Will Borrowing From PEPFAR Kill Paul?

On World AIDS Day, December 1, 2011, President Barack Obama publicly pledged to make an “AIDS-free generation” part of his administration’s legacy.

This past Monday, the president released his proposed Fiscal Year (FY) 2013 federal budget. In light of his recent promise, I hoped his proposed spending levels for both domestic and global HIV/AIDS would be sufficient to begin to end the pandemic.

They are not.

This photo and all others in this blog were taken by me on my last trip to Kenya. The HIV status of those in the photos is unknown. They were taken at a variety of health clinics that serve a variety of health conditions.

In fact, the president’s proposed spending levels and the reallocation of funds for the President’s Emergency Plan for AIDS Relief (PEPFAR) endanger the lives of people living with HIV--both at home and abroad.

At first brush, the president’s budget suggested good news for people living with the virus stateside. Obama requested an additional $75 million in funding for Ryan White programs, including $67 million for the AIDS Drug Assistance Program (ADAP); $30 million in HIV/AIDS prevention funding for the Centers for Disease Control and Prevention (CDC) and $20 million to support care provided by HIV clinics across the country.

The president included a provision in the budget that if enacted into law would allow local communities the power to use federal funds for syringe exchange, a smart move that will help stop the spread of HIV and hepatitis among injection drug users. And, the budget rejects discretionary funding of failed abstinence-only-until-marriage sex education programs.

The president also proposed a $1.65 billion funding level for the Global Fund to Fight AIDS, Tuberculosis and Malaria; the increase of 26.9% would allow the U.S. to make good on its Global Fund pledge of $4 billion over 3 years.

All these things are wonderful and speak to the president’s desire to stop the illness and death caused unnecessarily by HIV.

But my job is to look the gift horse in the mouth. And when I did, things started to look less rosy.It’s critical to remember the president’s budget is mostly a campaign document indicating areas he believes are worthy of our nation’s resources. In this regard, the increases for funding for HIV/AIDS speak to the president’s intent to support people living with the virus. But since spending levels are likely to change when Congress votes to decide on the actual budget it’s also critical we understand that the president’s numbers, while trending in the right direction, are insufficient to begin to end AIDS. And that therefore we need to calculate what is required to do so--and be sure we get that figure in front of Congress and lobby hard for the money the president has not requested to effectively fight the pandemic.

The first reason the president’s budget will not start to end AIDS is it doesn’t cover the unmet treatment needs of one million Americans with HIV/AIDS.

Of the 1.2 million Americans estimated to be living with the virus in America, only approximately 262,000 are on antiretroviral treatment (ARVs).

This means there are almost 1,000,000 people in the United States not taking the drugs that can save their lives while stopping the spread of disease (as treatment can reduce the risk of HIV transmission by 96%). It is both a humanitarian crime against people with HIV and an affront to the public health of our nation to fail to provide care to this many people with a treatable disease. Especially when that treatment helps contain its spread.

Now, some of those million untreated people don’t know they have HIV (1 in 5 of the overall 1.2 million to be exact) and some don’t need or don’t choose to take medicine yet. But many people with HIV know it, need and want medicine and can’t access it. Most will eventually discover their HIV status when they begin to get critically or fatally ill and most will eventually require medicine.

The funding required to provide health care to 1,000,000 more Americans living with HIV is substantial and is not accounted for in the president’s current proposed FY 2013 budget. His budget primarily addresses the cost of those currently seeking care as well as some prevention and testing programs. Remember, with just 262,000 on treatment we still have waiting lists for the AIDS Drug Assistance Programs that address the treatment needs of low income Americans with HIV. Can you imagine what the treatment cost would be if the additional 650,000+ people who know they have HIV but aren’t taking pills today lined up for AIDS drugs tomorrow? And what if we added to that list the 250,000+ people who currently don’t know they have the virus? The cost to deliver care to an additional million people with HIV would be a much bigger number than is in the president’s current budget.

Don’t get me wrong, I am very grateful that new money is flowing to HIV. And I feel like a sourpuss pointing out funding inadequacies in the face of such generosity. But I would not be doing my job of fighting for the lives of all people with HIV if I didn’t paint the accurate picture of the HIV treatment gap. Too many domestic AIDS advocacy groups let the U.S. government get away with refusing to address the nearly million Americans with HIV for whom we have no funding for treatment. Let alone the 28 million total people around the world with HIV not on lifesaving pills.

