[Ip-health] Wash Post: AIDS Funding Binds Longevity of Millions to U.S.

[Sarah Rimmington]

[snip] Few experts think that the financial responsibilities, whatever
their magnitude, will end in 2015. As patients live longer they will
take drugs longer, and many will eventually need more expensive ones, too.

Studies suggest that after several years of treatment, about 5 percent
of patients each year become resistant to one or more of their
antiretrovirals. If 8 million people are on treatment by the end of this
decade -- which many experts think is realistic -- about 800,000 will
need "second-line" therapy, which now costs 10 times as much as the
cheapest starting combination. [snip]


AIDS Funding Binds Longevity of Millions to U.S.
Open-Ended Commitment of Money Is Implied
http://www.washingtonpost.com/wp-dyn/content/article/2008/07/25/AR2008072503350.html?hpid=topnews&sub=AR

By David Brown
Washington Post Staff Writer
Saturday, July 26, 2008; A01

President Bush plans to sign a bill next week that commits the United
States to spending about $40 billion over the next five years to fight
AIDS overseas, a major expansion of what many consider his most
successful foreign policy initiative.

The legislation also extends an implicit pledge that has little
precedent in the history of U.S. foreign assistance: to continue
purchasing lifesaving drugs for millions of individual people in
developing countries for an indefinite period of time.

Foreign aid for health care has traditionally been used to put up
buildings, buy equipment and train workers. Direct medical care of
individuals was limited to one-time interventions such as vaccinations,
emergency treatment after natural disasters, and curative treatments of
limited duration for diseases such as tuberculosis or leprosy.

Bush's program is fundamentally different. So far, it has purchased vast
quantities of antiretroviral drugs and supported day-to-day medical care
for more than 1.4 million people whose survival depends on continued
treatment.

"It is the first time I can think of where we have foreign aid treating
a chronic disease," said Michael H. Merson, director of Duke
University's Global Health Institute and a former head of the World
Health Organization's AIDS office. "It's a challenge to take this on. I
think the questions it raises are going to be important ones for the
future."

Once started, AIDS therapy must continue indefinitely, because stopping
it can rapidly lead to death. As a consequence, international health
experts and medical ethicists say it would be immoral to withdraw the
financial assistance that pays for the therapy unless someone else steps
in to replace it.

Although all governments and organizations supporting AIDS patients
overseas have made an implied open-ended commitment, it looms largest
for the United States, which provides about 40 percent of global AIDS
assistance. Few experts say they think the needy countries now getting
help from the United States will be able to fend for themselves anytime
soon.

"We've never really been confronted with this in the international
health arena," said Paul De Lay, a physician formerly with the U.S.
Agency for International Development who is now with UNAIDS, a United
Nations program in Geneva.

The President's Emergency Plan for AIDS Relief (PEPFAR), a surprise
announcement in the 2003 State of the Union address, has spent about $19
billion in the last five years. The president sought to double it to $30
billion in a bill reauthorizing it for another five years, but Congress
trumped him, sending him a larger bill that when it passed on Thursday
authorized the spending of $48 billion -- $39 billion for AIDS and the
rest for other diseases.

The money is provided to governments, charitable organizations and
academic medical centers to buy drugs and equipment, train workers and
run programs. By the administration's estimates, PEPFAR in five years
has provided antiretroviral drug therapy for 1.4 million people;
treatment for 1 million infected women during pregnancy so they are less
likely to transmit the virus to their babies; care for nearly 3 million
AIDS orphans; and 33 million counseling-and-testing sessions.

Although Bush's initiative enjoys support in both parties and has been
praised around the world, some policy experts say the implications of
its open-ended commitment have been largely ignored. A few view PEPFAR
as essentially an open-ended "entitlement program" for citizens of other
countries.

One person with that view is Mead Over, a former World Bank economist
who is now at the Center for Global Development, a Washington think
tank. He fears that if PEPFAR's commitments grow, as they are likely to,
they will squeeze out funding for other, equally important, foreign aid.

He also worries that with such lopsided and personal relationships
between countries, providing life-sustaining care may become a
"strategic resource that will be used, or will be an implicit bargaining
chip, in negotiations." He added that "sovereign countries are likely to
feel quite vulnerable if they perceive that the lives of a substantial
number of their citizens are dependent on the continued largess of a donor."

Over's solution is to spend much more AIDS assistance on prevention
efforts, and to channel money for treatment through international
organizations to spread future obligations among as many donors as possible.

