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Africa: AIDS Activists Speak Out

AfricaFocus Bulletin
May 21, 2010 (100521)
(Reposted from sources cited below)

Editor's Note

"In 2001 in Abuja, African heads of state promised us 15% of budget spending on health - where is this money? ... Only two countries in the continent have met the Abuja target, which African finance ministers recently dismissed as a colossal mistake. the true colossal mistakes are the wasteful spending habits of many governments who prioritise wars, luxury for politicians and sports over social spending, which cost thousands of lives every day".- James Kamau, Kenyan Treatment Access Movement

Kamau was one of a group of African health and human rights activists who met in Dar es Salaam on the eve of the World Economic Forum meeting there early this month. Tanzanian authorities banned a proposed march, which was then cancelled. But after the activists presented a statement to Forum representatives on May 6, nine of them were detained and later expelled from the country. The following week, eight AIDS activists among a group of 500 protesters demonstrating in New York outside a fundraising speech by U.S. President Obama were arrested (see and Although the two events received relatively little media coverage, they showed the growing outrage among activists at government betrayals of previous commitments to achieve universal access for AIDS treatment.

This AfricaFocus Bulletins contains two press releases from the AIDS activists who gathered in Dar es Salaam, and a statement by U.S. activists released at the demonstration in New York, along with an memo on U.S. policy by South African AIDS activist Zackie Achmat.

Another AfricaFocus Bulletin, available on the web (, but not sent out by e-mail, contains a press release and substantive excerpts from the latest report by the International Treatment Preparedness Coalition (ITPC), documenting early warning signs of declining international and national commitment to universal access to treatment for AIDS, in Kenya, Malawi, and Swaziland as well as 3 non-African countries (India, Latvia, and Venezuela). The full ITPC report is available on

For previous AfricaFocus Bulletins on health issues, visit

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

AIDS activists detained by Tanzanian Authorities at World Economic Forum on Africa

6 May 2010

Press Statement:

AIDS Rights Alliance for Southern Africa (ARASA)

Contact Persons:

  • Paula Akugizibwe (ARASA) +27 83 627 1317
  • Bactrin Killingo (ITPC) +27 73 392 3377
  • Linda Mafu (WAC) +27 72 896 2453
  • Sydney Hushie (GYCA) +233 244 50 56 57

Thursday 6 May, Windhoek -- On Wednesday 5 May, the opening day of the World Economic Forum on Africa (WEF) in Dar Es Salaam, a group of nine AIDS activists from across the continent were detained for questioning by Tanzanian authorities after they handed over a memorandum entitled "Health is Wealth", which emphasised the need for increased investment in health and particularly HIV, TB and Malaria in Africa, to two prominent speakers at the WEF.

Yvonne Chaka Chaka, a popular South African musician and UN Goodwill Ambassador for the region, and Christoph Benn, the Director of External Relations for the Global Fund to fight AIDS, TB and Malaria, had arranged with the group to receive the memorandum from them outside the conference centre.

The small group had been delegated by 40 NGO representatives from more than ten African countries, who were gathered in Dar Es Salaam to discuss global and regional advocacy strategies to address the urgent need for resource mobilization for universal access to HIV prevention, treatment and care (universal access), and for replenishment of the Global Fund in October 2010.

One such strategy included the submission of a memorandum to participants of the World Economic Forum, which outlined the concerns and demands of civil society organizations working on HIV and TB in response to the rapid backtracking of both donors and national governments on their commitments to funding universal access.

The group had chosen the WEF as a focal point for advocacy because of the inextricable links between health and socio-economic development. As mentioned in the memorandum, African heads of state, in the Abuja Declaration of 2001, stated that HIV, TB and other infectious diseases "constitute not only a major health crisis, but also ...the greatest global threat to the survival and life expectancy of African peoples, [and] a devastating economic burden, through the loss of human capital, [and] reduced productivity..."

In calling on global leaders to mobilize at least US$20 billion for the Global Fund replenishment in October 2010, the memorandum also pointed out that, as warned by the World Bank, "responding to immediate fiscal pressure by reducing spending on HIV treatment and prevention will reverse recent gains and require costly offsetting measures over the longer term".

The memorandum was originally intended to be handed over at a peaceful march with around 800 supporters, largely from Tanzanian community groups. However, the march was cancelled the night before, after the government revoked the permit to demonstrate.

