Health Economist says New US Administration must Modify HIV AIDS Policy - PART 4 of 5 | Voice of America - English
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.
?Thenext president will inherit a program (the President?s Emergency Plan for AIDSRelief, PEPFAR) that in some respects has been extraordinarily successful,?says Mead Over, a senior fellow at the Center for Global Development think tankin Washington, D.C. ?Atthe beginning of PEPFAR, there were only a few thousand people on AIDStreatment in the whole world. (But the program) has managed to increase thenumber of people [on treatment in 13 African nations and in two countriesoutside Africa] by almost three million people. That?s an extraordinaryachievement,? he says. Over,a former World Bank specialist, concentrates on issues related to the economicsof efficient, effective and cost-effective health interventions in developingcountries and is the author of several books on the subject. He?s also anexpert in the field of HIV/AIDS and is intensively researching health servicedelivery in poor countries around the globe, especially in Africa. Oversays with about 33 million people in 147 countries living with HIV/AIDS, mainlyin sub-Saharan Africa, the new president will have to prioritize the epidemicin his foreign policy approach. He points out that PEPFARcan properly be described as the ?largest global health initiative directed at a single diseasethat any nation has ever undertaken.? Many analysts have called it Mr. Bush?sgreatest foreign policy success. Asa result of PEPFAR, says Over, the United States is today the largest singlecontributor in the response to the international AIDS epidemic, giving billionsof dollars to such efforts and providing life-prolonging antiretroviralmedicines to more than a million people in Africa alone. The plan has also provided care and supportfor orphans and other vulnerable children, and its officials say it?s preventedmany cases of HIV infection. ButOver maintains the new man in the White House will have the opportunity ofensuring that the US response to the global AIDS pandemic is ?even better.? ?Thebiggest challenge for the next president will be to make sure that the qualityand the sustainability of the treatment is maintained, but at the same time hemust try to strengthen the prevention effort,? Over argues. Hesays PEPFAR?s claims about the high number of HIV infections it?s prevented andthe number of orphans, widows and other vulnerable people that it?s cared for are?dramatic? but also ?hard to substantiate, especially the prevention claims.? Heexplains that current US AIDS policy charges Washington with preventing acertain number of HIV infections each year, yet it remains unclear exactly howthese preventions are counted. PEPFAR?s success in terms of preventing new HIVinfections remains ?hazy,? says Over. ?Forexample, 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) notclear on that and the statistical message for accounting for prevention doesn?tallow for the distinction between those two, and those are radically differentmeasures of success.? Over maintains that the new president must ensurethat ?concrete goals? are set in terms of the number of infections US effortsare to prevent each year. In a recent paper, Over writes, ?It is depressing and evenscandalous that after more than twenty years of donor-funded (HIV) preventionefforts, so few prevention interventions have been rigorously evaluated.? He continues, ?The USgovernment has funded a great many innovative and in some cases very successfulprevention efforts. But the problem is that most prevention has been operatedon a very small scale, small boutique operations in small groups of intravenousdrug users or sex workers, which have achieved substantial success but havebeen swamped by the ongoing epidemic around them.? Over says the new USadministration must make a more sustained effort to count all HIV infections inPEPFAR countries and to establish the ?hot spots where the most infections arebeing generated? - such as at truck stops inAfrica where sex workers and long-distance freight drivers interact. ?There has been no country in Africa that hasattempted that?sort of universal coverage?and the US government should take thelead 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 toknow what specific factors are driving each epidemic, and what particularinterventions would be the most successful for each country in preventingfurther spread of HIV.? Over?s convinced that onlythrough ?rigorous evaluation? will the new administration by able to ?seewhat?s really working? in the fight against AIDS, and he says the nextpresident must take the lead in making sure this happens. Over points out that despite PEPFAR?s achievements,about 1.4 million people in the program?s focus countries continue to beinfected with HIV each year. He says several new methods debated by some scientistsas being successful in preventing HIV infection offer hope for the future andshould be ?enhanced? by Washington. ?The evidence on malecircumcision is very promising. The AIDS community, with the support of theadministration in the next presidency, should move as fast as possible toexpand the availability of male circumcision, and to make sure than any countryor any region of a country that would like to expand that practice can do so.? But he emphasizes that new methods ?aren?t the onlyway to go? in terms of improving HIV prevention efforts. ?The most important thingto do is to have every single municipality of any substantial size, incountries that have a serious AIDS epidemic, be charged and be reallyaccountable for assuring 100 per cent coverage of prevention programs in all ofthe places in the whole municipality where people might meet in order to form(sexual) partnerships,? Over explains. ?Every bar, every marketplace, every single hoteland guest house should have access to prevention messages and to condoms. Andthere?s been no attempt to even move slightly in that direction?.The absence of that in Africa needs to be addressedby the next presidency.? Over says Africa, through US leadership, shouldfollow the ?prevention example? set by certain other countries. ?Thailandstands out as a country which did in the 1980s adopt the goal of 100 per centcoverage of every hot spot and brothel in the country and they achieved thatgoal and largely eliminated the threat of a catastrophic AIDS epidemic.Cambodia