[Ip-health] Wall Street Journal: War on AIDS Hangs in Balance as U.S. Curbs Help for Africa

[Thiru Balasubramaniam]

<SNIP>

Seven years after the U.S. launched its widely hailed program to fight
AIDS in the developing world, the battle is reaching a critical
turning point. The growth in U.S. funding, which underwrites nearly
half the world's AIDS relief, has slowed dramatically. At the same
time, the number of people requiring treatment has skyrocketed.

<SNIP>

The most immediate concern is getting enough lifesaving drugs to all
those who need them. Under the Bush administration, the President's
Emergency Plan for AIDS Relief, or Pepfar, set aggressive goals for
getting people with HIV, the virus that causes AIDS, into drug
therapy, eventually enrolling some 2.4 million by the end of last
year. The Obama administration, which plans to expand international
AIDS treatment to at least 4 million by 2013, nevertheless has
signaled nearly flat budgets through fiscal 2011. Critics are
questioning whether the reduced spending pace means the administration
doesn't plan to use the full $48 billion authorized by Congress by 2013.

<SNIP>

Eric Goosby, President Obama's AIDS czar, said the president is
committed to the AIDS fight despite the global economic decline,
adding that the U.S. doesn't intend to turn away anybody who needs
treatment: "Our commitment to universal coverage hasn't wavered."

The challenge is enormous. Some 33. 4 million people worldwide have
HIV, and under new guidelines by the World Health Organization, the
number eligible for treatment has grown to 14 million, dwarfing the 4
million in treatment currently. Another 2.7 million people become
infected each year. Those who don't die first will eventually need to
take antiretroviral drugs, a mixture of medications that helps the
body suppress the disease and must be taken every day for life. The
therapy, which doesn't cure AIDS but allows people with HIV to live
normal lives, means the number of people who need drugs will continue
to grow.


---------------------------------


     *JANUARY 30, 2010

War on AIDS Hangs in Balance as U.S. Curbs Help for Africa

By MICHAEL ALLEN

KAMPALA, Uganda=97Ninsiima Agatha, a 20-year-old mother of two, showed
up at a medical clinic here last month, weak, coughing, and desperate
to save herself and her two children. She had just discovered that her
husband was infected with HIV=97and now she had the virus too. If she
didn't get access to life-saving drugs quickly, she could easily pass
the disease to the baby she was breast-feeding.

But the staff at the Joint Clinical Research Centre had to tell her
the bad news. Even though her husband, a clothes merchant with a
girlfriend on the side, was already receiving the so-called AIDS
cocktail of drugs elsewhere, there would be none for her. The clinic
had enrolled its full quota of patients under its contract with the
U.S. government. Ms. Agatha, sprawled on a hospital bed with a toddler
and an infant, could barely move. "I feel desperate," she said.

Seven years after the U.S. launched its widely hailed program to fight
AIDS in the developing world, the battle is reaching a critical
turning point. The growth in U.S. funding, which underwrites nearly
half the world's AIDS relief, has slowed dramatically. At the same
time, the number of people requiring treatment has skyrocketed.

And lately, the global campaign to prevent new infections has suffered
some reversals. In Uganda, a lush East-African country that once stood
out as a shining star in the fight against AIDS, the rate of HIV in
the population has begun to tick up again after a long decline. That's
putting an even greater strain on a health system that's struggling to
cope with the hundreds of thousands who already have the disease and
could be a harbinger of what's to come in the rest of Africa.

"I personally worry that Uganda showed the way on how best to fight
the disease and now is in danger of showing how to lose the fight,"
says Dr. David Serwadda, a professor at Makerere University School of
Public Health in Kampala and a pioneer in researching the origins of
the AIDS epidemic.

