There has been a lot of debate recently concerning the funding of international aid programs for treatment and prevention efforts for HIV/AIDS. Specifically, current funding levels have been so stagnant that AIDS activists, who normally are to the left politically, have been openly and brazenly attacking President Obama over his failure to allocate more funds to AIDS programs.
I am not an expert of congressional budgets, or even a professional HIV/AIDS activist, however I do see that the HIV/AIDS pandemic is a major source of suffering and mortality worldwide. It seems a no-brainer that President Obama would increase the budget-this has not happened.
This article describes some of the cold hard facts surrounding the HIV/AIDS pandemic, and what people in power are thinking about future HIV/AIDS budgets.
The Global Fund to fight HIV/AIDS, Tuberculosis and Malaria.
A group of 100 members of Congress have supported a request for a $6 billion dollars-three year commitment to the Global Fund to fight AIDS, Tuberculosis and Malaria. Recently, donor nations pledged $11.7 billion for the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria. Which is less than the $13 billion needed the fund current programs, and less than the $15 billion dollars a year target that the Bill and Melinda Gates Foundation say the organization needs to treat and prevent HIV/AIDS, tuberculosis and malaria.
The Obama administration recently pledged of $4 billion to the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria over the next three years, which is 38% higher than previous funding levels. And team Obama promised more if funded programs could show that they are effective and not wasting the money. However, this funding has not been approved by Congress, and obviously, the need for these funds is increasing each year. When looking at the total amount of funds given for HIV/AIDS, only about 25% of funds for global HIV/AIDS programs come from the Global Fund.
Bulk of US Financial Commitment to HIV/AIDS Fight Channeled Through PEPFAR.
Most American funds for the fight against HIV/AIDS come from PEPFAR, the President’s Emergency Plan for AIDS Relief. This program was started under George W. Bush and has provided over $15 billion in funds between 2003 and 2008. In 2004 there were about 50,000 people receiving antiretroviral medication under PEPFAR, a number which increased to 1.2 million people in 2008. President Bush, as a lame duck president, signed a five-year global health budget for fighting HIV/AIDS, Tuberculosis, and Malaria outside of the U.S., which authorized $48 billion dollars for the fiscal years 2009 to 2013. Of this amount, approximately $39 billion is for AIDS. This act by President Bush also increased the funds for the Global Fund to fight AIDS, Tuberculosis and Malaria to $2 billion a year.
The Obama White House has extended the five year PEPFAR program by one year and added $3 billion to the $48 billion dollar budget. This is viewed as being a small potatoes effort by HIV/AIDS activists. In fact, the 2009-2010 the budget for PEPFAR was effectively flat-lined. And President Obama’s plans to increase the PEPFAR budget for 2010-2011 by only 2.2%, which barely keeps up with inflation.
This is markedly different from President Obama’s campaign promise of increasing PEPFAR funding to fight AIDS so that $50 billion is spent on HIV/AIDS in the time frame from 2009 to 2013. For 2010-2011 budget PEPFAR will get about $7 billion. The biggest increase in PEPFAR to date occurred when PEPFAR went from $1.5 billion in fiscal year 2003 to $6 billion in FY 2008. Let’s say that the PEPFAR budget increases to perhaps $8 billion in 2013, that would put the five year budget at roughly $34 billion, far short of the $50 billion promised by then-candidate Obama in 2008.
AIDS activists are rightly up in arms over team Obama’s apparent decision to flatline funding for PEPFAR, which would mean that in a time of increasing need there would be a growing mismatch between demand for life saving antiretroviral therapy and the money to buy them. While PEPFAR is far from perfect, as it for example does not give funds for needle exchange programs which could slash HIV infection rates, at least it is saving millions of lives.
White House Wants Other Countries to Do More
While previous administrations, such as Bill Clinton’s White House, claimed that they could have done more for the HIV/AIDS pandemic had they understood the full extent of the problem-such a claim of ignorance can not be made by President Obama’s team. One odd reason for the crunch in global, HIV/AIDS budgets may be that President Obama wants other donors, such as developing countries such as China, India and Brazil to do what he believes is their fair share. And withholding even inflationary increases in PEPFAR forces them to do so.
China has pledged a token $14 million dollars to the Global Fund over the next three years, which has upset many policymakers in Washington as China receives about a billion dollars worth of funds. Some have advocated that so-called “middle income countries” which swallow up to 20% of the United States HIV/AIDS global donations should be phased out as supposedly these countries can support domestic HIV/AIDS programs themselves. Poor countries, in places such as Africa, would remain dependent on external sources of funding for decades to come.
The AIDS2031 project concludes that between 2009 and 2031 the global costs for the HIV/AIDS pandemic will be between $397 and $722 Billion American dollars. That is quite a chunk of change.
Quietly, donor organizations such as PEPFAR and the Global Fund are discussing ways to have “middle class” countries such as China, take over the HIV/AIDS relief programs that they set up. Some also prefer to fund national programs, instead of grass roots community programs, in an effort to get recipient countries involved in the funds given to them in the hopes that they will start to devote a significant portion of their budget to the cause.
The net result may be that PEPFAR and other donor programs are becoming removed from the personal tragedy of the HIV/AIDS pandemic and will increasingly blame some countries for falling to fund treatment and prevent programs within their borders. The end result: HIV positive patients are caught in the middle.