Personally, I have wondered whether this is intentional and asked myself if the feds are waiting until health care reform starts to kick in fully in 2014 and the cost burden of all these Americans with HIV will be covered by the health insurance companies rather than the federal government and/or the pharmaceutical companies that manufacture the medications. It should be noted that the pharmaceutical companies often give out drugs and/or lower prices to help address unmet treatment needs of people with HIV on ADAP waiting lists. It’s a gracious act for sure but one that would be less necessary if drug pricing were more affordable in the first place.

The issue is that for some people living with HIV, the two year window between now and when the Affordable Care Act kicks in in 2014 may be too late.

Now is the time to put an accurate price tag on what’s needed to handle the true caseload of people with HIV in America--and around the world--and to ensure that number is known all over Capitol Hill.

When we’re starting from a deep deficit for the funds required to begin to end AIDS,
we can’t celebrate budget increases simply because they are increases. The champagne should only get uncorked when the incidence rate of new HIV cases and the number of deaths from AIDS in America (and around the world) begin to decline. If Asia can achieve a 25% reduction in HIV incidence, and other parts of the world can see 15-17% drops, it’s proof that the tools to reverse the AIDS pandemic exist.

The fact that the developed West and other parts of the world are not seeing similar dips in incidence and death is not because it can’t be done--it’s because of inadequate funding levels. Frankly, it’s an embarrassment that the United States, the nation that gives the most international aid for AIDS in the world, has yet to achieve the same reduction in HIV stateside that we’ve helped facilitate in other nations. And that the District of Columbia has an HIV-infection rate that rivals that of some sub-Saharan nations and would qualify it for American foreign aid.

The U.S.-based national HIV/AIDS advocacy groups who so glowingly applauded the president’s budget this week should have highlighted these facts. They should regularly beat the drum about the million Americans and 28 million people globally who face death from AIDS because of lack of access to care. One of the reasons I suspect they do not is that many of them are funded by the same government that does not wish to admit it’s spending far too little to identify and care for people with HIV.

Can you imagine if 1 million Americans remained untreated for a different communicable disease even though we had the drugs in our possession to control it? If the disease was anything other than HIV/AIDS, the story of unmet need would be front page news in national media. Try it. Replace “AIDS” with “SARS.” You get my point.

If the million Americans with HIV were mostly rich white men rather than predominantly disenfranchised people of color, or if this was not a disease that is transmitted via sex and injection drug use (and therefore carries an enormous stigma), I bet we’d find the money to treat them.

If white teenage girls could get HIV via inhalation, and we had the drugs to keep them well and prevent other girls from getting sick and dying, every last one of those kids would be medicated. HIV should be treated the same as any other disease because it acts like any other disease and affects every kind of person despite the myth that it is somehow naturally quarantined among the deviant and derelict. Rich white men and teenage girls get HIV too so let’s stop allowing the myths and misperceptions around AIDS to continue to lead to sickness, death and the need to spend billions of American tax payer dollars on something we really don’t need to.

Instead, let’s cure AIDS and apply the money we would have spent on AIDS on Alzheimer’s or autism or breast or cervical or prostrate or ovarian or skin or lung cancer or any other disease.

Which brings me to the next reason the president’s budget is not poised to end AIDS: It flat funds critical HIV research initiatives at the National Institutes of Health (NIH). Dr. Anthony Fauci, head of NIAID at the NIH, has declared we can end AIDS. A man has actually been cured of HIV and though his treatment is not widely replicable, the scientific insight provided by his case indicates several potential cures that are nearly ready for human trials. The barrier? Just plain money and not that much of it. Some AIDS research scientists estimate we’re a mere $100 million away from securing a workable cure. In light of all this, a flat-funded NIH budget is a disastrous decision. America spends around $19 billion a year on HIV/AIDS. Some say we could find its cure for as little as $100 million. Can’t we find $100 million somewhere in the $19 billion to prevent endless years of spending billions on a disease we can instead cure? Just saying...

The third and final reason the president’s budget will not herald in the end of AIDS is it reduces the global total of U.S. funding for foreign aid for AIDS by about $471 million. Remember, 28 million people still require treatment. Removing hundreds of millions of dollars from international aid for AIDS will not enable us to put more, but rather fewer, people on drugs. This will not lower HIV incidence nor the AIDS death rate.

While it is certainly incredibly good news that the president has indicated a desire to fund the Global Fund, his choice comes ultimately at a price to people around the world with HIV/AIDS. This is because to help source the $1.65 billion the president proposed in his budget for the Global Fund, he reduced the budget of the President’s Emergency Plan for AIDS Relief (PEPFAR) by 11%--or $546.4 million.

“This senselessly harsh budget will directly contribute to millions of preventable illnesses and deaths among people living with HIV, hepatitis C and TB in the U.S. and around the world,” Mark Harrington, executive director of TAG said of the PEPFAR cut. “Why does President Obama want to turn his back on the most effective, life-saving global health and development program in history?”