Others, including PEPFAR's director, do not see such problems.

"The notion that this is going to have a harmful effect on our
relationship with other countries in the long term is exactly the
opposite not only of what I believe but of what is being shown," said
Mark R. Dybul, a physician and AIDS researcher who also holds the rank
of ambassador at the State Department, which administers PEPFAR.

Dybul said the program is sowing goodwill at the same time it is
stabilizing AIDS-ravaged countries in a way that will ultimately serve
American interests. The fact that AIDS is a disease requiring lifelong
treatment may even have an unexpected benefit, he says. The AIDS
treatment programs are forcing permanent improvements in medical care --
with spillover benefits for the whole population.

"We are building systems and capacity for country ownership in ways that
has never happened before," Dybul said. "That's real development."

What is certain is that the AIDS-treatment lifeline between rich and
poor countries is growing rapidly. About 3 million people in low- and
middle-income countries are now on the drugs. Five years ago, the number
was 250,000.

As of the end of March, Bush's program was directly underwriting the
care of 1,383,300 AIDS patients. Most were in 15 "target" countries:
Haiti and Guyana in the Americas, Vietnam in Asia, and 12 in sub-Saharan
Africa. The care of another 344,700 people is supported indirectly by
money going to improve laboratories, information systems, logistics and
other improvements of health-care delivery.

The other big funder is the Global Fund to Fight AIDS, Tuberculosis and
Malaria, an independent organization in Geneva that gets money from rich
countries, foundations and individuals, and awards it to approved
programs in low-income ones. As of last December, the fund was
underwriting treatment of 1.4 million AIDS patients, more than twice as
many as the year before.

The expanded U.S. program aims to have 3 million people on
antiretroviral AIDS treatment by 2015. Both the U.N. General Assembly
and the Group of Eight industrialized countries are on record as
supporting "universal access" to AIDS treatment, defined as providing
treatment to 80 percent of those who need it. That would mean 18.6
million people on daily AIDS drugs by 2015, according to an estimate by
UNAIDS.

The cost is huge, even considering the recent steep decline in the price
of AIDS drugs. By 2015, the price tag for "universal access" to AIDS
treatment would be $19 billion a year.

When the full package of prevention services, aid to orphans, and
"health systems building" is added in, the global bill for AIDS services
in the developing world will be $50 billion a year. Two-thirds of that
money will have to come from rich countries. This compares with $110
billion spent last year for all foreign aid by all countries of the
world, of which about $10 billion went for AIDS.

Few experts think that the financial responsibilities, whatever their
magnitude, will end in 2015. As patients live longer they will take
drugs longer, and many will eventually need more expensive ones, too.

Studies suggest that after several years of treatment, about 5 percent
of patients each year become resistant to one or more of their
antiretrovirals. If 8 million people are on treatment by the end of this
decade -- which many experts think is realistic -- about 800,000 will
need "second-line" therapy, which now costs 10 times as much as the
cheapest starting combination.

Although there is debate in the global health community about whether
programs are obliged to switch all failing patients to second-line
treatment, or even third-line "salvage" therapies, everyone agrees that
first-line treatment can never be stopped.

"The train is out of the station. People who are on treatment -- we
can't drop them, if for no other reasons than ethical ones," said Peter
Piot, the Belgian physician who heads UNAIDS.

The Global Fund already recognizes that treatment, once started, is
essentially an irrevocable entitlement. If the fund cancels a country's
AIDS grant for reasons of graft or incompetence, it promises to find a
way for patients already on antiretroviral therapy to stay on without
interruption.

Nevertheless, some experts think AIDS-treatment programs are not so
different from other forms of foreign aid. Their obligations are just
more obvious.

Dean T. Jamison, a health economist at the University of California at
San Francisco, recalled recently that when he worked at the World Bank
in the 1970s, Robert S. McNamara, the bank's president, required that
staff overseeing projects in Africa demonstrate in writing how the
recipient countries would shoulder the responsibility after five years.

Jamison said he and his colleagues dutifully complied, making up rosy
economic scenarios that none of them believed. Privately, they all knew
that whenever they drew up an assistance project, "we were putting
together a set of implicit financial commitments that were likely to
last for decades," he said.

And they have.

--
Sarah Rimmington
Attorney
Essential Action, Access to Medicines Project
Washington, DC
Tel: (202) 387-8030
Cell: (202) 422-2687
www.essentialaction.org/access/