February 2004
The Global Pandemic: AIDS in Africa, China, and Russia
The HIV/AIDS epidemic continues to ravage much of Africa and threatens to do the same elsewhere. Last year, President George W. Bush pledged $15 billion in aid to combat HIV/AIDS, tripling the U.S. commitment to fighting the epidemic. On February 5, five experts gathered at AEI to assess the status of the epidemic and the U.S. commitment. Their discussion highlighted the looming AIDS explosions in Russia, China, India, Nigeria, and Ethiopia; the problems of drug resistance and the questionable capacity of African healthcare systems to roll out antiretroviral (ARV) therapy; the unforgiving cost-benefit calculus of ARV provision in low-income settings, arguing for concerted efforts to develop a vaccine and thereby change the realm of the possible; the progress in awareness and education campaigns in China; and the pharmaceutical industry's role in, and commitment to, fighting the epidemic. They were joined by global AIDS coordinator Randall L. Tobias and Health and Human Services secretary Tommy Thompson, who explained the President's Emergency Plan for AIDS Relief and its role in broader U.S. foreign and health policy.
Opening Address
Randall L. Tobias
Global AIDS Coordinator, U.S. Department of State
This is a time of hope in the global fight against the HIV/AIDS pandemic. The President's Emergency Plan for AIDS Relief (PEPFAR) is the largest commitment to an international health initiative in our nation's history. This plan will provide $15 billion of aid to help countries around the world combat the HIV/AIDS epidemic. Of that $15 billion, $9 billion in new funding will be provided to 14 countries in Africa and the Caribbean that are home to 50 percent of the world's population living with AIDS: Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia. Congress has mandated that a fifteenth country, outside Africa and the Caribbean, be added to this group of countries that will receive large sums of aid and particularly intense U.S. involvement in anti-AIDS efforts; that country will be chosen soon. An additional $5 billion will be provided to seventy-five countries with which we have existing bilateral assistance programs. The final $1 billion will be U.S. contributions to the Global Fund for AIDS, Tuberculosis, and Malaria, the UN program that aims to provide access to medicine to individuals in the developing world who would not otherwise be treated.
This aid will be provided over five years, starting with smaller amounts and rising over time. Congress has just approved the deployment of the first $350 million to established programs operating in the areas of prevention, treatment, and care. We look forward to diversifying the scope of our funding as we ramp up our commitment in the next funding cycles. Currently, our programs will be aimed at HIV/AIDS prevention through behavior-change and abstinence education, antiretroviral therapy, programs for orphans and vulnerable children, ensuring the safety of national blood transfusion programs, and eliminating HIV transmission due to unsafe medical injection practices.
The President's goals are to provide treatment to at least 2 million HIV-positive individuals in this five-year period, to prevent 7 million new HIV infections, and to care for 10 million people: those living with HIV/AIDS and orphans and vulnerable children who have been directly impacted by the disease. The plan offers an opportunity to harmonize HIV policy and management across all of our bilateral programs. In so doing, we will integrate prevention, treatment, and care into a comprehensive approach. We will focus on evidence-based, results-oriented methodologies. And we will reorganize our efforts so that we act as members of a single U.S. government team, making it easier to coordinate with other actors in the global fight against AIDS, such as the Global Fund. We will measure our success in lives saved, families held intact, and nations freed to move forward with development. It will require innovative approaches, dedication, and patience-but it can be done, and it will be done.
Panel Discussion
David Gordon
Central Intelligence Agency
The number of people with HIV/AIDS threatens to rise significantly by the end of this decade, perhaps reaching 50 million. Much of this increase will be due to the spread of the virus in five populous countries-China, Ethiopia, India, Nigeria, and Russia-the "next wave" of the epidemic. The international response, particularly last year, has been better than anyone had previously imagined possible. Governments in the "next wave" countries, and elsewhere, are increasingly recognizing that HIV/AIDS poses a challenge to their countries. Although some of the "next wave" countries (China, India, and Ethiopia) present a more optimistic outlook than others (Russia and Nigeria), major obstacles remain. There is a real risk that with greater outside assistance, countries will elect to "outsource" management of the epidemic to international organizations and foreign aid donors, leading to the problems of ownership that plague foreign aid of all forms. This attitude is already apparent in Russia. Absent domestic commitment, the international community cannot succeed.
In addition, socioeconomic and security transitions around the world are furthering the spread of the disease. Transitions to peace are always desirable-but the HIV/AIDS risk they pose argues that the disease should be addressed during conflict resolution as an important part of transition planning. Socioeconomic transitions, such as those in Eastern Europe, the former Soviet Union, China, and much of Southeast Asia, also result in stresses and mobility that pose risks that must be met by robust health system responses that include an HIV/AIDS component.