“In December the president promised a bold new effort to reach millions more people with AIDS programs--ARV treatment, condoms, medical male circumcision and more--to reverse the AIDS crisis. But [his budget] suggests the president was not serious about this promise. It’s simply not credible to cut a half a billion from the U.S.’s bilateral global AIDS program and say you’re doing all you can to end AIDS,” said Matthew Kavanagh, Director of U.S. Advocacy for Health GAP.

“In December 2011, we stood to applaud President Obama’s commitment to lifesaving AIDS treatments for an additional 2 million people by 2013,” said Leigh Blake, founder of ACT V: The End of AIDS. “We were not alone, as people living with HIV/AIDS around the world were reassured the U.S. government would keep its word and continue its commitment to an AIDS-free generation. With millions of new infections each year and nearly 2 million deaths, it is hard to understand how we end AIDS with such a large cut to PEPFAR.”

Let’s look more carefully at the math. A total of $546.4 million was taken from a U.S.-led, bilateral program 100% dedicated to HIV/AIDS. $350 million--was shifted to the Global Fund, a non-U.S.-led, multilateral program that addresses HIV/AIDS as well as tuberculosis and malaria--or three diseases instead of one.

If the $350 million moved from PEPFAR to the Global Fund gets divided equally for AIDS, TB and Malaria, it would mean people with HIV/AIDS would be getting about $434 million dollars less than they would had the PEPFAR budget remained uncut (this accounts for the $196.4 million that was shifted out of HIV altogether, the $117 million that would be shifted to TB and the $117 million that would be shifted to malaria). The president’s budget took $546.4 million slotted for people with HIV and reduced it to about $117 million. (Remember, these numbers only relate to the cut and not to overall totals of government foreign spending on AIDS. But the fact remains. People with AIDS just got royally jipped.)

The president’s proposal to slash PEPFAR by more than half a billion dollars begs several burning questions:

1) On World AIDS Day 2012, President Obama pledged we could get an additional 2 million people with HIV/AIDS on treatment via PEPFAR by 2013. (There are currently about 4 million people with HIV in care via PEPFAR now for a global total of 6 million in care. The pledge the president made on World AIDS Day raised the PEPFAR number to 6 million and the global total to 8 million.) How is meeting that pledge possible in the face of a cut of more than half a billion dollars?

2) And, if we can indeed meet the World AIDS Day targets with such a cut, does that mean there was really more than a half a billion dollars of fat in PEPFAR’s budget?

3) If so, given the relationship between treatment scale up and the end of AIDS, why would that much money be considered “fat” rather than be applied to unmet treatment need?

4) Why didn’t all of the half a billion PEPFAR dollars get shifted to the Global Fund?

5) Where did the other $200 million taken from PEPFAR go?

6) Since experts say we could be as little as $100 million dollars from the cure for AIDS, why not take $100 million of the $200 million that was taken from PEPFAR and apply it to AIDS cure research? For purposes of disclosure I’ll mention I’m on the board of amfAR, The Foundation for AIDS Research. We have AIDS-cure scientists lined up brandishing viable potential cures that deserve funding.

A group of AIDS advocates are meeting with the federal government today and I will be eager to hear their reports and hopefully the answers to the above questions.

In a blog on the White House site, Global AIDS Coordinator Ambassador Eric Goosby said, “I want to address any concern that our increased investment in the Global Fund may interfere with PEPFAR’s ability to reach its bilateral goals. I can say with conviction that if this was the case, we would not be doing it. Our Global Fund investment is critical to the ability of our bilateral PEPFAR program to reach its goals. These two U.S.-supported efforts on global AIDS are now truly independent and collaborative. We are jointly funding many country programs and specific service sites, and as we review our country PEPFAR programs, again and again we see that the success of the Global Fund grants is a critical factor in the success of our work.”

Even if that’s true it doesn’t specifically answer how any program can take a half a billion dollar hit and still deliver the same services. Ambassador Goosby speaks frequently of the efficiencies realized in PEPFAR, the lowered cost of drugs and how individual countries are pulling more weight themselves. All of these things are real and are a testament to Ambassador’s Goosby’s leadership of PEPFAR. But none of them compensate for or address the remaining 28 million people who need AIDS drugs to stay alive. Why, if the program’s more and more efficient, aren’t we helping more people? True, the number of people on treatment via PEPFAR impressively doubled between 2008 and 2011 (it went from 1.7 million to 4 million). And if Goosby’s right that we can still get to 6 million with PEPFAR taking a half a billion dollar hit, okay, but why then wouldn’t we use the money to get millions more into care rather than taking it out of AIDS altogether? I am confused that a president and administration claiming to want to end AIDS is refusing to address the treatment gap of tens of millions of people.

