Evidence grows: Global Fund financial slack and proposed cuts to PEPFAR are hurting progress against AIDS

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Report:  Without continued support for PEPFAR, HIV’s long-term human and economic burdens will be substantially greater

The Foundation for AIDS Research (amfAR) released a memorandum Friday that makes the case for continued funding for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program at least at fiscal year (FY) 2012 funding levels.

The piece comes in response to President Obama’s budget request to Congress for FY 2013, which calls for a $562.9 million cut to the program, which would be the first reduction in U.S. contributions to bilateral AIDS in history.  The more than 12 percent cut would be inconsistent with the Obama Administration’s stated goal of achieving an “AIDS-free Generation,” which President Obama augmented by setting a goal of putting 6 million people on lifesaving antiretroviral therapy by the end of 2013 – a scale up of 2 million people from 2011 numbers.

A key point in the brief, the PEPFAR program’s new strategy for an AIDS-free generation aims “to significantly reduce the rate of new HIV infections while lowering the future cost curve for the HIV response,” by supporting the accelerated scale up of three key interventions::

    • Antiretroviral therapy (ART):  Recent models have shown costs associated with ART “programs in developing countries result in economic returns of 87 percent to 287 percent in the form of increased labor productivity, averted orphan care, and averted or deferred medical care,” meaning it will eventually cost more not to provide treatment than to continue to scale up treatment programs, according to amfAR.
    • Adult voluntary medical male circumcision: “Achieving 80 percent coverage of adult male circumcision by 2015 would avert more than 20% of new HIV infections in high-prevalence countries by 2025 and save an estimated $16.6 billion in future medical costs,” according to the report.
    • Prevention of mother-to-child transmission of HIV (PMTCT): Analyses consistently confirm that this intervention is highly cost effective if not cost saving.
Chart demonstrating that, according to UNAIDS modeling, strategic allocation of resources along the lines of the PEPFAR strategy for an AIDS-free generation would lead to a reduction in new HIV infections. (Source: Scwartlander et al, Lancet, 2011)

Through expedited expansion of these and other high-value, high-impact strategies, amfAR argues, PEPFAR can minimize the economic burden of the pandemic and modelers at UNAIDS anticipate that strategic allocation of resources along these lines would enable annual HIV related costs to begin to decline by 2016.

AmfAR sent the report to a targeted list of congressional leaders with jurisdiction over PEPFAR or the appropriations committees that fund it – including the offices of Reps. Kay Granger (R-TX) and Nita Lowey (D-NY), the chair and ranking member of the House State& Foreign Operations Subcommittee respectively; and Sens. Patrick Leahy (D-VT) and Lindsey Graham (R-SC), chair and ranking member of the Senate Appropriations subcommittee on the Department of State and Foreign Operations.

“Though the White House insists the U.S. can still achieve its treatment and prevention targets set by the president in December 2011, it is inevitable that PEPFAR program managers, faced with seriously diminished resources and ambitious targets in a few specific areas, will reduce services for which there are no specific goals,” according to the amfAR memo.

Evidence is surfacing to support that statement. The HIV/AIDS funding summaries of the Department of State Congressional Budget Justification for Foreign Operations – which lay out how the president’s proposed budget cuts will play out in individual countries – show some are slated for some dramatic funding reductions in fiscal year (FY) 2013 as compared to funding enacted for  FY 2012 (See Chart), even those with high HIV prevalence. 

Per the justification document, funding in FY 2013 for Mozambique – a country with more than 11 percent HIV prevalence among adults and more than 1.6 million people living with the virus – is set to be cut by 18 percent.

The World Health Organization reported in 2007 that Mozambique has only three medical doctors and 21 nurses per 100,000 people, and 30 social workers at the central level. “This shortage reflects one of the most dire health personnel shortages in the world and an enormous demand on a weak system,” according to PEPFAR’s 2011 executive summary on the country. “In addition, weak infrastructures, commodity and procurement insecurity, poor monitoring and evaluation, management and financial systems to support the national HIV response present significant challenges in reversing trends in HIV prevalence in the country and providing much needed quality services.” The proposed cut to PEPFAR support would only further that trend.

The Democratic Republic of Congo (DRC)
A recent report by Medicines Sans Frontieres (MSF) describes how shortages at The Global Fund to Fight AIDS, Tuberculosis and Malaria and PEPFAR are already jeopardizing the fight against HIV and TB in the DRC.

“There are 15,000 people currently wait-listed for HIV treatment because funding shortfalls led to a cap on the number of new treatment slots (only 2,000 in 2011),” according to the MSF report, which also says that treatment targets have been reduced from 82,000 people to 54,000 on treatment by the end of 2014. Approximately 1 million people are living with HIV in the DRC. Although 350,000 are in need of treatment only 15 percent of those have access to it, and only one percent of HIV-infected mothers have access to treatment to prevent transmission to their babies, according to MSF.

The justification document shows a proposed increase in funding for the DRC of 37 percent, or $12.6 million dollars. However, when comparing the proposed allocation for FY 12 ($58.8 million) with what was actually appropriated that year ($33.8 million), it is too early to hedge any bets on increases headed the DRC’s way. 

In the U.S. State Department’s blog DipNote, U.S. Global AIDS Ambassador Eric Goosby wrote that they are reassessing their financial levels of support in countries with either low HIV prevalence or that have other resources available. “For example, we are freeing up resources by reducing programs in lower HIV prevalence countries like Ethiopia, and are eliminating support to countries like Russia (which has stated its intention to become a donor country),” according to the blog post. The Department of State budget justification document puts Ethiopia in line to receive a 79 percent funding decrease in 2013 from 2012 funding levels, and Russia’s proposed funding is not listed.

Advocates are also concerned about future funding for Kenya, where the treatment target may be as much as 100,000 additional people, according to an email sent to Ambassador Goosby from Health Global Access Project (GAP) advocates in response to the PEPFAR Country Operation Plans, which are being reviewed at the Office of the Global AIDS Coordinator this week. The Health GAP email highlights that Kenya’s treatment scale up agenda is less than the accelerated pace that modeling from the U.S. Centers for Disease Control and Prevention recommend as a cost-effective strategy that would reverse the epidemic. “The massive proposed funding cut has already slowed the National AIDS and STI Control Program’s plans to eradicate mother-to-child transmission by offering lifelong ARVs to all pregnant women,” according to the email.

“Kenya is an example of a mature program focused on sustainable country systems for program implementation and building up the capacity of local implementers,” writes Goosby in the DipNote blog.  “As a result, we are able to adjust Kenya funding to better match its capacity to absorb funds through these new mechanisms,” as is reflected in the budget justification, which shows the Kenya program is slated for a 40 percent decrease in FY 2013.

The MSF report, however, says that this cut goes against the joint agreement between PEPFAR and the Kenyan Government Partnership Framework – which specifies a joint target of 80 percent coverage of antiretroviral therapy (ART), HIV testing and prevention of mother-to-child transmission (PMTCT) by 2013. Currently only 61 percent of those in need of treatment in the country have access to it. “…Instead of increasing treatment slots, the same number of people will be enrolled on ART in 2012 as were in 2011, with uncertain predictions for scale up in 2013,” according to the MSF report, and this is before considering the proposed decrease to come in 2013.

One thought on “Evidence grows: Global Fund financial slack and proposed cuts to PEPFAR are hurting progress against AIDS

  1. Pingback: Evidence grows: Global Fund financial slack and proposed cuts to PEPFAR are hurting progress against AIDS | Knowledge of Medicine

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