Interview

The Long Emergency

Barack Obama's administration is taking an expansive, ambitious approach to global health. Does that mean giving up on combating HIV/AIDS?

Is AIDS still an emergency?

How you answer that question probably says a lot about whether you think U.S. President Barack Obama's approach to fighting HIV/AIDS abroad is a good idea or a dangerous detour.

In recent weeks, a growing number of organizations have stepped forward to criticize the Obama administration for allegedly backtracking on a global health battle the world was starting to win. Groups as diverse as Médecins Sans Frontières and the Congress of South African Trade Unions argue that Obama is flat-lining funding for lifesaving anti-retroviral (ARV) treatments, just as the financial crisis is biting hard at other international funding too. They worry that the world could start to lose momentum, failing to keep up with the epidemic's alarming advance.

The U.S. administration counters that more money than ever is going into global health -- it's just no longer myopically focused on HIV/AIDS. The United States responded to the HIV/AIDS emergency a decade ago, the policy's defenders say; now it's time to take a broader, more sustainable approach that can eventually move patients away from their reliance on the United States. As congressional appropriations come up for 2011, battle lines are being drawn.

The fact that this debate is even taking place is a credit to the unsung legacy of a man global AIDS campaigners never expected would be their biggest ally: George W. Bush.

Bush's plan for combating the disease, called the President's Emergency Plan for AIDS Relief (PEPFAR) was an astounding success, exceeding all hopes. When his administration launched the program in 2003, HIV/AIDS was ravaging the developing world, taking the harshest toll on Africa. In some countries in southern Africa, as many as one in four were infected. Public awareness about infection and prevention was minimal, and ARV treatments, which help suppress HIV in infected patients, were scarcely available outside the West. The death rates were staggering -- 8,000 a day worldwide -- picking off adults in the prime of their economic lives and robbing countries of able-bodied workers.

PEPFAR was nothing less than a breakthrough. Bush offered $2.4 billion in its first year alone, pumping funds into preventing the disease through an ABC approach (Abstinence, Be faithful, use Condoms), testing patients for HIV infections before they spread, and treating patients with ARV drugs. Today, about 2.5 million people receive ARV treatment through PEPFAR -- more than half of the global total of patients on ARV treatment.

It was also a breakthrough politically. By focusing heavily on treatment, liberal and conservative members of Congress dodged the political flashpoints of abortion and condom use and forged an overwhelming consensus of support. "The United States is doing far more for Africa today than a decade ago largely because evangelicals became a strong constituency for the Pepfar AIDS program and the PMI malaria program," New York Times columnist Nicholas Kristof explained in February. With the Bush's firm backing, PEPFAR also avoided the kind of slow, cumbersome bureaucracy that has long held back the U.S. Agency for International Development, for example, and became one of the single most efficient aid efforts of the last half-century.

When the Obama administration came into office, PEPFAR's success was clear. But there were also two big concerns: how sustainable the program would be in the long run, and whether it was too narrowly focused, when much of the mortality in the developing world is not related to HIV. "We're in a constrained environment with people asking tougher questions about health impacts from the dollars invested," said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic and International Studies. "The desire is to move into a greater emphasis on health systems ... taking a strategic look over the long term rather than short term."

A paper co-written by Ezekiel J. Emanuel, now a senior advisor at the White House, for the Journal of the American Medicine Association seemed to crystallize the point (though an administration official denied that it was alone in motivating a policy shift). "[D]oubling or tripling PEPFAR's funding is not the best use of international health funding," the authors argued, questioning Bush's 2007 call for Congress to double U.S. HIV/AIDS funding. "By extending funds to simple but more deadly diseases, such as respiratory and diarrheal illnesses, the US government could save more lives." They offered a dramatic example: For the amount now spent on ARV treatment, 44 million children could be vaccinated against "diphtheria, pertussis, polio, tetanus, and measles," and their families could receive insecticide-treated bed nets.

