President 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.?
?The 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.
?At 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.
Over, 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.
Over 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.
As 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.
But 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
?The 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.
He 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.?
He 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.
?For 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 ?prescribing?
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.
?Thailand 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.?
While 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.?
?I?d 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 forthcoming.?
Over 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 treatment
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 government?s support.?
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 caregiver.
. 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 treatment.?
Reduce cost of medicines
Over says the new president must dedicate himself towards reducing the costs of ?prohibitively expensive? HIV medication.
The 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.
?Adherence is very difficult with regard to antiretroviral medication,? Over says.
If 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.
?If 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 takes over.?
What happens then is that the drug that used to be inexpensive and very effective, no longer works.
?If 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.?
Over 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.?
Nevertheless, 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.?
That?s 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.
?If, 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 commitment.