The most immediate concern is getting enough lifesaving drugs to all
those who need them. Under the Bush administration, the President's
Emergency Plan for AIDS Relief, or Pepfar, set aggressive goals for
getting people with HIV, the virus that causes AIDS, into drug
therapy, eventually enrolling some 2.4 million by the end of last
year. The Obama administration, which plans to expand international
AIDS treatment to at least 4 million by 2013, nevertheless has
signaled nearly flat budgets through fiscal 2011. Critics are
questioning whether the reduced spending pace means the administration
doesn't plan to use the full $48 billion authorized by Congress by 2013.

"Unless the promised funding is forthcoming soon we will see an
absolute disaster in the next year or so," says Shepherd Smith, a
longtime Christian activist for HIV issues in Africa. "The human
tragedy that is nearly upon us is significant and I believe will be a
huge disservice to the people of the United States because we will be
unable to keep humanitarian commitments we have made."

Eric Goosby, President Obama's AIDS czar, said the president is
committed to the AIDS fight despite the global economic decline,
adding that the U.S. doesn't intend to turn away anybody who needs
treatment: "Our commitment to universal coverage hasn't wavered."

The challenge is enormous. Some 33. 4 million people worldwide have
HIV, and under new guidelines by the World Health Organization, the
number eligible for treatment has grown to 14 million, dwarfing the 4
million in treatment currently. Another 2.7 million people become
infected each year. Those who don't die first will eventually need to
take antiretroviral drugs, a mixture of medications that helps the
body suppress the disease and must be taken every day for life. The
therapy, which doesn't cure AIDS but allows people with HIV to live
normal lives, means the number of people who need drugs will continue
to grow.

One irony is that lifesaving medicine makes the prevention message
harder to deliver. That much is clear in Uganda, once a leader in
preventing the spread of HIV.

In the 1980s, long before foreign aid groups arrived on the scene,
President Yoweri Museveni grasped the seriousness of the disease,
known as "slim" for its debilitating effects. He made it his personal
mission to mobilize the country. At the time, there was no known
treatment for AIDS, which at its peak infected around one in five
Ugandan adults.

The government's message was simple, delivered relentlessly on radio
to the sound of beating drums: AIDS kills. In 1988, Ugandan music
sensation Philly Lutaaya announced he had AIDS and spent his final
days, gaunt and ridden with sores, touring the country to raise
awareness.

The solution was a homegrown remedy that came to be known by its
shorthand, ABC. The only escape, went the government message, was to
practice abstinence until marriage and to be faithful afterwards=97and
if all else failed, to use condoms. The prevalence of AIDS eventually
fell to around 6% of the adult population, and ABC was soon in use in
much of Africa.

But over time, Ugandans agree, they let down their guard. Some here
say it was only natural for President Museveni to declare mission
accomplished and move on to other pressing needs. Others say
ideological battles in Washington played a role. U.S. congressmen
quarreled over how much of the growing AIDS budget should be allocated
to preaching abstinence and fidelity and how much to condom use.
Nongovernmental organizations here that were accustomed to advocating
a range of prevention options say they sometimes felt paralyzed.

But the biggest distraction from prevention was likely the sudden
flood of lifesaving drugs beginning in 2005. Fear of HIV dissipated as
memories faded about the disease's ravages. People gradually increased
their number of sexual partners again. "Women are now more scared of
getting pregnant than getting AIDS," says researcher Phoebe Kajubi,
who conducted a survey in a poor area of Kampala funded by the AIDS
Prevention Research Project at Harvard University.

"People think that when they get [anti-retrovirals] they get cured of
HIV," says Joseph Lubega, a 30-year-old electrical engineer-turned
AIDS activist. His cubbyhole office is crammed with tens of thousands
of free condoms that go unclaimed. "People aren't using condoms like
they used to."

The result: New infections have begun to jump again, to around 135,000
per year, and prevalence is believed to be approaching 7%.
[UGANDA]

"Really we took our eyes off of prevention and focused on treatment
and care," says Dr. David Kihumuro Apuuli, director general of the
Uganda AIDS Commission.