“In Malawi, patients are facing a huge shortfall for antiretroviral medicines in coming years; in the Democratic Republic of Congo, waiting lists for ARVs have hit over ten thousand HIV+ people; in Zimbabwe, ambitious door-to-door testing programs have identified many people in need of treatment who are not being put on waiting lists for ARVs for lack of financing,” said Asia Russell, Director of International Policy at Health GAP. “PEPFAR’s bilateral programs and the president’s new promise of expanded treatment and elimination of mother-to-child transmission should put us back on track to universal access and in doing so, halt the AIDS crisis--yet with this massive budget cut this simply will not be possible.”

I want to be very clear that I support the president’s decision to propose we significantly support the Global Fund to Fight AIDS, TB and Malaria. It’s a great program and it needed to be saved. Recently, a dearth of funding resulting from allegations of mismanagement required the Global Fund to announce it couldn’t fund its next round--round 11--of grants. Since then, there is new leadership at the Global Fund and at the World Economic Forum in Davos, Bill Gates pledged a promissory note--to the tune of $750 million dollars--to the fund. Gates’ pledge served as a vote of confidence that the fund is again a safe place for wealthy individuals and nations interested in supporting global health. The support of the U.S. president will likely further the world’s confidence in the fund.

There is no question that U.S. support of the Global Fund is essential to global health. But so is PEPFAR. The two programs work hand-in-glove and often provide complementary services to the same communities. Make no mistake: the president’s proposed cuts to PEPFAR will prove deadly. The proposed shift of funds will leave some we previously helped via PEPFAR to die.

“Reducing PEPFAR resources makes no sense given the tremendous track record of this program and the opportunity we have to begin to end this terrible epidemic, ” said Chris Collins, amfAR’s vice president and director of public policy. “Starving one of the most effective global health programs in history--a program with strong bipartisan support--threatens to undermine progress toward an ’AIDS-free generation’.”

In the same budget, the president has indicated support for--and a strike against--global funding for HIV. And the absolute math represents an overall reduction in funding for people with the virus. If a new strategy for U.S. foreign aid for AIDS suggests that the Global Fund is a better delivery vehicle for our support, fine. But then don’t cut the funding from PEPFAR without redirecting all of it to the Global Fund. And remember that even if the entire PEPFAR cut had been applied to the Global Fund, it would still be diluted over multiple disease categories and therefore mean less absolute dollars for people with HIV/AIDS.

When the man who claimed on World AIDS Day that he wanted to personally jump start the beginning of the end of AIDS by putting millions more people on treatment worldwide issues a budget that clearly indicates he’s willing to allocate less money for people with HIV and put fewer people on treatment it’s hard to believe he is really committed to an AIDS-free generation.

If President Obama truly wants his legacy to include beginning to end AIDS, he must redo his math. Leaving 28 million people (1 million of them in America) living with HIV/AIDS deprived of the treatment that can keep them alive and stop HIV from spreading is no way to stop a pandemic.

Paul Farmer, of Partners in Health, put it simply in the New York Times in a piece titled “Why the Global Fund Matters”: “The world needs to expand, not contract, access to health care because of the sheer burden of disease. It is unconscionable that in 2012, we are still living in a world where millions of poor people die of preventable and treatable diseases....a recession is a lousy excuse to starve one of the best...instruments we have for helping people who live on a few dollars a day. Most marginalized populations around the globe have always faced economic contraction; ”financial crisis“ has been ongoing for them since the day they were born. It would be a great mistake to allow one of the world’s most effective global health institutions to fail because we need to get out own fiscal house in order.”

“President Obama’s deadly prescriptions for [the] HIV, TB and viral hepatitis pandemics threaten to enshrine a two-tiered system of HIV care where the rich can access life-saving combination therapy, while the poor will continue to be doomed with premature, and avoidable, deaths,” said Harrington of TAG. “We join our colleagues with HIV and their loved ones around the world in calling on President Obama to back off his misguided, heartless cuts to life saving PEPFAR programs.”

“Robbing Peter to pay Paul in the global AIDS fight is likely to leave both Peter and Paul dead without access to lifesaving services--services that would have been there if the president were not proposing to cut global AIDS programs,” said Health GAP’s Kavanagh.

With all of this in mind Mr. President, bravo on your decision to fund the Global Fund. Now, if you’re serious about ending AIDS, don’t borrow from PEPFAR or you will fail to prevent new HIV infections, deprive orphans and vulnerable children of life-saving care and put at risk the lives of many you were once able to save.