George W. Bush’s administration has in recent years won widespread
international praise for its efforts to prevent AIDS and treat people infected
with HIV. Health workers expect the new American president to continue, and
even expand, these initiatives. International health economist Mead Over
advises the next administration in Washington to modify the current US strategy
to provide AIDS relief to many in the developing world from an “Emergency Plan”
to what he terms a “sustainable policy.”
next president will inherit a program (the President’s Emergency Plan for AIDS
Relief, PEPFAR) that in some respects has been extraordinarily successful,”
says Mead Over, a senior fellow at the Center for Global Development think tank
in Washington, D.C.
the beginning of PEPFAR, there were only a few thousand people on AIDS
treatment in the whole world. (But the program) has managed to increase the
number of people [on treatment in 13 African nations and in two countries
outside Africa] by almost three million people. That’s an extraordinary
achievement,” he says.
a former World Bank specialist, concentrates on issues related to the economics
of efficient, effective and cost-effective health interventions in developing
countries and is the author of several books on the subject. He’s also an
expert in the field of HIV/AIDS and is intensively researching health service
delivery in poor countries around the globe, especially in Africa.
says with about 33 million people in 147 countries living with HIV/AIDS, mainly
in sub-Saharan Africa, the new president will have to prioritize the epidemic
in his foreign policy approach.
He points out that PEPFAR
can properly be described as the “largest global health initiative directed at a single disease
that any nation has ever undertaken.” Many analysts have called it Mr. Bush’s
greatest foreign policy success.
a result of PEPFAR, says Over, the United States is today the largest single
contributor in the response to the international AIDS epidemic, giving billions
of dollars to such efforts and providing life-prolonging antiretroviral
medicines to more than a million people in Africa alone. The plan has also provided care and support
for orphans and other vulnerable children, and its officials say it’s prevented
many cases of HIV infection.
Over maintains the new man in the White House will have the opportunity of
ensuring that the US response to the global AIDS pandemic is “even better.”
‘Rigorous evaluation’ needed
biggest challenge for the next president will be to make sure that the quality
and the sustainability of the treatment is maintained, but at the same time he
must try to strengthen the prevention effort,” Over argues.
says PEPFAR’s claims about the high number of HIV infections it’s prevented and
the number of orphans, widows and other vulnerable people that it’s cared for are
“dramatic” but also “hard to substantiate, especially the prevention claims.”
explains that current US AIDS policy charges Washington with preventing a
certain number of HIV infections each year, yet it remains unclear exactly how
these preventions are counted. PEPFAR’s success in terms of preventing new HIV
infections remains “hazy,” says Over.
example, suppose that I am prevented from getting infected every day, 365 days
(of the year). So is that 365 infections prevented or only one? (PEPFAR’s) not
clear on that and the statistical message for accounting for prevention doesn’t
allow for the distinction between those two, and those are radically different
measures of success.”
Over maintains that the new president must ensure
that “concrete goals” are set in terms of the number of infections US efforts
are to prevent each year.
In a recent paper, Over writes, “It is depressing and even
scandalous that after more than twenty years of donor-funded (HIV) prevention
efforts, so few prevention interventions have been rigorously evaluated.”
He continues, “The US
government has funded a great many innovative and in some cases very successful
prevention efforts. But the problem is that most prevention has been operated
on a very small scale, small boutique operations in small groups of intravenous
drug users or sex workers, which have achieved substantial success but have
been swamped by the ongoing epidemic around them.”
Over says the new US
administration must make a more sustained effort to count all HIV infections in
PEPFAR countries and to establish the “hot spots where the most infections are
being generated” - such as at truck stops in
Africa where sex workers and long-distance freight drivers interact.
“There has been no country in Africa that has
attempted that…sort of universal coverage…and the US government should take the
lead in leading countries to that kind of ambitious effort,” Over advises.
The health economist says without
“behavioral data” about people who indulge in behavior that is considered at
“high-risk” of contracting HIV, “it’s difficult for countries and donors to
know what specific factors are driving each epidemic, and what particular
interventions would be the most successful for each country in preventing
further spread of HIV.”
Over’s convinced that only
through “rigorous evaluation” will the new administration by able to “see
what’s really working” in the fight against AIDS, and he says the next
president must take the lead in making sure this happens.
Advance new HIV prevention methods; stop
Over points out that despite PEPFAR’s achievements,
about 1.4 million people in the program’s focus countries continue to be
infected with HIV each year.
He says several new methods debated by some scientists
as being successful in preventing HIV infection offer hope for the future and
should be “enhanced” by Washington.
“The evidence on male
circumcision is very promising. The AIDS community, with the support of the
administration in the next presidency, should move as fast as possible to
expand the availability of male circumcision, and to make sure than any country
or any region of a country that would like to expand that practice can do so.”
But he emphasizes that new methods “aren’t the only
way to go” in terms of improving HIV prevention efforts.
“The most important thing
to do is to have every single municipality of any substantial size, in
countries that have a serious AIDS epidemic, be charged and be really
accountable for assuring 100 per cent coverage of prevention programs in all of
the places in the whole municipality where people might meet in order to form
(sexual) partnerships,” Over explains.
“Every bar, every marketplace, every single hotel
and guest house should have access to prevention messages and to condoms. And
there’s been no attempt to even move slightly in that direction….The absence of that in Africa needs to be addressed
by the next presidency.”
Over says Africa, through US leadership, should
follow the “prevention example” set by certain other countries.
stands out as a country which did in the 1980s adopt the goal of 100 per cent
coverage of every hot spot and brothel in the country and they achieved that
goal and largely eliminated the threat of a catastrophic AIDS epidemic.
