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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; A10

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.

The United Nations agency UNAIDS estimates that $23.6 billion was needed to address the epidemic in low- and middle-income countries last year. Yet only $15.9 billion was available from all sources, public and private. The U.S. government provided 27 percent of that money, mostly through PEPFAR, which Bush started in 2003 with a then-staggering commitment to spend $15 billion on prevention and treatment over five years.

The United States has been by far the biggest donor of money for AIDS treatment to the world's poor, last year providing 58 percent of the $7.6 billion given by governments. Britain, a distant second, gave 10 percent of the total. Japan, with the world's third-largest economy, contributed 2 percent.

This international AIDS assistance has climbed steadily from $1.2 billion in 2002 to last year's $7.6 billion. The cost of treating someone with HIV infection has fallen even more dramatically. In 2000, three-drug antiretroviral therapy cost about $10,000 a year. With concessionary pricing and the use of generics, it's now $120 for the world's poorest patients.

The trouble, activists say, is that the big gains in generosity and economizing have mostly stopped. International AIDS assistance was the same in 2008 and 2009, and is not expected to go up much, if any, this year. The White House request for global AIDS spending for the next fiscal year is only 2 percent higher than what is being spent this year.

Although there's argument about the exact numbers, there's little doubt the Obama administration is on track to spend less than planned by either the GHI or the Lantos-Hyde Act of 2008, which renewed PEPFAR and authorized spending $48 billion from 2009 through 2013. Many other donor countries are taking a similar go-slower approach.

A matter of principle

Still, the need to increase AIDS treatment in those places is a matter of principle, the activists say. They note that Obama supported the Lantos-Hyde Act as a senator and campaigned on a promise of increasing overseas AIDS spending.

"Bush made a commitment, and then circumstances changed. Despite the change, he kept his word," said Zeitz of the Global AIDS Alliance.

Many AIDS experts and activists also argue that treatment is an important prevention tool. That's because when a person is successfully on antiretroviral therapy, HIV virtually disappears from body fluids, greatly reducing the possibility that the patient will infect others.

The GHI "recognizes that we can't treat our way out of the HIV-AIDS epidemic," Ezekiel J. Emanuel, the president's special adviser for health policy, wrote in the Huffington Post during the conference in Vienna. "The key to ending it is to reduce the number of those who become HIV-positive in the long term -- and that takes improving their overall health and the health systems around them."

Word of the funding constraints is reaching villages and clinics.

A letter sent in October from the Centers for Disease Control and Prevention instructed PEPFAR partners in Uganda that they "should only enroll new patients if they are sure that these new patients can continue to be supported without a future increase in funding." Carter, the Global Fund board member, said she met a woman at the AIDS conference who works in that country and testified to the reappearance of things not seen in years.

"She is starting to see people die because they don't have access to antiretrovirals. She is also seeing people sharing medicines," Carter said. "The fact is, this crisis isn't looming. It's happening."

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