Lack of funding threatens the future of HIV drug therapy in the developing world

By David Brown
Washington Post Staff Writer
Thursday, July 29, 2010

Ten years ago, many experts thought you couldn't bring antiretroviral therapy to people with AIDS in poor countries. The drugs cost too much, there weren't enough doctors, the patients wouldn't take the medicines correctly, and the risk of creating a resistant virus was too high.

None of that turned out to be true. About 5.2 million people with HIV infections are on lifesaving treatment in low- and middle-income countries. In sub-Saharan Africa, antiretroviral therapy, much of it paid for by the U.S. government, is resurrecting whole communities.

But the world is facing a potentially more intractable problem: the price of success.

There's barely enough money to pay for people whose treatment is underway and who will need it for a lifetime. There isn't enough to start treatment for about 5 million more who urgently need it.

Those new concerns about costs dominated the 18th International AIDS Conference, which drew 19,300 participants from 193 countries to Vienna last week.

"If I were to characterize the mood here, I would say it was a combination of rage and panic," said Joanne Carter, director of the anti-poverty group Results and a board member of the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The rage is directed at the Obama administration, which many activists say is reneging on a commitment to continue big annual increases in global AIDS spending. The panic arises from the knowledge that in some African countries, patients who want antiretroviral treatment are being turned away and will soon start dying.

Some activists pine for former president George W. Bush, who launched a much-praised multibillion-dollar fund to fight AIDS around the world. But now, in the eyes of many, the U.S. government has replaced the pharmaceutical industry as the main impediment to progress.

"The paradox is that the United States government and other funding partners have decided to either flat-line or reduce their spending just when funding should be ramped up so we could actually win the battle," said Paul Zeitz, director of the Global AIDS Alliance.

U.S. overseas AIDS funding is part of the Global Health Initiative (GHI), the Obama administration's $63 billion, six-year program. The portion devoted to HIV and tuberculosis, an infection to which AIDS patients are particularly prone, is $44 billion. The rest goes to malaria, maternal and child-health programs, and the hard-to-define goal of "health systems strengthening." Although larger than Bush's revolutionary President's Emergency Plan for AIDS Relief (PEPFAR), Obama's GHI is spread across more agencies. It is less a bullet aimed at the heart of AIDS than a net cast to capture a flock of health problems.

"What it takes to save lives of those with HIV and those most at risk to contract it is a comprehensive approach that recognizes the roles of other diseases," Gayle Smith, Obama's special assistant for development and democracy, wrote on the White House blog last week.

An unmet need

AIDS activists say nobody should doubt that the need for treatment among the 33.4 million people infected with HIV globally is urgent and largely unmet.

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