Following the handing-over of the memorandum to Chaka Chaka and Benn outside the WEF, which lasted no longer than 15 minutes and caused no disruption to the conference activities, the group had boarded their bus and were preparing to return to their hotel when they were detained by police and taken to the police station for questioning. They were held for five hours, although ultimately no charges were issued or arrests made.

The group was then escorted under heavy security back to their hotel, where they were instructed to gather their luggage and proceed to the airport to wait through the night, under police supervision, until their flights departed from the country the following day. Although no formal "Prohibited Immigrant" notices were issued, members of the group were effectively treated as such and one member, who had planned to extend his stay by a few days, was compelled to accompany the group to the airport on standby for the next available flight.

Michaela Clayton, Director of the AIDS and Rights Alliance for Southern Africa expressed her concern about these actions on the part of the Tanzanian authorities, 'which display a complete disregard for the right to freedom of expression in respect of the conveyance of a message as critical as this. Unless donors and national governments make more resources available there will be no universal access".

Those detained were: Paula Akugizibwe and Lynette Mabote from the AIDS and Rights Alliance for Southern Africa; Bactrin Killingo, James Kayo and Netsayi Dzinoreva from the International Treatment Preparedness Coalition; Linda Mafu and Soraya Matthews from the World AIDS Campaign; Sydney Hushie from the Global Youth Coalition on HIV/AIDS; and Michael O'Connor from the Global Fund to fight AIDS, TB and Malaria. All have now left Tanzania.

Press Release: African activists decry backtracking on health funding commitments at opening of World Economic Forum on Africa African Civil Society Activists 4 May 2010

Governments being callous and unwise about health commitments

Contact details:

Paula Akugizibwe (ARASA), +27 83 642 0817
Bactrin Killingo (ITPC), +27 73 392 3377
Florence Umunna-Ignatius (PATA), +234 805 958 8858 / +234 806 001 4885
James Kamau (KETAM), +254 722 88 66 94
Catherine Tomlinson (TAC), +27 21 422 5463
Tapiwa Kujinga (PATAM), +263 912 318 638
Lydia Muhengera (TASO), +256 772 448 102

Dar Es Salaam - Donors and African governments are making callous and unwise decisions on funding commitments to HIV and global health, according to a group of African health and human rights activists gathered in Dar Es Salaam, Tanzania, to carry out strategic planning and advocacy in the lead-up to the World Economic Forum on Africa from 5-7 May.

Vuyiseka Dubula of South Africa-based Treatment Action Campaign highlighted the far-reaching benefits of initiatives such as the Global Fund to fight AIDS, TB & Malaria, and the United States' government's President's Emergency Plan for AIDS Relief (PEPFAR), both of whose future is uncertain due to funding cutbacks. "Thanks to the combined effort of the Global Fund and PEPFAR, more than 5,000 lives a day have been saved for the past ten years", she said, "but we know that the success does not end there".

There is a large body of scientific evidence demonstrating that HIV funding has strengthened health systems, improved maternal and child health and reduced the incidence of other major diseases like TB. By 2015, HIV in newborns could be ended if adequate funding is provided. Dubula warned that "if we do not invest adequately to sustain and build on this hard-won success, then we are effectively dismissing the right to health and throwing out the health-related Millennium Development Goals".

There is increasing political hostility towards funding the universal access to HIV prevention, treatment and care that has been repeatedly promised by leaders around the world. Paula Akugizibwe from the AIDS and Rights Alliance for Southern Africa said that clear public health and socio-economic gains do not appear to have convinced funders of the need to sustain scale-up of HIV programs, stating that "we have heard every line in the book from funders except the truth - namely, that because HIV treatment is expensive, they are no longer interested in universal access. This is callous and short-sighted, and sets an unacceptable precedent for the global response to costly health needs in the future such as drug-resistant tuberculosis."

Bactrin Killingo of the International Treatment Preparedness Coalition (ITPC) described the backtracking on universal access as "heartbreaking". He outlined the findings of a 6-country community-driven research report issued by ITPC last week, which warned that HIV could once again become a "death sentence" for people in the developing world if funding cutbacks persist.

He further warned that "all that these cutbacks achieve is to defer and increase costs," pointing out that research by various institutions including the World Bank has shown that the long-term costs associated with neglect of HIV and other health needs are far greater than the immediate costs of associated with mounting an adequate response to these needs.

Florence Umunna-Ignatius from Nigerian group Positive Action from Treatment Access elaborated on some of the consequences of funding cutbacks that have already been witnessed in Nigeria, where shortages of test kits are restricting access of new clients to testing and treatment. Similar reports have emanated from Uganda, where people in need of HIV treatment to stay alive are being turned away from clinics due to flat-lined PEPFAR funding, and the National AIDS Commission recently announced that treatment for the 350,000 people in need is unaffordable. "Let us not forget that each of the figures in these big numbers represents a real person for whom decisions on funding are literally a life or death matter," she urged.

