HIV, TB research, funding, policy developments, setbacks of 2013 lay out promises and challenges for 2014
The PEPFAR Stewardship and Oversight Act – In a year when Congress couldn’t even keep the Panda-cam on, expectations for the future of the legislation that launched PEPFAR and that was set to expire this year were low. The bipartisan, bicameral unanimous passage of the act renews authorization for the President’s Emergency Plan For AIDS Relief for another five years and was a heartening sign for those encouraged by the introduction at the end of 2012 of PEPFAR’s Blueprint for an AIDS-free generation. But with flat-lined funding over the previous four years followed by sequestration cuts, and a budget proposal that would further reduce PEPFAR resources, will the money be there to follow science down the road to a future when no child is born with HIV, chances of acquiring it are greatly reduced, and treatment prevents the virus from causing AIDS?
Global Fund Replenishment – An investment of $15 billion was the price tag experts set for what the Global Fund to Fight AIDS Tuberculosis and Malaria would need over the next three years to confront preventable deaths from these diseases, and bring their epidemics under control. The world came up with $12 billion, although more is likely to trickle in. The United States put its $5 billion on the table, but it can only be picked up when it is matched by twice that amount. Will the window of opportunity that former Global AIDS Coordinator, and now Global Fund Executive Director Mark Dybul said this moment in science has opened stay open? If so for how long?
WHO guidelines – In its first update to general guidelines in three years, the World Health Organization recommended that people with HIV start taking antiretroviral medicine before their immune cell or CD4 counts drop below 500 cubic millimeters of blood, that all children under five begin antiretroviral treatment upon diagnosis, and that all people with HIV and uninfected partners receive immediate treatment. This would raise the number of people who should be receiving antiretroviral medicine to 26 million people worldwide, in turn raising the same question as above: Will the world decide it can afford to prevent the three million infections and three million deaths that WHO says the new guidelines could prevent, and, can the world afford not to?
TB drops in PEPFAR countries, but then so does proposed spending on TB research — The history of tuberculosis has been marked by a consistent conundrum, experts like to note: Success seems to breed failure to seize the moment. So perhaps TB clinicians, researchers, and patients were more saddened than surprised when, although research now proves PEPFAR focus countries saw significant drops in TB illness and death, cuts in funding for TB research were proposed, in some quarters, accepted with equanimity. With those who face TB on its front lines making their voices heard, the question remains if funding in the coming year will reflect their warnings.
Gay rights abuses accelerate, while the world watches – Remember last year around this time when a Ugandan Parliament member promised to present his country with the “Christmas Present” of a revived anti-homosexuality bill? After a decade of global donor efforts to confront HIV by changing attitudes and behaviors, something had been left out, it seemed. The defunct Global Health Initiative’s switch to an Office of Global Health Diplomacy was hoped to address that by working in country with governments to recognize the link between health and human rights. The Global Fund To Fight AIDS, Tuberculosis and Malaria also had recognized the need to encourage human rights recognition. But 2013 has been a bad year in human rights, seeing reversals of progress, acceleration of efforts to enact and enforce discriminatory laws, and in the sheer brutality that flourishes in the face of inactivity. The list is long, and many of the outrages of the last year remain hidden in the shadows where they occurred, so here is just a sampling: In April, Zambian AIDS treatment activist Paul Kasonkomona was charged and arrested for speaking of gay rights recognition on a television talk show. In May, Nigeria legislators passed the “Same Sex Marriage Prohibition Bill and other Related Matters.” In July, Cameroonian gay rights and HIV treatment advocate and journalist Eric O. Lembembe, who had spent the last year documenting increasing anti-gay brutality in the face of law enforcement indifference in his country, was tortured and beaten to death. Paul Kasonkomona’s trial proceedings continued over the summer and fall, with testimony highlighting that the chair of Zambia’s National AIDS Council was among those concerned by Kasonkomona’s televised support of gay recognition and rights. Most recently, last week India’s Supreme Court threw four years of progress in the country’s HIV and human rights struggles into reverse, with a truly surreal ruling that explores, among other legal concepts, the definition of the word “buggery” and cites the minority opinion in the U.S. Supreme Court Case overturning a similar, state law. This brings us finally to this very disturbing article on how Ethiopia has become “A Graveyard For Homosexuals”, which highlights, among other factors, the role of American missionaries in inciting intolerance, bringing home at the end of a tragic year, the influence U.S.-based efforts can have, for better or worse.
Anti-prostitution oath overturned – The Supreme Court’s upholding the reversal of the anti-prostitution oath requirement tied to the disbursal of PEPFAR funds showed that constitutional principles can, in fact, override ideology. In South Africa this summer, however, when a representative of Sisonke, an organization of sex workers, asked how the elimination of the pledge requirement would help her group’s outreach efforts, the answer was that we don’t know. After years of the pledge requirement’s inhibiting affect, the question remains if efforts essential to one of the most highly impacted and least served populations confronting HIV, will now go to where they can be effective.
VOICE reveals challenges to promise of PrEP, microbicides – No correctly designed clinical trial fails if it yields data. So went the bright-side approach to the information gleaned from the 15-site VOICE trial that sought to measure the effectiveness of Vaginal and Oral Interventions to Control the (HIV) Epidemic. The trial showed that too many of the women enrolled in the trial, for up to three years, did not use the interventions enough to prove they were effective. Which, effectively, so to speak, meant they were not effective. Future trials will seek to discover why the methods made available in VOICE — daily pills and vaginal gels — were not used, what methods may be more successful, and how trial design can be adapted to better reflect and respond to reality.
Sanofi drops price of TB drug lower than advocates ask – After months of discussions during which TB clinicians, researchers, and patients asked pharmaceutical giant Sanofi to drop the price of the TB drug it had developed, with U.S. support, to an affordable $35 a box, they were pleasantly surprised when the company instead lowered the price to $32. The question now is whether TB patients globally will get access to the drug, which can shorten treatment for TB infection from nine months to three months. Another question: will more companies follow the example Sanofi has set to set affordable prices and enhance access to life-saving drugs?
WHO OK’s Medical Circumcision device – When the World Health Organization put its stamp of approval on a device as an alternative to surgery for medical circumcision, the Office of the Global AIDS Coordinator hailed the move as one that could “change the landscape” of scaling up a proven HIV intervention, and promised its support to country partners to weigh using the device in their settings. As PEPFAR countries take increasing responsibility for the technical, financial and service components of their responses to HIV, the question remains when and if they will be able to speedily evaluate and adopt a new measure.
Ambassador Goosby goes, leaving legacy of science and human rights based responses – When Global AIDS Coordinator Ambassador Eric Goosby decided to step down this year, those who have watched his work over the last four years hailed his accomplishments that saw him usher in emphases on science-based approaches and human rights responses during an evolutionary stage of the landmark program. Those who have watched the program over the last decade also called for a replacement to be named and in place with no delay. Observers inside the Global AIDS Coordinators’ office and out have said the lag of five months last time was too long, and that this moment in the U.S. HIV response is too pivotal to leave PEPFAR rudderless. So we are left with several questions. When will a new PEPFAR leader be named, who will that person be, what new dimensions will that person bring to the tasks ahead — are some of them. And finally, as Ambassador Goosby continues his public health work as a professor and physician at the University of California in San Francisco with a new institute for implementation science, what new directions will his career-long commitment to matching responses to the demographics of epidemics lead him?