Global AIDS: `An inevitable mismatch of resources and need’
Ambassador Eric Goosby, MD, the US global AIDS coordinator who assumed his position a little more than a year ago, will be a significant presence at the International AIDS Conference in Vienna, which kicks off Sunday night. John Donnelly interviewed him Wednesday about his expectations for the conference, what was behind the Uganda problem with shortages of AIDS medicine, and whether The New York Times was right when it reported in May that the Ugandan drug shortfall was “the first example … of how the war on AIDS is falling apart.’’
Q: You just wrote an article on the State Department blog on how you traveled to Uganda in June to address drug shortages, detailing how the Global Fund suspension of funding had a spillover effect on all AIDS treatment there. Why did you feel the need to go to Uganda to sort it out?
A: The reason was that I wasn’t getting a clear picture of what the problem was and why we were finding ourselves in a situation where seven of our clinics were saturating (reaching the limit of number of patients). Attempts to work through the PEPFAR team in country resulted in explanations … patients came, we saw them, that’s what happened. It wasn’t that they were withholding their explanation of the domino-effect of the Global Fund sites. The truth was, they weren’t aware of it. So when we went we interviewed every provider, and looked at all the records, and saw an abrupt increase in enrollment that had not been budgeted for in PEPFAR. I asked the question, `Why did that occur?’ I found out that 11 Global Fund supported public clinics in the course of 18 months or so had gone from stuttering to stopping. Their Global Fund grant stopped. There was no formal closing of these clinics. They quietly closed. Patients who went to those clinics just showed up at our door.
Q: So is this an isolated problem based in one country with one large grant? Was The New York Times wrong in reporting from Uganda in May that “Uganda is the first and most obvious example of how the war on global AIDS is falling apart,’’ or was there some truth to it?
A: There is some truth to the statement that we are working in an environment where we are only addressing a third of the known need. I think that every country that we are in has this large unmet need and every country is going to potentially hit a resource wall. It’s for that reason we have tried to change the way we are looking at the work we are doing, with the resources we have, and look for every opportunity we have and to be additive to the other large funders. We are now in a dialogue with the Global Fund about merging our planning processes in countries and increasing our oversight of that planning process and the need to not duplicate a procurement system, or a medical delivery system. We will be looking for being efficient and looking for synergy (of efforts). So instead of having 127 PEPFAR clinics, and 140 different clinics that are Global Fund funded, we now need to look at how many of our clinics (can combine services). We will realize large savings from this strategy. But that still won’t get us to address the totality of that unmet need. … An inevitable mismatch of resources and need is going to be seen.
Q: Where are the examples of savings that you’ve found?
A: Right now we are working with the Global Fund to identify 10 countries where the Global Fund and PEPFAR agree to (combine) our planning process. We haven’t yet identified the countries. We have a moral obligation to do everything we can and our conviction is that we should be able to realize a significant savings by this approach. We’ve already dropped the cost of drugs by going from brand names to generics – we are in the low 90 percent generics now – and there’s not a lot more savings left in that. We’ve been getting more efficient in our use of labs. We’ve focused on these types of efficiencies for a year now. I am humbled and gratified by the mammoth savings we have been able to free up.
Another area of savings is in the care of patients. In our original 15 countries, most of them have moved most of their response from in-patient to out-patient. That alone is a cost savings.
Q: Are you measuring those savings? Do you have specific figures?
A: What’s difficult in our measurement is we’re missing … how much the countries were contributing beforehand. What we’re finding now is many countries’ budgets have dropped for (AIDS) treatment – instead of remaining flat or increasing. It’s not an irrational thing for a minister of health or finance to say, `Since all the bilateral governments are funding AIDS, I’m going to shift money to education.’ But we’ve gotten savvy to it. In our framework discussions with countries now, we want to know how much they will contribute to the effort. We are mutually agreeing they won’t (reduce funding.) It’s not that they are doing something corrupt. It’s usually that that they are responding to an unmet need. But to make these programs as sustainable as we can, we need to hold them steady in their contribution.
Q: What’s your main goal from the Vienna conference?
A: We are at a different moment in our understanding of the need globally for treatment, care and prevention. I think people are realizing how difficult it is to put a prevention strategy in place that sustains a drop in high-risk behavior, not for a day, not a week, but forever. It’s an ephemeral change in behavior we usually see. It’s not sustained. Nobody has done that well for a long period of time. I have been in this almost 30 years, and I am humbled by the prevention challenge still in front of us.
I think the discussion now in this meeting will be more candid, more reflective of that frustration, or our impotence to move it (the infection rate) in the other direction.
I also think there will be an acknowledgment on the treatment end of things that this unmet need is greater than any one country can fill. We are the richest country, we have the ethical obligation to increase our response, but we have to be clear that other countries also need to increase their response – and that includes the countries we’re working in and European countries.
I hope this meeting is the pivotal point to moving toward a shared global responsibility. Every government, every foundation, every multilateral organization needs to look at what they are doing. Are they effective? Are they maximizing benefits from what they spend?
Q: The AIDS Healthcare Foundation recently said that treatment cost per patient in PEPFAR programs is higher than in other programs. It called on the US government to limit administrative overhead for contractors to 10 percent and all indirect costs to 20 percent. What’s your response?
A: Those types of resource constraints need to be on the table for discussion. It doesn’t mean doing this work doesn’t have real costs; they absolutely do. But those costs need to be fair and transparent. We need to find cheaper ways of doing things, but at the same time not to drop the impact or the efficacy of the program we are funding. The Global Fund and PEPFAR showed the world that an aggressive deployment of resources can indeed have a big impact. We’ve proven that this is indeed possible. Now we need to prove we can do it cheaper and do it well.