But to governments, these decisions are often more a matter of political sport - according to James Kamau of the Kenyan Treatment Access Movement. "In 2001 in Abuja, African heads of state promised us 15% of budget spending on health - where is this money?" he asked. Only two countries in the continent have met the Abuja target, which African finance ministers recently dismissed as a colossal mistake.

According to Kamau, "the true colossal mistakes are the wasteful spending habits of many governments who prioritise wars, luxury for politicians and sports over social spending, which cost thousands of lives every day". He brandished spoof dollar bills highlighting examples such as the cost of President Yoweri Museveni of Uganda's private jet, which could have paid for HIV drugs for more than 200,000 people.

Tapiwa Kujinga of the Pan-African Treatment Access Movement outlined the activists' demands to leaders at the World Economic Forum on Africa, which include setting a clear time-bound roadmap to achieving the Abuja target of 15% of health and ensuring more transparent and accountable use of health funding. They are also calling on global leaders, particularly the G8 and G20, to fully replenish the Global Fund in October 2010; and on President Obama to ensure that PEPFAR supports addition of new patients onto treatment in future. Tomorrow (Wednesday 5 May) they will stage a demonstration at the World Economic Forum where a memo detailing these demands will be handed over to a representative of the Tanzania Minister of Health and the Global Fund, to champion these messages at the WEF.

Memo to the US Government -- We will reverse your policy through activism locally and globally

Zackie Achmat

May 13, 2010

On 22 August 2006, Senator Obama met with the Treatment Action Campaign in South Africa. He visited Khayelitsha -- a place that I regard as the home of people living with HIV across the world. There Norute Nobula explained to him how medicines saved her life and Sizwe Nquqe explained how TAC organises young people with prevention and treatment messages. Phumeza Runeyi explained our campaign against gender-based violence to the President. He visited the Site B Clinic -- the oldest community-based ARV programme on the African continent started by Medicins Sans Frontieres in partnership with government and saw how thousands of lives were saved in that community alone. Across our country, the SA government has put the majority of people on treatment but former President George Bush's PEPFAR helped save the lives of the 1 million people on treatment in South Africa. President Obama knows all these things first hand and he took an HIV test in Kenya where his father's family lives and another place where PEPFAR works.

He gave us his word that he will work for the US play an enlightened role in global affairs especially and that he will help to ensure increased support for HIV, health and development as opposed to war. Central to his Senate agenda would be work to strengthen the Global Fund Against TB, AIDS and Malaria. He also promised to campaign for the first National Strategic Plan for HIV in the US. When President Obama was elected we all celebrated and his election will forever be an affirmation of the dignity of every human being but particularly Black people across the world.

The memo below this introduction explains why we protesting President Barack Obama in New York today. When Mbeki was removed from power and the ghosts of two million dead receded, most activists could catch a breath, now a new sense of foreboding in relation to HIV has returned. After a decade long battle and a two year respite, a new unnecessary battle lies ahead for people living with HIV, one where people who love and respect one another (irrespective of differences) will find ourselves on opposite sides when there are so many other pressing battles we will have to fight. President Obama's struggle for healthcare, financial regulation, economic growth and jobs, environmental justice, immigration reform and equality for LGBTI people are fundamental to secure a more just world for all of us. These are some of the issues that we all have to work on.

Tragically, the President has inherited a local and global economic catastrophe, two wars, phenomenal public debt and much more. His election has also galvanised the deep race, class and religious hatred of the Republican Right. We understand this cannot be fixed in a day -- or a decade. However, the misguided manner that President Obama's advisors are seeking short-cuts to solve these incredibly difficult questions of HIV, health and development will rebound not on them but on his Presidency because he will take the decisions to decide who will live and who will die. It is my view that the President is ill-advised with "quick-fix solutions" and "good public-health" sound bytes. These solutions are disguised as a broader "global strategy for development" but they are another way of making poor, working and middle class people pay for the crisis. Investment in health, HIV and broader development is not only the right thing to do -- new investments in health-care and in HIV result in growth and improved quality of life for the most vulnerable.