The Obama administration's answer to these concerns was the Global Health Initiative, a $63 billion "whole-of-government approach" unveiled in May 2009 that took PEPFAR under its umbrella and shifted the focus from HIV/AIDS to including malaria, tuberculosis, maternal health, child health, nutrition, family planning and reproductive health, and neglected tropical diseases, according to the program's initial consultation document. On HIV/AIDS specifically, that has meant a greater emphasis on prevention, in addition to treatment. "I believe everyone agrees that we can't treat our way out of the HIV/AIDS epidemic," the U.S. global AIDS coordinator, Ambassador Eric Goosby, told Foreign Policy. The new program also implies giving local governments a bigger share of the stakes, getting them on board for the long haul so that patients are not dependent on U.S. funding.

"I don't think I'd describe it as a shift, as much as an expansion," a senior White House official explained. "We took a look at the foundation that had been laid by President Bush ... and asked ourselves: How can we build on this and get greater outcomes? Our conclusion was that the HIV and AIDS piece is critically important, which is why it will remain the largest piece by far, but that in order to address the global health deficit, we have always got to be able to do some other things."

But the administration's plan set off alarm bells within the HIV/AIDS advocacy community. The president's fiscal year 2011 budget proposal increased PEPFAR funding 2.3 percent -- an amount that activists claim is tantamount to a cut because the infection rate and inflation dwarf it. At a Feb. 11 House committee hearing, Peter N. Mugyenyi, executive director of the Joint Clinical Research Centre in Uganda, said that "the twin realities of the economic crisis and flat-lining of funding for PEPFAR threaten to reverse ... positive changes and miss opportunities to defeat the epidemic." He continued, "We are forced to turn away desperate patients daily." Weeks later, nearly 300 health professionals wrote to Rep. Nita Lowey, who chairs the House Appropriations Committee's State, Foreign Operations, and Other Programs Subcommittee, warning, "We cannot retreat from the lifesaving mission we as a nation embraced in 2003 through the creation of the PEPFAR program." The letter continues, "The President's FY 2011 budget reflects such a retreat."

Then, on May 27, Médecins Sans Frontières (MSF) released a report that warned of a decline in political will to fight the disease. Emi MacLean, the U.S. director of MSF's Access to Essential Medicines Campaign, told me the U.S. government had taken on "both the ethical and financial responsibility for patients enrolled under PEPFAR -- which is something that the U.S. government wants to step away from now." Additional concerns were raised about a $50 million budget cut for the Global Fund to Fight AIDS, Tuberculosis and Malaria, a multidonor vehicle that funds projects across the developing world. The New York Times followed the MSF report with dramatic reporting from the field, describing the growing number of patients turned away from treatment and prompting swift rebuttals from the administration that it was not, in fact, backing away on HIV/AIDS.

The administration has a strong case. It plans to scale up ARV treatment to 4 million people in the coming years, nearly double the current total. Getting countries invested in their own health systems, as PEPFAR's strategy aims to do, is certainly the best long-term way to ensure that patients have access to treatment. And on top of AIDS, who wouldn't love to see malaria, tuberculosis, and diarrheal diseases stop killing the millions that they do each year?

The only trouble is that there's really no guarantee that it will work. "Building health systems" is essentially what the development community has been trying to do for decades. Billions of dollars in aid and decades later, bilateral, multilateral, and private aid to the developing world has -- with notable but few exceptions -- failed to create health systems in poor countries that can respond to crises of the magnitude of HIV/AIDS.

"In the 1970s and the 1980s, people were saying we need, one, economic growth and, two, to build [health] systems. And then once we have that, we have all the elements; therefore we have health -- you know, as a consequence," Michel Kazatchkine, head of the Global Fund, told me. "But that doesn't work, and it didn't work. That's how we failed to respond to the AIDS crisis, and that's how we kept malaria a neglected disease."

