the Caribbean, and South America.
Had Obama attended the International AIDS Conference (Secretary of State Hillary Clinton, HHS Secretary Kathleen Sebelius, PEPFAR chief Eric Goosby, and NIH AIDS supremo Anthony Fauci and other members of the administration have been speaking or attending in his stead), he would have heard deep gratitude for the U.S. role in responding to the HIV epidemic around the globe. He would have heard optimism that the world is on the cusp of being able to do something long thought unthinkable -- actually bring about an end to the AIDS pandemic.
But since he won't be there, here's a to do list the president should consider if he wants to walk the walk to truly begin to make that happen:
1. Fully fund PEPFAR and support its reauthorization in 2013. Restore the $546 million in proposed cuts to PEPFAR in fiscal year 2013, and begin planning now for the program's upcoming legislative reauthorization in 2013.
2. Restore cuts to the Centers for Disease Control and Prevention (CDC) tuberculosis program. TB is the leading cause of HIV related death worldwide, yet the last budget continues a deplorable pattern of cutting the CDC's TB control budget. As a result of the cuts, the New York City Department of Health is being forced this week to suspend an innovative pilot program to treat cases of latent TB infection with a three-month course of treatment, instead of the older standard nine-month course, which imposes much greater inconveniences on patients and health workers alike.
3. Fully support the Global Fund to Fight AIDS, Tuberculosis and Malaria, and enable it to replenish depleted funding coffers for countries trying to expand their programs for prevention, care, and treatment of the three diseases, which often spread in tandem and occur at the highest rates in the same countries.
4. Reject the congressional ban on federal funding for needle exchange. As part of last year's budget deal, Obama conceded to congressional demands that the ban on federal funding for needle exchange be reinstated. The administration did this despite knowing that needle exchange programs save lives and reduce HIV transmission -- and despite having reversed the previous ban. Last year's decision was wrong and could lead to unnecessary increases in HIV incidence among drug users and their sex partners.
5. Revise and revitalize the National HIV/AIDS Strategy (NHAS) to incorporate new scientific findings and to more rapidly scale up HIV prevention and treatment programs nationally. A recent paper by David Holtgrave, a department chair at the Johns Hopkins Bloomberg School of Public Health, and colleagues found that "[w]ithout expansion of diagnostic services and of prevention services for [people living with HIV], scaling up coverage of HIV care and treatment alone in the U.S. will not achieve the incidence and transmission rate reduction goals of the NHAS. However, timely expansion of testing and prevention services for [people living with HIV] does allow for the goals to still be achieved by 2015, and does so in a highly cost-effective manner." The goals of the NHAS include:
- lowering new HIV infections by 25 percent and HIV incidence by 30 percent
- increasing Americans' knowledge of their own serostatus from 79 percent to 90 percent
- increasing the proportion of newly diagnosed Americans linked to clinical care within three months from 79 percent to 90 percent
- increasing the proportion of Ryan White HIV/AIDS program clients who are in continuous care (at least two visits for routine HIV medical care in 12 months at least 3 months apart) from 73 percent to 80 percent
- increasing the percentage of Ryan White HIV/AIDS program clients with permanent housing from 82 percent to 86 percent, and
- increasing the proportion of HIV-diagnosed gay and bisexual men, Blacks, and Latinos/Latinas with undetectable viral load by 20 percent each
all by the end of 2015.
Recent scientific discoveries have shown that earlier initiation of antiretroviral therapy can reduce HIV transmission by a whopping 96 percent among couples with differing HIV status.
This led Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health (NIH) to write:
The fact that treatment of HIV-infected adults is also prevention gives us the wherewithal, even in the absence of an effective vaccine, to begin to control and ultimately end the AIDS pandemic....For the first time in the history of HIV/AIDS, controlling and ending the pandemic are feasible; however, a truly global commitment...is essential. Major investments in implementation now will save even greater expenditures in the future; and in the meantime, countless lives can be saved.
Revising the National AIDS Strategy to incorporate these new findings could enable the administration to set more ambitious targets of reducing HIV transmission and incidence by 50 percent or more -- as South Africa has committed to doing by 2016 -- increasing linkage to care to 95 percent, increasing Ryan White care retention to 95 percent (the program funds care for those who cannot otherwise afford it), increasing Ryan White clients' access to housing to 95 percent, and increasing the proportion of blacks, Latinos and Latinas, and gay men with an undetectable viral load to at least 90 percent.
Of course, this revised National AIDS Strategy would cost more money up front. But as Fauci pointed out above, and as Bernhard Schwartländer of UNAIDS, who first proposed the scale-up efforts that led to PEPFAR and the Global Fund in a pivotal paper in Science magazine in 2001, and colleagues pointed out in their global strategic investment framework for HIV: "[t]he yearly cost of achievement of universal access to HIV prevention, treatment, care, and support by 2015 is estimated at no less than US $22 billion. Implementation of the new investment framework would avert 12.2 million new HIV infections and 7.4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29.4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone."
6. Increase funding for the National Institutes of Health (NIH) by 15 percent annually for the next five years. The NIH budget has been flatlined since 2004, with the exception of two years of stimulus funding in 2010-2011. The rate at which new grant applications are funded has fallen to 10 percent, meaning nine out of 10 applications are rejected. In his 2011 State of the Union address, Obama committed to reinvigorating the United States' commitment to and investment in scientific research:
This is our generation's Sputnik moment. Two years ago, I said that we needed to reach a level of research and development we haven't seen since the height of the Space Race. And in a few weeks, I will be sending a budget to Congress that helps us meet that goal. We'll invest in biomedical research, information technology, and especially clean energy technology -- an investment that will strengthen our security, protect our planet, and create countless new jobs for our people.
This year, his proposed 2013 budget flatlines NIH once again. We need increased investment in biomedical research to assure the discovery and development of the innovative tools we need to end the epidemic, cure HIV and find a vaccine to prevent its transmission.
7. Commit the administration to fully funding the research, prevention, care, and treatmentscale-up required to end the pandemic. Some of the steps needed to end AIDS are discussed in a report issued this week by our colleagues at AVAC and amfAR, An Action Agenda to End AIDS.
President Obama has shown himself capable of the vision to create a National HIV/AIDS Strategy and continued to ensure that the United States is the leader in support for global HIV programs. Now is the time for him to embrace the newest scientific results, which give America the power to map out an endgame for the epidemic around the world.
Mark Harrington since 2002 has been the executive director of the Treatment Action Group, which he co-founded in 1992 after four years working with the Treatment + Data Committee of ACT UP/New York. He was awarded a MacArthur Fellowship in 1997.