Today, I will join my US comrades in a demonstration to reverse the course of the Obama administration. We will not rest until we ensure that the US and all OECD countries play their full part in saving lives because we really can end the epidemic. We will work with the President and his advisors to reduce costs, clean-up corruption and further reduce medicine prices as we will support him on all other progressive initiatives. However, in every part of this world but particularly in Africa, my home, we will resist an abdication by the US and the other OECD countries of their international human right law duties to ensure that people living with HIV have the right to life and access to health-care as defined in the Universal Declaration of Human Rights.

Zackie Achmat

Memo from US Activists

Date: May 13, 2010

Re: Administration Global AIDS Funding Levels and Policies Risk Undermining Success

The negative impact of Obama Administration funding recommendations and policy decisions on AIDS treatment roll-out in Africa is garnering increasing attention. A growing number of media reports and comments by experts, researchers, activists, and Members of Congress share the same troubling message: this worrying trend undermines broader Administration global health and development efforts.

Approximately 4 million of the estimated 14 million people in immediate need of AIDS drugs in developing countries currently have access to them--with the U.S. directly supporting over 2.4 million people. Where treatment has reached high levels of coverage, substantial benefits have been shown including: decreased overall mortality, increased life expectancy, decreased HIV-negative child mortality, and increasingly there is evidence of decreased infection rates.

President Obama, Vice President Biden, and Secretary of State Clinton all made repeated public commitments as presidential candidates and as Senators to continue this positive trend. Specifically, they promised to invest $50 billion over five years for AIDS and to reach one-third of those in need with AIDS treatment through direct U.S. support. However, recent public assessments of U.S. government actions on AIDS in Africa describe the Obama Administration's response as weakening, rather than strengthening as promised. These include:

  • Media coverage in The Wall Street Journal ("War on AIDS Hangs in Balance as U.S. Curbs Help for Africa"), Newsweek ("AIDS Programs Hit Setbacks in Africa"), The Boston Globe ("U.S seeks to Rein in AIDS Program"), 60 Minutes and additional outlets describing a "curb" in the US response to AIDS in Africa and the scaling back or halting of AIDS treatment roll out in several African countries;
  • A letter from nearly 300 physicians and scientists to House Appropriations Committee Leadership characterizing the President's FY11 budget as a "retreat" in the fight against AIDS; and
  • A Congressional hearing convened by the House Foreign Affairs Subcommittee on Africa and Global Health, investigating reports of a halt in treatment enrollment in Uganda and elsewhere.

This memo provides background information and analysis regarding the following critical developments in current U.S. policy on global AIDS:

The FY10 and FY11 budget requests have included a flat-lining of AIDS funding, and decreased funding for treatment, despite promised increases. The FY11 budget requests a $50 million cut to the Global Fund compared with the FY10 appropriation. When calculating real funding available for bilateral AIDS-specific programming the FY11 budget requests roughly a 2% increase while inflation in Africa is estimated at 7-10%. Overall funding for AIDS medicines has decreased within PEPFAR, with some countries seeing 10%-15% decreases in funding available for commodities each year.

Worrying signs of either outright halts or significant slowing in PEPFAR treatment scale-up has been documented in Uganda, Nigeria, Mozambique, South Africa, and elsewhere. In Uganda, hundreds people are being turned away from AIDS treatment monthly while memos from the U.S. government to implementers instruct additional enrollment only where patients are lost to death or follow up. In Nigeria, Mozambique, and South Africa rationing of care is evident, for example with clinics forced to enroll only those who are severely immune compromised--those with CD4 counts that are at 1/7th the level recommended for treatment or rationing to only pregnant mothers.

With new evidence showing the path to defeating the AIDS pandemic, and AIDS as the leading killer of the women and mothers targeted by the Global Health Initiative, the Administration is seen as reversing successful trajectory. Key new scientific evidence has shown prevention benefits of up to 90% for those on effective AIDS treatment. Meanwhile, recent studies have shown AIDS to be not only the leading killer of women ages 15-44, but the key reason progress on maternal health in Africa has not been made. While the Administration's well-received strategy focuses on building off of PEPFAR's success, funding and policy decisions limiting treatment will prevent success of the broader Global Health Initiative.

A. Administration Global AIDS Funding Levels and Policies Risk Undermining Success

Campaign Promises and Supporting the Lantos-Hyde Act

Many global health, scientific, clinical, progressive, faith, student, and people of color organizations applauded when then-Senator Obama made bold commitments to tackle global AIDS and followed through on those promises with bi-partisan legislation passed just before the 2008 Presidential election. For example, on World AIDS Day Senator Obama pledged to provide $50 billion by 2013 to fight the pandemic--increasing spending levels with $1 billion in additional resources each year--and contribute the U.S. fair share to the Global Fund, and backed this pledge with legislation--co-sponsoring the Lantos-Hyde Act (along with Senator McCain and then-Senators Clinton and Biden) that authorized $48 billion in spending by 2013. In addition, then-Senator Obama promised to "continue to provide treatments to one-third of all those who desperately need them."