Cambodia shows great progress in that same direction, and Brazil has adopted as
a national objective to have thorough coverage of the high risk areas and
behavior in the country.”
Over agrees that PEPFAR’s major achievement has been the provision of essential
medicines to HIV-positive people, he also says the criticism of the plan’s
emphasis on encouraging abstinence from sex and faithfulness to partners as
primary methods of preventing new infections is “valid.”
like to see the US government and all donors step away from prescribing exactly
what should be done to reduce the rate of new infections, towards an
alternative objective, which is to simply reduce them,” he says. “Countries
should be charged with first of all measuring the number of new infections that
occur each year, and then once those measurements are made, then the countries
should be rewarded for reducing that number of infections. And for every
reduction of 10 per cent, there should be a certain amount of money that is
continues that it should be “up to (each) country to decide what proportion of
their effort should be based on very short run, targeted, highly effective
interventions – like condoms – and longer run but also useful interventions
like girl’s education in secondary school.”
‘Impossible’ for the US to scale back HIV
Over is just one of many
commentators concerned about the possible impact of the present financial
crisis in the US on the country’s ability to provide essential aid to those in
need. But he’s convinced that no matter how bad the economic problems in the US
become, the new president will be compelled to continue funding PEPFAR’s
provision of AIDS medicines to HIV-positive Africans and others.
“I believe it’s the first
time in history that US foreign assistance – or any foreign assistance from any
foreign country – has become engaged in an international program from which it
can not easily back out,” Over asserts.
He describes PEPFAR as an
“altruistic program” of US foreign assistance “designed to help desperately ill
people and their families, and to prevent orphan-hood by keeping parents alive.
And it’s an extremely valuable and praiseworthy program for those reasons.”
But he warns in his paper that the “potential
for several serious failures lies hidden within this apparent success. If the
U.S. is seen to renege on its implied commitment to existing AIDS patients or
if it is thought to have allowed treatment quality to degrade over time, (and)
failed to prevent new cases of HIV infection from swelling the ranks of those
needing treatment…President Bush’s initial success will metamorphose before our
eyes into a deadly and shameful example of overreaching American incompetence –
to be blamed inevitably on the new president.”
PEPFAR, says Over, has
created an “international entitlement” – countries that benefit from the plan now
“justifiably” feel “entitled” to it.
“When I use the term
‘entitlement’ for PEPFAR, some people might think it’s a bit of a stretch. But
I think it applies to PEPFAR, and the reason is that if the US government were
to stop treating people who are currently on treatment, those people would die
within a few months. There are now two to three million people out there whose
very [lives] from month to month depends on the continuation of the US
If the US cuts funding to
PEPFAR’s treatment component, says Over, and people begin dying because of
this, America will suffer immense damage to its reputation as an international
“…. The reputation danger to
the US is so great that the US cannot pull out of those (treatment) programs
and must continue funding those programs…. I think AIDS treatment will not be
cut,” he states. “Possibly the rate of growth of AIDS treatment will slow, and
perhaps of HIV prevention, but if the cuts to the foreign assistance budget are
dramatic, the one area that I hope that the US president will be forced to
protect because of this reputation danger to the United States and because of
the ethical consequences of cutting people off of treatment, will be AIDS
Reduce cost of medicines
says the new president must dedicate himself towards reducing the costs of
“prohibitively expensive” HIV medication.
first step that must be taken in this regard, he argues, is that HIV-positive
people must be supported as they try to follow the strict regimen necessary
when taking antiretroviral medicines.
is very difficult with regard to antiretroviral medication,” Over says.
the medicine is to be effective, patients must take a pill twice a day – and
sometimes multiple pills at multiple times. It’s extremely important that the
medication is taken at exactly the hour that the doctor has prescribed.
you vary from that by even an hour or two, the problem is that HIV is very
clever and it will essentially evade the defenses that are set up in your
system by that antiretroviral medication. And when it evades that medication,
it means that it becomes resistant to the drug,” Over explains. “And then the
resistant form of the virus actually multiplies inside the patient’s body and
happens then is that the drug that used to be inexpensive and very effective,
no longer works.
the patient is to survive, he or she must then move to what’s called a ‘second
line’ drug treatment. Now the first line drugs cost from $100 to $300 a year,
depending on the country – but the second-line drugs can cost up to $10,000 a
year, depending on the country. So the cost implications of moving to the
second-line treatment are very, very large.”
therefore advises that the “very first thing” the next president should do is
to “ensure that the quality of treatment is such that people stay on first-line
treatment as long as they can.”
he says, very few people are capable of staying on first-line therapy “forever.
It’s very difficult for a patient to adhere perfectly for decades and so after
a certain number of years, most patients usually fail first-line treatment and
must move to second-line drugs.”
when another opportunity arises for the new president to decrease costs of HIV
medicines, Over maintains. He wants the next US administration to “engage” with
pharmaceutical companies and the US National Institutes of Health “to bring
down the costs of second-line drugs. And if those second-line drugs can be
brought down from thousands of dollars a year, down to a few hundred dollars a
year, it will greatly reduce the cost of the program.”
Over remains optimistic that the next administration
can prevent “worst case scenarios”
pertaining to its efforts in the field of HIV/AIDS.
in the existing fifteen PEPFAR focus countries, the next government can
effectively manage the current AIDS treatment entitlement, prevent the future
need for treatment, and help ensure the AIDS transition to the point that the
disease becomes a manageable chronic condition, the next president will deserve
a full measure of credit for the long-run benefits of PEPFAR – credit equal to
or greater than that due to President Bush for launching the program.”
Over acknowledges a “tall order” will confront the next
president, but he’s convinced it’s “entirely possible” through heightened