shows great progress in that same direction, and Brazil has adopted asa national objective to have thorough coverage of the high risk areas andbehavior in the country.? WhileOver agrees that PEPFAR?s major achievement has been the provision of essentialmedicines to HIV-positive people, he also says the criticism of the plan?semphasis on encouraging abstinence from sex and faithfulness to partners asprimary methods of preventing new infections is ?valid.? ?I?dlike to see the US government and all donors step away from prescribing exactlywhat should be done to reduce the rate of new infections, towards analternative objective, which is to simply reduce them,? he says. ?Countriesshould be charged with first of all measuring the number of new infections thatoccur each year, and then once those measurements are made, then the countriesshould be rewarded for reducing that number of infections. And for everyreduction of 10 per cent, there should be a certain amount of money that isforthcoming.? Overcontinues that it should be ?up to (each) country to decide what proportion oftheir effort should be based on very short run, targeted, highly effectiveinterventions ? like condoms ? and longer run but also useful interventionslike girl?s education in secondary school.? Over is just one of manycommentators concerned about the possible impact of the present financialcrisis in the US on the country?s ability to provide essential aid to those inneed. But he?s convinced that no matter how bad the economic problems in the USbecome, the new president will be compelled to continue funding PEPFAR?sprovision of AIDS medicines to HIV-positive Africans and others. ?I believe it?s the firsttime in history that US foreign assistance ? or any foreign assistance from anyforeign country ? has become engaged in an international program from which itcan not easily back out,? Over asserts. He describes PEPFAR as an?altruistic program? of US foreign assistance ?designed to help desperately illpeople 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 ?potentialfor several serious failures lies hidden within this apparent success. If theU.S. is seen to renege on its implied commitment to existing AIDS patients orif 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 thoseneeding treatment?President Bush?s initial success will metamorphose before oureyes into a deadly and shameful example of overreaching American incompetence ?to be blamed inevitably on the new president.? PEPFAR, says Over, hascreated 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. ButI think it applies to PEPFAR, and the reason is that if the US government wereto stop treating people who are currently on treatment, those people would diewithin a few months. There are now two to three million people out there whosevery [lives] from month to month depends on the continuation of the USgovernment?s support.? If the US cuts funding toPEPFAR?s treatment component, says Over, and people begin dying because ofthis, America will suffer immense damage to its reputation as an internationalcaregiver. . The reputation danger tothe US is so great that the US cannot pull out of those (treatment) programsand must continue funding those programs?. I think AIDS treatment will not becut,? he states. ?Possibly the rate of growth of AIDS treatment will slow, andperhaps of HIV prevention, but if the cuts to the foreign assistance budget aredramatic, the one area that I hope that the US president will be forced toprotect because of this reputation danger to the United States and because ofthe ethical consequences of cutting people off of treatment, will be AIDStreatment.? Oversays the new president must dedicate himself towards reducing the costs of?prohibitively expensive? HIV medication. Thefirst step that must be taken in this regard, he argues, is that HIV-positivepeople must be supported as they try to follow the strict regimen necessarywhen taking antiretroviral medicines. ?Adherenceis very difficult with regard to antiretroviral medication,? Over says. Ifthe medicine is to be effective, patients must take a pill twice a day ? andsometimes multiple pills at multiple times. It?s extremely important that themedication is taken at exactly the hour that the doctor has prescribed. ?Ifyou vary from that by even an hour or two, the problem is that HIV is veryclever and it will essentially evade the defenses that are set up in yoursystem by that antiretroviral medication. And when it evades that medication,it means that it becomes resistant to the drug,? Over explains. ?And then theresistant form of the virus actually multiplies inside the patient?s body andtakes over.? Whathappens then is that the drug that used to be inexpensive and very effective,no longer works. ?Ifthe patient is to survive, he or she must then move to what?s called a ?secondline? 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 ayear, depending on the country. So the cost implications of moving to thesecond-line treatment are very, very large.? Overtherefore advises that the ?very first thing? the next president should do isto ?ensure that the quality of treatment is such that people stay on first-linetreatment 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 aftera certain number of years, most patients usually fail first-line treatment andmust move to second-line drugs.? That?swhen another opportunity arises for the new president to decrease costs of HIVmedicines, Over maintains. He wants the next US administration to ?engage? withpharmaceutical companies and the US National Institutes of Health ?to bringdown the costs of second-line drugs. And if those second-line drugs can bebrought down from thousands of dollars a year, down to a few hundred dollars ayear, it will greatly reduce the cost of the program.? Over remains optimistic that the next administrationcan 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 caneffectively manage the current AIDS treatment entitlement, prevent the futureneed for treatment, and help ensure the AIDS transition to the point that thedisease becomes a manageable chronic condition, the next president will deservea full measure of credit for the long-run benefits of PEPFAR ? credit equal toor greater than that due to President Bush for launching the program.? Over acknowledges a ?tall order? will confront the nextpresident, but he?s convinced it?s ?entirely possible? through heightenedcommitment.