Treatment Scale Up Substantially Less Than Promised

Currently an estimated 14 million people are in immediate need of AIDS treatment, and that number is growing each year. Exciting new science, discussed below, shows that reaching Universal Access (or 80% treatment coverage levels) could potentially turn the tide against the epidemic--with infection rates, death rates, and the financial costs of AIDS all falling as a direct consequence of accelerated treatment scale up. This was why the Obama pledge to do the U.S. share--treating 1/3 of those in immediate need--is critical. At promised funding levels, between 6-10 million people could be treated by 2013. Unfortunately, the new PEPFAR strategy predicts only "at least 4 million" people on treatment by 2014. This means adding 1.6 million more people over the coming five years--roughly 400,000 per year--far fewer than the current rate of treatment expansion and a number that does not keep pace with the epidemic.

Funding Levels Flat-lined

Unfortunately, multi-year projections and yearly budget requests signal this necessary--and promised--level of global AIDS funding is not forthcoming.

The FY10 Administration budget request to Congress described--for the first time since PEPFAR's inauguration--essentially flat-funding U.S. global AIDS investments, with an increase of roughly 2%. Congress added several hundred million dollars to the President's FY10 request.

The Administration's FY11 budget request again proposed essentially flat-funding global AIDS programs, including:

  • $50 million cut from 2010 appropriated levels for the Global Fund to Fight AIDS, TB, and Malaria
  • only $180 million added to global AIDS care, treatment and prevention (not including research)--with $100 million of that $180 million redirected into a new "Global Health Initiative Plus Fund," and therefore not available for AIDS treatment scale-up, according to currently available information. This leaves only $80 million in new funding for service delivery--a 1.5% increase. An $80 million increase does not even keep pace with inflation, which is estimated by the IMF to be approximately 7-10%.

Furthermore, the President's Global Health Initiative (GHI)--welcomed with enthusiasm by many in the global health community in principle--has neither sufficient funding nor the policy choices needed to meet its stated goals, including those related to AIDS. Specifically:

  • GHI AIDS programming is framed as a six-year plan, rather than the five authorized by Congress and promised in the presidential campaign, but there is no additional funding for the sixth year;
  • In a leaked 2009 presentation--the only publicly available description of out-year budgets--the anticipated total increase is $1 billion over 6 years, although Obama promised increases of $1 billion per year for AIDS.
  • The total amount to be spent on AIDS over those 6 years--$37 billion--is less than the $39 billion anticipated in six years under the PEPFAR Reauthorization by the Lantos-Hyde Act.

B. Evidence from the Field: Halting and Slowing AIDS Treatment Scale up in Africa

PEPFAR funding shortfalls--and a response to HIV that is de-prioritizing scale up of life-saving treatment--is resulting in policy outcomes that are already having a grave impact on country programs and on people with HIV in urgent need of treatment and care. Here are recent examples:

PEPFAR has explicitly instructed partners to stop enrolling new patients on HIV treatment: In Uganda, CDC wrote on October 29, 2009 to implementers: "PEPFAR Implementing Partners who directly provide antiretroviral treatment should only enroll new ART patients if they are sure that these new patients can continue to be supported without a future increase in funding. . . . In filling treatment slots that are made empty through attrition--i.e., deaths and loss to follow-up estimated at 12-30% annually--priority should be given to the sickest patients, eligible pregnant women, children, TB/HIV patients, and family members of persons on ART [antiretroviral treatment]."

In Nigeria, CDC has instructed implementers that expansion of treatment is not allowable under current funding levels. Treatment providers are concerned that turning away patients in need will backtrack on years of work done to encourage people to get tested for HIV.

PEPFAR sites are turning away new patients in clinical need of AIDS treatment: For example, the Uganda-based Joint Clinical Research Centre (JCRC), one of the earliest HIV treatment providers in Africa, announced in March 2009 that they were not starting new patients on treatment and that they could not guarantee support for patients enrolled on treatment in the prior five months.