Domestic Budgets for HIV/AIDS Programs Stalled As Well
So to has the President forced state legislators to take up the issue of funding for HIV/AIDS programs in their states. States budgets for HIV/AIDS treatment and support aren’t keeping up with demand domestically. In New York, money for rent subsidies for HIV/AIDS patients was vetoed by the New York’s democratic governor.
Currently 3,200 Americans who are HIV positive are on wait-lists for HIV medications. The federal program which helps funds antiretroviral medication for HIV positive patients needs $126 million, but only received $25 million. AIDS activists are so upset by the White House’s decision to refuse to fund ADAP, that they had decided to publicly “vote no confidence” in the democrat’s leadership on this specific issue. The wait lists are especially sad in this day and age when it is known that HIV positive people live healthier lives if they are started immediately on antiretroviral medication. This is because it is now known that HIV begins to damage the human body from day one.
Why should state government provide housing money for HIV/AIDS patients you ask?
I can’t help but remember a young woman who was HIV positive and who was admitted to a hospital just outside of Washinton D.C.. Though in her early 20’s, she had dementia caused by her chronic HIV infection and was unable to understand that she needed to consistently take her antiretroviral medication or she would die. Her housing and transportation resources were unstable to say the least, and she had lost the ability to care for herself. The infectious disease doctor decided to discontinue her antiviral medications because he felt that she would not be able to take the medication consistently, which meant that she would probably die of AIDS in the coming months.
Unstable housing and transportation would doom many patients to her fate as lack of housing and reliable transportation to doctor visits can be a vicious cycle with many HIV positive patients. The simple fact is that keeping such patients healthy and independent saves their lives, and tax payers money as well.
Why is the World Becoming Increasingly Apathetic with the Global HIV/AIDS pandemic?
As a medical student I tried to setup a “gap year” to volunteer in Botswana, a country in Africa hit hard by the HIV/AIDS pandemic-an effort which unfortunately was unproductive. Even in this age of a well recognized progressively deadly HIV/AIDS pandemic, American institutions have let interest in the HIV/AIDS pandemic whither on the vine.
Even though rich countries have non-monetary resources available for the HIV/AIDS pandemic, such as clinical and research expertise, these resources are not being efficiently mobilized. And more so, even in this age of increased awareness of the HIV/AIDS pandemic, complacency has taken root in countries with a domestic HIV epidemic localized in traditional stigmatized populations such as recreational drug users, minorities, homosexuals and bisexuals.
What is the best long term approach?
The best long term approach to the HIV/AIDS pandemic is expensive but offers the best outcome and is described as the “Rapid Scale-Up” approach as described in a recent article in the prestigious medical journal the Lancet. Key points of the Rapid Scale Up approach are listed below:
1. Spending on the HIV/AIDS pandemic increases to $30 billion a year in 2031. As the United States provides perhaps half of funding for the response to the HIV/AIDS pandemic, this may not be achievable unless President Obama, drastically increases the PEPFAR budget. In 2009 about $15 billion was spent worldwide on the HIV/AIDS pandemic.
2. Direct approaches for preventing the spread of HIV are instituted, and preventive care and treatment is provided on a universal basis by 2015.
3. Countries push forward with their specific goals for the prevention and treatment of HIV/AIDS.
If HIV/AIDS funding levels remain stagnated where they are, then there could be approximately 3.2 million adults infected with HIV in 2030, compared with the 2.3 million infected in 2009. Under the best case scenario, there would still be 1.2 million infected in 2030, barring the discovery of an HIV vaccine or such groundbreaking technology.
What Are the Powers that Be Thinking about Funding for the HIV/AIDS Pandemic?
After reading multiple articles on the issue a series of common explanations are being offered for the stagnation in funding by the White House and many other sources as well.
1. The Great Recession has hobbled the budgets of rich countries and donors so much that it has cut into even the HIV/AIDS budgets. The sentiment has been echoed by doctors and politicians alike, such as former president Bill Clinton. (There seems to be enough money for wars and for new military weapons programs which cost billions of dollars though . . . )
2. Other donors, such as countries besides the United States, need to step up to the bat and take responsibility for the pandemic. (However, as the United States ramped up its spending on HIV/AIDS programs, other countries around the world followed suit, meaning that the world is watching what the US does).
3. HIV/AIDS programs might somehow be poorly run, such that changes need to be made to make sure “redundant” services aren’t offered. (This may be true, to a small degree, but as treatment clinics in Africa have to put people on growing wait-lists for medication, living with some waste appears to be preferable to letting millions of people die.)
4. Global health dollars need to be redistributed to other causes besides the fight against HIV/AIDS which save more lives per dollar. (This assertion may be disputed based on facts which show that HIV/AIDS is a major cause of maternal mortality and as the pandemic affects more people. At any rate, dealing with the HIV/AIDS pandemic now appears to be preferable to letting it progress unattended for several more decades.)
For a number of different reasons, the powers that be have decided that for now the tide of momentum for providing expanding preventive and life-saving treatment for HIV positive people world wide has been stopped in its tracks.
Volume 376, Issue 9748,
Pages 1254 – 1260,
9 October 2010