Doing More with Less

Dwindling funding for the global fight against AIDS doesn't mean the battle is lost -- but it does mean we have to think about what we're getting for our money.

BY CHARLES KENNY | NOVEMBER 28, 2011

Last week, the Global Fund, the world's largest multilateral source of financing for the fight against AIDS, made a grim announcement: its donors had cut their funding by $1.6 billion, a big enough bite out of the organization's budget that the fund would be bankrolling no new AIDS treatment projects until 2014.

The announcement casts a pall on the international community's observance of World AIDS day this week, an occasion on which, the Global Fund's problems notwithstanding, we have a great deal to celebrate.  Never before have we had the abundance of tools to fight the global AIDS epidemic that we have today. Male circumcision has proven a powerful means of reducing infection -- a free circumcision service offered in South Africa's Orange Farm township, for example, reduced HIV prevalence there by 55 percent. An article published in the New England Journal of Medicine suggested that putting HIV-infected patients on antiretroviral drugs immediately after they were diagnosed dramatically reduced the risk of infecting their partners. Looking forward, although hopes for the impact of a microbicide gel to reduce infection amongst women appear dashed -- at least for the moment -- early stage HIV vaccine trials have shown 90 percent success.

Meanwhile, 33 developing countries have seen annual rates of new HIV infections drop by a quarter or more from their peak. From 2006 to 2010, the number of people in developing countries on antiretroviral drugs tripled to over 6 million. Costs for those drugs have come down markedly; antiretrovirals that went for $1,100 a year in 2004 can now be had for $335. The annual death toll from the disease plateaued in the middle of the last decade and has since begun to drop. Between 2002 and 2006, AIDS mortality in Kenya fell by 29 percent.  These breakthroughs give new hope in the struggle against a disease that has devastated some of the world's poorest countries, killing 30 million people and infecting 30 million more worldwide.

But the breakthroughs don't amount to a global reprieve -- and last week's reminder of the perennial uncertainty surrounding the resources available to fight the epidemic, on top of news that donor funding for HIV/AIDS leveled in 2009 and then declined 10 percent in 2010, should be a wake-up call to focus on cost-effective responses.

Doing that requires getting our balance of treatment and prevention right. Because for all the promise of recent advances, we are not expanding treatment rapidly enough to cover the newly infected. For every new recipient of retroviral drugs, two people get infected. And while costs of treatment are dropping, they are not doing so fast enough. Today, as much as four-fifths of the cost of AIDS treatment in developing countries goes not to the drug but to the staff, health system administration costs, and testing necessary to deliver it -- costs that are harder to reduce with a technological breakthroughs.

STEPHANE DE SAKUTIN/AFP/Getty Images

 

Charles Kenny is a senior fellow at the Center for Global Development, a Schwartz fellow at the New America Foundation, and author, most recently, of Getting Better: Why Global Development Is Succeeding and How We Can Improve the World Even More. "The Optimist," his column for ForeignPolicy.com, runs weekly.

TOM TOBIN

9:58 PM ET

November 28, 2011

male circumcision is very questionable

I truly don't believe the figure that "Male circumcision has proven a powerful means of reducing infection -- a free circumcision service offered in South Africa's Orange Farm township, for example, reduced HIV prevalence there by 55 percent".
Wow. Someone should tell the United States. The US, in the 1980s, had an adult population which was 80% to 85% circumcised. Why was its HIV infection rate among the highest in the world,,,where it remains to this day?
Someone played hard and fast with the figures. Who?
Perhaps Bertran Auvert, who has ties to the circumfetish group the Gilgal Society (Hebrew for hill of foreskins).
The WHO isn't exactly clean or unbiased, either.
Dr. David Tomlinson is chief expert to the World Health Organization
on circumcision. He invented the "improved" Gomco, the "improved"
Plastibell and the "improved" Accu-circ. Obviously, it is a conflict
of interest for him to hold the position, when he stands to make money
from each of these circumcision clamps sold.

Here Dr. Tomlinson is quoted in the advertising brochure for the Accu-circ.
http://todayshospitalist.com/index.php?b=articles_read&cnt=647
and an ad:
http://www.kentecmedical.com/media/document/AccuCircWorkshopBrochure.pdf

If these figures are actually true, why did Americans bury nearly a million mostly circumcised men, who died of AIDS?

Here's another good one:
"For a start, AIDS prevention is not only better than treatment, it is cheaper, too: Mead Over estimates that adult male circumcision costs about $42 per year of life saved from lower HIV infection rates, compared to $780 per life year saved by antiretroviral treatments."
Is Mead Over including the cost of condoms? No one else, to the best of my knowledge, recommends circumcision as being safe, without using a condom. Is Over going to be the first? If so, on what basis?

Perhaps it's just me, but I take removal of an average of 50% of the skin of the genitals of someone seriously...especially when it includes about 60% of the nerves.

How much would condoms cost, when compared to the $42 for a circumcision?

 

MR DAVID

7:32 AM ET

November 29, 2011

We need to accept that every

We need to accept that every country needs a focused AIDS strategy, and we should encourage them to adopt it to suit their own culture. An initiative that might work from home in the West will not necessarily translate to a successful policy in Africa. Only when we can fully appreciate the diversity of thought will we be able to adopt best practice throughout the world.

 

MARKTHOMPSON

10:15 AM ET

November 29, 2011

OMG

We all should stand up against AIDS. Its not an easy taask to kick out AIDS from our society but we have to stand out against this deasies. This is not an easy work to do. we have to take care many precautionary measures to kick out this AIDS from our world.
There is a hope found :
Until recently, the possibility seemed little more than wishful thinking. But the experiences of two patients now suggest to many scientists that it may be achievable.

One man, the so-called Berlin patient, apparently has cleared his H.I.V. infection, albeit by arduous bone marrow transplants.