PEPFAR sites are rationing HIV treatment to only the sickest, while waiting lists expand: Mildmay, one of the largest PEPFAR implementers in Uganda, has a large and growing waiting list of people in urgent need of treatment. They have shifted from enrolling 260 patients on treatment per month to about 25 to 30--just enough to accommodate slots opening up due to patients currently on treatment who are transferred out, die, default, or are lost to follow up. Mildmay staff report that women and children will suffer the most as a result of these restrictions because they are least able to afford to pay out of pocket for treatment. Those few patients being enrolled are only the sicker patients (<150 CD4 cells/mm3). Mildmay, like other providers, are unable to implement new national treatment guidelines which were enacted to better adhere to clinical knowledge and the revised World Health Organization (WHO) recommendation to initiate ART enrollment earlier in order to stave off opportunistic infections and increase survival.

Right to Care (RTC), a PEPFAR implementer in South Africa, operates 170 AIDS care and treatment sites supporting 100,000 people living with HIV. RTC recently told their sub-recipients to halt ART enrollment. At issue was a radical change in policy: RTC and its sub-recipients would only provide ART once the South African government agreed to assume responsibility for the purchase and provision of commodities. RTC estimated that in 2009 funding was effectively reduced by 30%. Despite delays in government support, RTC still prohibited sub-recipients from initiating any new patients on treatment. One RTC sub-recipient, AIDS Care Training and Support (ACTS), with approximately 3000 patients on treatment, reported that only patients with CD4 count below 50 cells/mm3 and pregnant women were considered exempt from the directive. As a result, ACTS denied treatment to 60 treatment-eligible patients each month from November 2009 through February 2010. In March 2010, after four months, they were able to initiate new patients on treatment, after signing a Memorandum of Understanding with the government.

PEPFAR sites are reducing HIV testing: Over the last 6 months Mildmay in Uganda has reduced HIV testing efforts in keeping with the reduced provision of ART. Mildmay used to provide voluntary counseling and testing to more than 320 clients four days out of the week, they are now reduced to 120 tests and only on two days a week.

PEPFAR and government implementers are filling partial drug prescriptions because of the uncertain or insufficient funding: Patients in some areas in Uganda are reporting government HIV sites have shifted from providing three-month supply of ARVs, a critical component of supporting good adherence, to just one month or even requiring people to return to clinic from week to week, sometimes at great cost and over a great distance. HIV positive patients in Zambia at a PEPFAR clinic have reported getting only one-third of their prescriptions filled. When one woman asked why, she was told she "should be grateful she got anything at all" and that "next month she may not get anything." Short-term supplies of medicine undermine the perception that HIV treatment will be reliably provided for patients when the need arises.

PEPFAR is spending less to save lives, and more on "technical assistance": PEPFAR appears to be returning to an era in which US foreign aid funded "technical assistance" instead of direct services and the recurrent costs of AIDS treatment. Unfortunately with such technical assistance comes a lack of commitment to coverage targets and measurable impact. Without funding for medicines, laboratory supplies and other essential commodities, technical assistance has limited value. From FY08-FY09, PEPFAR Focus Country treatment funding was cut 12%, from $1.56b to $1.38b, the allocation for AIDS medicines decreased 17% (from $477m to $394m) and the allocation for adult and pediatric AIDS services and treatment decreased 12% (from $884m to $777m).

In Mozambique, USAID announced a budget cut for commodities from 10% to 15% annually over the next four years. It is unclear who will step forward to take responsibility for the purchase of ARVs. In the Democratic Republic of Congo, PEPFAR has replaced budget lines dedicated to funds for medicines for opportunistic infections and laboratory supplies, replacing these with funding for technical assistance, sero-prevalence studies, and training. In this case, Global Fund funding that was intended to expand treatment coverage had to be reprogrammed to cover the costs created by PEPFAR's budget cuts. This is a growing problem.

PEPFAR is proposing a decrease in US funding for the Global Fund, while encouraging countries to rely more on the Global Fund for financial support to maintain and expand treatment programs: the Global Fund's resources are overstretched, in part due to the US refusal to fully fund it. The Global Fund needs $20b over the next three years (2011-13), $8.5b of which is for existing commitments. The Global Fund's funding needs place at great risk proposals to scale up treatment--and also place in jeopardy existing initiatives. The Global Fund is expected to absorb the costs of supplies previously funded by PEPFAR--instead of scaling up treatment for new patients who are left with their treatment slots in jeopardy.