The increased infection rate is putting a heavy burden on health-care
providers such as JCRC, one of the preeminent research and care
facilities in the country. As one of the early recipients of Pepfar
money, JCRC aggressively enrolled people, swelling to 32,000, and
hitting the limits of its contract even during the Bush
administration. The campus has tents set up to handle the overflow of
patients, and now sees over 300 people every day. It routinely turns
away new enrollees now.

"The dilemma here is that we made a promise to patients=97if they came
here for HIV care, we said if you qualify for treatment, you'll get
treatment," says Dr. Fiona Kalinda, clinical manager. "Now we have to
tell them to go elsewhere."

In the case of Ninsiima Agatha, turned away last month by JCRC, no
other clinic would take her on. And the news soon got worse.

Dr. Peter Mugyenyi, JCRC's founder, says he just learned that Ms.
Agatha's older child, an 18-month-old girl named Natero Mariam, died
on Jan. 7 of AIDS, despite receiving drug treatment funded by the
Clinton Foundation. Defying instructions from the U.S. not to add new
enrollees, Dr. Mugyenyi says he's decided to begin dispensing drugs to
the mother so that her remaining child, two-month-old Anisha Nabuuma,
doesn't also catch HIV through breast milk.

"The cheapest way to save the child is to treat the mother. In the
process the mother's life will be saved too," he says. "Without doing
this my conscience would be haunted."

Meanwhile, he's still trying "desperately" to find spots at other
facilities for 82 women he can't accept into treatment. What's more,
clinic doctors have detected disturbing cases of patients who are
already on medication who are sharing their supplies with partners who
can't enroll, In those cases, each patient gets too little medicine,
raising fears that the practice could spawn HIV strains that are
resistant to ARVs. "What's going on is terrible," he says.

At Catholic Relief Services, another big treatment provider, officials
say they stopped taking all but a few new patients a year ago in
Uganda. Jack Norman, country representative, says blocking new
patients from drugs encourages the disease to spread. For one thing,
people on ARVS are less contagious. "No drugs means no hope; people
don't get tested and they run around and infect other people," he
says. "It's a very dangerous cycle."

In theory, the Ugandan government will eventually take greater control
over treatment, as more doctors and nurses get trained under U.S.-led
programs. But that day is clearly far off. Last year, the U.S.
provided $285 million toward Uganda's HIV/AIDS prevention and
treatment efforts, or about 70% of the country's budget.

In many parts of the country, poverty is the biggest enemy. In the
dirt-poor northeast, Amuria district health officer Dr. Eumu Silver
makes the two-hour trek himself to tend to the people in one village
because he can't find anybody else to take the job. The region has
been beset by war, cattle rustlers and now an entrenched drought.
Herded into refugee camps, people spread the AIDS virus like wildfire.
About 350 are currently on treatment, but Dr. Eumu figures as many as
600 are sick enough to qualify=97if the single testing machine in the
nearest big town weren't constantly on the fritz.

At a recent gathering in a village, people with HIV made known their
needs. For one man, it was simple: He wanted a bit of porridge to take
with his medicine, because it's hard to absorb on an empty stomach.

Back in Kampala, another drama was unfolding. Eve Nakitto, a 23-year-
old woman with a 5-year-old daughter, had been diagnosed with HIV a
month earlier and had sought treatment at Family Hope Centres, a
facility run by the U.S.-based Children's AIDS Fund. The clinic didn't
have any slots available and sent her to find treatment at one of a
number of government facilities that theoretically had openings. But
after seeking help for a month=97including lining up for four straight
days at one facility to no avail=97she was back.

After a pleading phone call, the clinic medical director managed to
scrounge a slot. Ms. Nakitto's eyes welled up, and she spoke of people
in her neighborhood who didn't even bother to get tested now. "They
don't want to know their status," she said. "Some don't want to be
depressed."

Write to Michael Allen at mike.allen@wsj.com

------------------------------------------------------------


Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International (KEI)
thiru@keionline.org


Tel: +41 22 791 6727
Mobile: +41 76 508 0997