This post is by Global Center Director Christine Lubinski, reporting this week from CROI in San Francisco.
The opening day of CROI included a session on the future of PEPFAR, featuring the US lead on global AIDS, Ambassador Eric Goosby, MD, as well as the health minister of Namibia and the UNAIDS deputy director. Kevin De Cock, MD, recently named the head of global health at the CDC, moderated the session.
Goosby opened his talk by assuring this HIV scientific audience that the Obama Administration is focused on “maintaining, extending and increasing” the US response to global AIDS and described the President’s FY 11 $7 billion for PEPFAR, the largest request to date. (Presumably, this $7 billion figure includes bilateral global TB activities as well as the Administration’s request for the Global Fund—which actually reflects a net reduction from the amount that was appropriated for the current fiscal year.) Goosby talked about using key lessons learned to build the future of PEPFAR. He catalogued those lessons as follows:
*The HIV response has benefited both health systems and health status with, for example, reductions in hospitalization, coinfection, and stigma
*Goals and targets help to drive programs and need to be modified as programs mature
*Prevention programs require targeted, data-driven responses
*Emergency response mechanisms must be supplanted with efforts to build country capacity to develop and coordinate a response to the epidemic
*The US must be able to demonstrate the impact of every dollar we spend.
Goosby then highlighted some of the major components of the new 5-year PEPFAR strategy, released in December:
- Promotion of sustainable country programs
- Strengthening partner government capacity
- Expansion of prevention, care, and treatment in both concentrated and generalized epidemics
- Integration and coordination of HIV programs with broader global health and development programs
- Investments in innovation and operations research.
Ambassador Goosby told the audience that his office was actively engaged in dialogue with the Global Fund , other bilateral programs, and foundations about ways to effectively converge resources and to identify efficiencies and savings. As he has frequently done in other public statements, he spoke about the need for country ownership, but he explicitly described this as ownership by country and civil society. This inclusion of civil society will no doubt be reassuring to some, but so far, civil society participation in the development of the 5-year partnership frameworks that the Office of the Global AIDS Coordinator is working on with a number of countries has been extremely variable and quite limited in some contexts. He also pointed out that in most cases, in the near term, country ownership was more about control in identifying priorities and administering programs than actually providing the financing. In particular, he highlighted transitioning to local partners as the dominant source for service delivery.
He noted that he thought that PEPFAR could make an important contribution to the global evidence base around effective prevention and described prevention as a combination of biomedical interventions, behavioral interventions, and structural/policy and social changes.
In regard to HIV treatment, Goosby said that expanding treatment and ensuring quality would continue to be a priority as the program moved from providing treatment access to 2.4 million to the “mid 4 millions.” PEPFAR would also continue to provide technical support around treatment guidelines, ensuring retention adherence, and monitoring drug resistance. PEPFAR is also committed to maximizing the use of pooled procurement for drugs and laboratory commodities and the use of generic ARVs , which is currently 89 percent.
He told this research audience that PEPFAR would lead the way and redouble support for high quality monitoring, evaluation and operational research, but qualified that we must not be afraid to scale up bold, innovative approaches to regional or national levels, working with governments to evaluate what works without delaying implementation of key programs. PEPFAR is also expanding its use of costing studies and modeling.
He said that PEPFAR’s programs for orphans and vulnerable children (OVC) presented him with his steepest learning curve and announced that PEPFAR would be providing “a tail of case management” for children and infants as they matured.
Richard Kamwi, the health minister of Namibia, and Paul Delay, the deputy director of UNAIDS, each offered brief remarks after Goosby’s talk. Although their remarks were described as responses, neither could really be categorized as a response to Goosby’s presentation, or to evolving US policy for that matter. One wonders whether the financial dependence of both Namibia and UNAIDS on US dollars made both speakers poorly suited to respond candidly.
Kamwi reported on progress in Namibia’s battle against AIDS, which includes a 5 percent reduction in estimated HIV prevalence among young women since 2004 and 70 percent coverage of PMTCT services. But he also noted that prevention strategies must evolve and that Namibia is committed to combination approaches that address multiple behavioral risk factors for diverse populations.
He said his country is interested in a true partnership with donor nations, although the economic downturn presents some real challenges. The government of Namibia has consistently devoted more than 10 percent of its budget to health care and is serious about moving to 15 percent. He described PEPFAR support as vital and said that 20 percent of the clinical workforce in the public sector is financed by PEPFAR. He said expansion of the healthcare workforce in Namibia is vital—in the form of doctors, nurses, pharmacists, lab workers, community workers and clinical officers–and he expressed hope that additional PEPFAR investment in health systems strengthening will help Namibia manage its response.
DeLay, of UNAIDS, described PEPFAR as the game changer that really jump-started treatment and was more rapid in implementing treatment than the Global Fund.
He said that transparent access to country-level data has been a problem under PEPFAR—basic data including ART survival data, switching rates, and CD4 initiation rates. He voiced hope that data would now become much more available at the country level. He also lauded a new commitment to evidence-based combination prevention, but said that he hoped that PEPFAR would also be courageous in responding to policies that are undermining prevention and threatening human rights. He described a wave of policies across the world that criminalize HIV risk behaviors, and he urged PEPFAR to be part of the leadership in combating this trend. DeLay also joined the chorus of voices calling for new tools.
On the subject of treatment, he said that the implications of the new WHO treatment guidelines are profound—15 million need treatment today. He noted that the US government’s goal of treating 4 million was not very impressive when viewed in that context. He called for leadership and innovative thinking in figuring out where the funding for the “treatment mortgage will come from” and noted the need to think about social insurance and social protection as we continue to face these challenges that are inherent in providing chronic adult care.