PEPFAR is handing over responsibility for treatment provision and scale-up to unprepared and unequipped governments: PEPFAR is transitioning away from direct service provision in South Africa on an unrealistic timetable, according to those familiar with the situation. South Africa's national program is struggling to meet the needs of world's largest population of people on ARVs and people in need of treatment. In the Free State province, only about one-quarter of those needing treatment have access and last year people living with HIV in the province experienced a four-month moratorium on treatment initiation due to lack of funding. The Southern African HIV Clinicians Society estimated the moratorium caused 3,000 deaths. In this precarious environment, one PEPFAR sub-recipient ceased ART initiation in its clinics in the province and no new organization was funded to take their place. Thus PEPFAR required both continuing and new patients be transferred to the public sector imminently. The organization's approximately 2500 continuing patients include 1000 transferred from the Department of Health (DoH) during the moratorium because the DoH was unable to subsequently retain them. According to the organization's program manager: "It is like playing roulette. We had to wait for decrease in patient load through natural loss to follow up in order to get new patients on board, while always having to see how far our budget will go every month."

In Nigeria, there are troubling early signs that PEPFAR intends to cut its investments in HIV treatment over the next five years, effectively "winding down" some HIV treatment programs regardless of government lack of preparedness to take on a massive increase in burden of patient care.

PEPFAR flat funding means missed opportunities to improve sub optimal care: Major U.S. implementers have measured an increased risk of mortality from later treatment initiation. In a large cohort, AIDSRelief has found that patients starting treatment with a CD4 count of under 50 cells/mm3 have a mortality that is 2.5 to 6 times that of patients starting treatment at a CD4 count greater than 100 cells/mm3. Recently news reports indicate that PEPFAR's director, Dr. Eric Goosby, is not going to implement new WHO treatment guidelines to start treatment earlier--despite better patient outcomes and long term cost savings associated with earlier initiation. The messages from Washington suggest a return to the chilling era of people with AIDS on the verge of death brought to a clinic in a wheelbarrow--a common sight in the early phase of treatment scale up.

Children with HIV and patients on second-line treatment are falling through the cracks: The Clinton Foundation's HIV/AIDS Initiative (CHAI), in partnership with UNITAID, has been procuring pediatric and second-line ARVs for 40 countries, with the aim of mainstreaming those procurement streams into the larger funding streams represented by the Global Fund, PEPFAR and national budgets. CHAI took on this responsibility because pediatric populations and populations failing first-line medicines were neglected, and with higher drug costs. However, due to the challenging funding environment and limited growth in available funds, national programs have found it difficult to transition procurement responsibilities to these funding streams. As a result, CHAI has had to request bridge funding from UNITAID for a significant number of these countries, which would otherwise have to resort to measures such as turning away or wait-listing eligible patients. In several countries, it is likely that despite the additional funding requested from UNITAID, which covers only a small proportion of patients, current funding levels will not be sufficient to meet patient demand.

Also, in some countries, the mechanism envisioned to reliably transition patients from UNITAID and CHAI funding in the short-term places at risk treatment scale-up for adult patients. For instance, despite Zimbabwe's devastating disease burden, the scale-up of adult patients is at risk in 2011 as PEPFAR and the Global Fund resources must be used to retain coverage of pediatric patients previously covered by UNITAID.

PEPFAR funding shortfalls have contributed to increased volatility in national programs, with newly emerging drug stockouts and instability of supply lines: For example, over the past 18 months, CHAI has observed the impact of the increasingly challenging funding landscape for HIV across many of its 40 programs and partner countries. In several countries, short-term funding gaps have been observed, partially as a result of the fragmented funding architecture, but exacerbated by the overall shortage of funding. In many countries, significant long-term funding shortfalls are projected, and are beginning to have an impact on the ability of national programs to meet the needs of existing patients. Such shortfalls result in real and harmful impact to patients, as clinics are forced to turn away eligible patients, including family members of treated patients. In addition, national programs are forced to make quality trade-offs, such as limiting access to diagnostics services and delaying the implementation of WHO guideline revisions which call for earlier initiation of ART and a move to lower-toxicity drugs.