More recently, a 50-year-old man in Trenton underwent a far less difficult gene therapy procedure. While he was not cured, his body was able to briefly control the virus after he stopped taking the usual antiviral drugs, something that is highly unusual.

“It’s hard to understate how the scientific community has swung in its thinking about the possibility that we can do this,” said Kevin Frost, chief executive of the Foundation for Aids Research, a nonprofit group. “Cure, in the context of H.I.V., had become almost a four-letter word.”

There were attempts in the past to cure the disease, but most experts thought it more feasible to focus on prevention and treatment.

The push for a cure might seem even less urgent now that antiviral drugs have turned H.I.V. infection from a near-certain death sentence to a chronic disease for many people.

But the drugs are not available to everyone, and they do not eliminate the infection. Even if undetectable in the blood, the human immunodeficiency virus lurks quietly in the body. If a patient stops taking the drugs, the virus almost always comes roaring back.

So people with H.I.V. now must take drugs every day for life, which some researchers say is not a sustainable solution for tens of millions of infected people.

“I don’t think the world has the resources to deliver these drugs to everyone who needs them for decades,” said Dr. Steven Deeks, professor of medicine at the University of California, San Francisco.

A cure may be the only realistic solution. The National Institute of Allergy and Infectious Diseases, which says a cure is one of its top priorities, this year awarded grants that could total $70 million over five years to three research teams in pursuit of that goal. More grants are coming.

California’s stem-cell agency has committed a total of $38 million to three projects intended to find a cure. Companies like Merck, Gilead Sciences, Sangamo BioSciences and Calimmune have begun research.

It will be years before there is a cure, if there ever is, though some scientists are more optimistic than others.

“I think we are much closer to a cure than we are to a vaccine,” said Rafick-Pierre Sékaly, scientific director of the Vaccine and Gene Therapy Institute of Florida.

There are two main approaches. One is a so-called sterilizing cure — the eradication of H.I.V. from the body. The other, a functional cure, would not eliminate the virus but would allow a person to remain healthy without antiviral drugs.

Hope for a cure was raised in part by the experience of the Berlin patient, an American named Timothy Brown who had both H.I.V. and leukemia.

In 2007 and 2008, while living in Berlin, Mr. Brown received two bone-marrow transplants to treat his leukemia. The donor was among the 1 percent of Northern Europeans naturally resistant to H.I.V. infection because they lack CCR5, a protein on the surface of immune cells that the virus uses as an entry portal.

With his own immune system replaced by one resistant to infection, Mr. Brown, 45, who now lives in San Francisco, has apparently been free of the virus for about four years. But bone marrow transplants are grueling, risky and expensive. Moreover, it is hard enough to find an immunologically matching donor, let alone one with mutations in both copies of the CCR5 gene.

So scientists are trying to modify a patient’s own immune cells to make them resistant to infection by eliminating CCR5.

This is what was done with the Trenton patient. Some of the man’s white blood cells were removed from his body and treated with a gene therapy developed by Sangamo BioSciences with agenda software. The therapy induced the cells to produce proteins called zinc-finger nucleases that can disrupt the CCR5 gene.

The treated cells were then infused back into the man’s body. One month later, as part of the experiment, the man stopped taking his antiviral drugs for 12 weeks.

Thanks

 

HUGH7

5:30 PM ET

November 29, 2011

Circumcision not proven

It is premature to say that "Male circumcision has proven a powerful means of reducing infection" or that "a free circumcision service offered in South Africa's Orange Farm township, for example, reduced HIV prevalence there by 55 percent."

In the Orange Farm trial, 1550 adult volunteers were cicumcised and a similar number left intact, After less than two years, 20 of them had HIV, 25 fewer than the control group made to wait. 100 circumcised and 151 intact men dropped out, their HIV status unknown. Contacts were not traced so it is not even certain which if any of them contracted HIV from women, when contaminated instruments and informal injections are a real problem, and men are unwilling to confess to sex with men.

Claims about future prevention and relative costs are pure speculation.

A study in Uganda started to find that circumcising men INcreases the risk to women, but that was cut short for no good reason before it could be confirmed.

In 10 out of 18 countries for which USAID has figures, more of the CiRCUMCISED men have HIV than the non-circumcised. This certainly needs to be explained before blundering ahead with mass-circumcision campaigns.

 

ARCONDICIONADOFBF

9:21 AM ET

December 7, 2011

i Agree in Circumcision not proven

After less than two years, 20 of them had HIV, 25 fewer than the control group made to wait. 100 circumcised and 151 intact men dropped out, their HIV status unknown. Contacts were not traced so it is not even certain which if any of them contracted HIV from women, when contaminated instruments and informal injections are a real problem, and men are unwilling to confess to sex with men. Seguro Imoveis Massagistas Acompanhantes Ar Condicionado Carro

 

YARINSIZ

4:20 PM ET

December 24, 2011

But the drugs are not

But the drugs are not available to everyone, and they do not eliminate the infection. Even if undetectable in the blood, the human immunodeficiency virus lurks quietly in the body. If a patient stops taking the drugs, the virus almost always comes roaring back. seslichat So people with H.I.V. now must take drugs every day for life, which some researchers say is not a sustainable solution for tens of millions of infected people.

 

FRIVCITY

11:41 AM ET

December 28, 2011

The eradication of H.I.V

There are two main approaches. One is a so-called sterilizing cure — the eradication of H.I.V. from the body. The other, a functional cure, would not eliminate the virus but would allow a person to remain healthy without antiviral drugs. Miniclip, Starfall, Funbrain, Miniclip, Armor Games. After less than two years, 20 of them had HIV, 25 fewer than the control group made to wait. 100 circumcised and 151 intact men dropped out, their HIV status unknown.