What Keeps Dr. Eric Goosby Up at Night?

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You’ll find the answer to that question, and other fresh insights into the Administration’s plans for PEPFAR, in this ScienceInsider interview with Dr. Goosby, President Obama’s global AIDS coordinator.

Among the highlights, Dr. Goosby tells SI that efforts to nix the ban on needle-exchange programs are well underway within the Administration and the PEPFAR office. “I have spent much of my life focused on matching demographics to responses. If you do not base responses to the demographics of your epidemic, you will not be successful at reaching the populations who are already infected,” Dr. Goosby says. When asked how he plans to get around the ban, Dr. Goosby notes that it’s domestic prohibition and PEPFAR is not subject to it.

Asked about what it’s like to take over such a successful initiative, Dr. Goosby gave this answer: “I’m grateful to PEPFAR for the work it has done, putting a finger in the dike, but we have by no means reached the threshold by which we can relax or view this as a job well done. The job that has been done is precariously positioned to not sustain itself.”

On what direction PEPFAR is headed, he offered this: “We need to look at how to build country-based, country-run, country-owned delivery systems. We can’t just build islands of excellence with HIV care and not address the larger health needs of that same individual. That’s shortsighted. The president and Secretary Clinton have been very clear about wanting all the vertical programs—HIV, TB, malaria, immunization, maternal and child health—to now look at expanding the service constellation and bringing in those broader health needs of what is a complete overlap in populations. The discussion is mostly focused on using women as that access point to children, husbands, and partners.”

At the end of the interview, Dr. Goosby talked about the mismatch between the current scientific and budget realities:

“It’s a no brainer in terms of the science to use tenofovir instead of d4T [an ARV that has serious side effects]. The problem is the cost. The same with using the current policy of 200 CD4 cells to start treatment versus 350 CD4s as the cutoff. The science has been there for a long time. That’s why no else is doing 200. The United States has been at 350 forever. You could argue we should be in the 400 to 500 range. The science is clear. What isn’t clear is how we can pay for that. We need to be honest: We’re in the business of trying to find resources to cover that extraordinary expansion of need. And the elephant in the room again is the second-line treatment cost, going up three, four times the cost of first-line for the most part. That’s the final thing that keeps me up at night.”

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