The administration official disagreed. "PEPFAR showed you can fix the supply-chain problem -- that you can deliver complex treatments in rural areas and can train people to deliver these kinds of interventions," the official told me. "We have more experience than we have in the past in developing health systems."

Still, in the case of PEPFAR, many wonder if it is wise to fix something that wasn't really broken, especially in Washington, where the politics of health were always delicate. A State Department official put it to me this way: "The key to all this [stopping HIV/AIDS] is prevention, but [PEPFAR] was pragmatic enough to know that it's the absolute epicenter of all social and moral debates, and we could not allow that to get in the way of providing efficacious medical care."

The Obama administration's renewed focus on maternal health and family planning could, some fear, put that consensus on the rocks. (One Hill staffer told FP, "Hopefully people have learned some things over the last couple of years, and we won't find ourselves bogged down in debates like that.") Either way, however, some in PEPFAR are feeling marginalized, according to a former State Department official -- no longer enjoying the same freedom from bureaucracy to do their work.

On the ground, too, there are real concerns. Many argue that the proposed shift to more long-term care simply comes too soon. Kazatchkine and MSF, among others, say that we are still in the emergency phase of the epidemic and treatment should still come front and center; administration officials disagree. The Obama administration has not proposed dollar cuts in PEPFAR funding, but the pace of funding increases has slowed -- a trend that began with the Bush administration.

So, is HIV/AIDS still an emergency or not? Unfortunately, there are 33 million people around the world whose lives depend on the answer. And the trouble is, the answer is neither "yes" nor "no"; it's "both." On the one hand, three decades after the first cases of HIV, infection is no longer a death sentence. Treatment is increasingly available; mothers with HIV can give birth to virus-free children; awareness is up; and societies are finally coming to grips with the crisis.

On the other hand, the emergency could come back at any moment, and many fear it will if treatment stops. If the absolute number of patients on ARV treatment stays constant but the epidemic grows, the ranks of untreated patients could soar to dangerous levels, with potentially devastating consequences for their health, their families, and their societies.

Prevention is certainly key to bringing down those numbers. Yet the funding choice between preventing and treating is a false one. For starters, there is a preventive aspect to ARV treatment; a recent study cited by Joanne Carter, executive director of Results, an anti-poverty advocacy group, in her March congressional testimony found that ARV treatment lowered risk of infection 92 percent in discordant couples -- ones in which one partner is HIV positive and the other is not.

The prevention benefit goes further. "When you find out you are HIV positive, you have two choices," explains Joseph Amon, head of the global health program at Human Rights Watch. "You can do something with that knowledge -- and what people want is to get treatment and feel like they are being supported -- which leads to behavior change. The other option is to find out you're positive, but we don't have any drugs available for you, so come back in a few years. That doesn't lead to behavior change." One aid worker in Nigeria echoed that concern: "If we test 185,000 people [this year for HIV] and we find 7,400 positive [but have less than half that many treatment slots], what are we going to do with them?"

The gap between U.S. ability and patient needs is one reason that the administration has emphasized a need to get other donors on board, in addition to local governments. The $50 million cut to the Global Fund, however, has been met with concern by the same groups that have criticized Obama's global-health policy, and Kazatchkine calls it "a big test for the multilateralism and the move to multilateralism for the administration."

The bigger test will be whether Obama's health initiative can really build the environment that would be conducive to a shift from emergency to long-term HIV treatment, strengthening health-care systems where many have tried before and failed. In an ideal world, there would be enough money to fund both emergency and long-term solutions. But here's the truth: There isn't. So this was an inevitable juncture: A global recession, constrained budgets across the developed world, and a simple realization that treating HIV/AIDS is expensive have forced the U.S. government and other governments to answer hard questions about how their dollars will be spent. If Obama can make those hard decisions and manage the transition from emergency to long term, the fight against HIV/AIDS will be on a more sustainable footing. A wrong turn, however, could endanger the incredible gains made in recent years. And that's what advocates fear most of all.

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