C. Ignoring the Science and Missing the Chance to End the AIDS Pandemic

The Obama Administration is poised to scale back its commitment to fighting AIDS in sub-Saharan Africa and the rest of the developing world at the same time groundbreaking research indicates that comprehensive access to effective HIV treatment is likely the most powerful HIV prevention tool currently available and the best hope for reducing the incidence of new HIV infections and ultimately ending the HIV epidemic. The evidence shows:

  • Antiretroviral therapy reduces HIV transmission in heterosexual couples by more than 90%. A review of 14 studies reporting rates of HIV transmission in sero-discordant heterosexual couples found no cases of transmission where the HIV-positive partner on ART had blood levels of HIV ("viral load") that were undetectable (<400 copies of viral load/mL). A study that followed 3,400 heterosexual sero-discordant couples in seven African countries for one to three years showed that access to ART was associated with a 92% reduction in rates of new HIV infection. When viral load is controlled through treatment, HIV is less likely to be transmitted.
  • Antiretroviral therapy reduces HIV transmission at the population level. HIV treatment was associated with a 53% reduction in new HIV-positive diagnoses between 1997 and 2002 in Taiwan. New HIV infections decreased by approximately 50% between 1996 and 1999, coinciding with the introduction of HIV treatment in British Columbia. And in San Francisco a substantial increase in HIV testing and treatment between 2004 and 2008 was accompanied by a decline in new HIV diagnoses, a decrease in the average viral load in people living with HIV in San Francisco, and a decline in HIV incidence of around one-third.
  • Antiretroviral therapy reduces HIV transmission among people who use injection drugs. Recent studies among injection drug users in Vancouver have shown that, independent of other risk factors such as unprotected sex and syringe sharing, the recent measure of average viral load among HIV positive drug users was strongly associated with an individual's risk of becoming HIV infected during the period of 1996-2007. (Over that time period the use of antiretroviral therapy rose from 42.5% to 69.6% among the study cohort) Across British Columbia, researchers estimate that the steady increase in HIV treatment coverage was associated with a 50% decrease in new HIV infections diagnosed among people who use injection drugs.
  • Access to antiretroviral therapy for HIV-positive pregnant women is key for ending transmission of HIV from pregnant women to their babies. By 2015 cases of pediatric AIDS resulting from transmission of HIV during pregnancy, delivery, or breastfeeding could be virtually eliminated in sub-Saharan Africa--as it has been virtually eliminated in most developed countries--if all HIV-positive pregnant women have access to optimal HIV treatment regimens. Despite these facts, PEPFAR implementers in some countries are reporting the inability to ensure pregnant HIV-positive women have access to quality combination therapy--in part because of insufficient funding.

Over the preceding seven years, the U.S. has scaled up HIV treatment in developing countries significantly. Now, the U.S. appears prepared to squander that investment, and change course--abandoning its commitment to ART scale up. Given promising new data showing the public health imperative associated with maximizing the preventive effect of HIV treatment, this troubling policy shift could lead to millions of new HIV infections. Moreover it will simply postpone--and likely increase--ballooning treatment costs. Urgent course correction is needed--so that communities benefit fully from the direct and indirect benefits of HIV treatment, contributing ultimately to reduced rates of new HIV infections, declining HIV prevalence, and--potentially--an eventual end to the pandemic.

D. Threats to Women, Girls, and the Success of the Global Health Initiative

The women and girls-centered approach of the GHI, and strengthening of health systems, cannot be realized if the U.S. backtracks on its global AIDS response.

  • In Africa, HIV care and treatment is required to address women's health: According to the WHO, HIV is the leading cause of death globally among women of childbearing age. Data released last month show that in Eastern and Southern Africa HIV has not only blocked progress toward maternal health, but is responsible for an additional 61,000 maternal deaths per year. Further, the rationing of HIV treatment in the past has resulted in of the use of the least effective PMTCT protocol (single-dose nevirapine) in preventing transmission from mother.
  • Flatlining spending ignores the importance of HIV treatment for the health of children. HIV treatment for an infected mother has been found to be strongly linked to the health of their uninfected children. A study in Uganda found that ART roll-out was associated with an 81% reduction in mortality in uninfected children, and an estimated 93% reduction in orphanhood. A major killer of children is orphanhood. A child who loses his or her mother is ten times more likely to die because of lack of care. In 2008 UNAIDS estimated a scaled phase-up to universal access to treatment by 2015 would result in a number of orphans that is approximately four million below current projections. Further, stalling ART expansion increases the vulnerability of young female children because they are often the first to drop out of school and provide care for sick or bedridden family members. Children's school attendance and nutritional status tend to improve in households with access to treatment.
  • Insufficient treatment creates massive burdens on the health system. Those without access to treatment flood the health systems. HIV and tuberculosis also reduce the capacity of an already strained health workforce. According to a WHO sponsored study, the incidence of HIV in the Kenyan health workforce is twice the national average, and death of health workers is the main cause of attrition. On the continent as a whole, 43% of deaths or medical retirement of health workers were known or suspected to be caused by HIV, and 37% by TB.

AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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