The effects of HIV/AIDS are far-reaching but difficult to quantify. We know that there is an economic impact at the individual, household, and community levels, but it is challenging to translate these measured effects into national-level, macroeconomic effects. Similarly, while it is clear that militaries will be affected in terms of manpower and readiness, it is difficult to determine whether that will mean less war, less peacekeeping, or something else entirely. The social and political effects are equally murky; one aspect we are beginning to appreciate is that of AIDS orphans, a phenomenon that places a high burden on all aspects of society.
Roger Bate
AEI
Poverty drives disease in Africa, and HIV/AIDS is no exception. Even though we have antiretroviral drugs, they are prohibitively expensive for most Africans. Usually patents and prices are blamed for this state of affairs, but in Africa, patent protection is only a minor reason for the lack of treatment. Pricing is an issue, and downward pressure on prices is welcome for its impact on the number of people being treated. But the main reason drugs are not being used is the lack of political will, medical facilities, and infrastructure. Falling prices, threats of compulsory licensing, and possible patent attenuation reduce the incentives for continued HIV research in the private sector. Small start-up companies are responding to this reduction in incentives and ceasing their HIV/AIDS research activities. This is particularly alarming because problems of drug resistance mean that new breakthroughs are critical.
HIV mutates quickly, so drug resistance is no idle threat. Today doctors face substantial resistance problems for tuberculosis and malaria, to name just a few. The Global Fund's response to malaria, as described in recent issues of the Lancet, the leading British medical journal, raises serious questions about the judgment of the Global Fund and its ability to effectively provide HIV/AIDS medication in the face of significant drug resistance problems. The Global Fund and the WHO's defenses include legitimate arguments: that changing drug policies in poor countries is time-consuming and requires bureaucratic cooperation that is not always forthcoming. But the multilateral health agencies can't have it both ways. It can't be impossible to roll out user-friendly malaria drugs in under five years but possible to treat millions of AIDS patients over the same period.
At the moment, 75,000-100,000 Africans are being treated with ARVs. It may be impossible to raise that figure to 3 million people in the next four to five years. But falling short of that target should not be seen as failure. Rolling out drugs too quickly, without the requisite infrastructure development, will lead to greater drug resistance-real failure. The U.S. government should carefully examine the practices of the Global Fund and invest its AIDS dollars wisely. If we fail to provide incentives for new drug development, succeeding with treatment will be impossible.
Nicholas Eberstadt
AEI
The cost-benefit calculus for antiretroviral therapies is extraordinarily unforgiving in low-income areas. Rough estimates show that administering generic ARVs comes at a price tag of around $2,500 per person per year of life extended; if the drugs are obtained free of charge, it still costs about $750. These numbers rely upon the following assumptions-all of which are reasonable, but none of which are sacred. First, they assume the median incubation period between contracting the HIV virus and the onset of AIDS is nine years. Second, they assume life expectancy after the onset of AIDS is two years. Third, they assume that treatment with ARVs provides three additional years of life. Fourth, they assume that the administrative costs of providing ARVs total to about $150 per person per year. Finally, they assume the discount rate on the expenditure is 10 percent.
Compare these costs-$2,500 for generic ARVs, $750 for free ARVs-to some alternate healthcare interventions. Anti-malarial interventions cost $10-15 per person per year of extended life. Tuberculosis treatment with the WHO's recommended directly observed therapy (DOTS) runs about $15 per person per additional year of life. Vaccination campaigns, or the provision of clean drinking water, cost even less. Changing the parameters of the ARV cost-calculations changes the resulting cost per person per year, but only at the margins. It will not affect the order of magnitude, as is required if we are to bring the cost of ARV treatment for AIDS in line with other potential health care expenditures.
This is the crux of the ethical and practical problem we face with ARV interventions in low-income settings. They are only economically justifiable as part of a prevention campaign, providing necessary hope to encourage people to be tested. We must decide that this is an unacceptable reality and act to change it, altering the realm of the possible through medical breakthroughs. Those breakthroughs will depend first and foremost upon research and innovation, which holds out the only realistic prospect for a vaccine to protect against HIV in the not-too-distant future.
Marwyn Samuels
U.S.-China AIDS Foundation
New STD estimates from China's CDC suggest that there are probably 2,000 new STD patients per practicing doctor trained to handle them per year. In the case of HIV/AIDS, the ratio is literally absurd: about 12,500 patients per doctor, with an additional 5,000 new patients per doctor per year if no new specialists are trained. The Chinese healthcare system is not prepared for this challenge, so only two near-term solutions are practical: a sustained prevention campaign, and training of medical personnel. These strategies are complementary.
Legal and political constraints are no longer the core obstacle to broad public awareness of HIV in China. The three major obstacles in China today are money, market segmentation, and attention span. Television markets are fiercely competitive, and programming is saturated with advertisements. Chinese watch relatively little television, so identifying one's target demographic and tailoring the message to the market becomes even more important. The public education component of anti-AIDS programs is best conveyed in a soap opera format or through a special television network.
The Chinese polity is transforming. China has recently experienced tremendous growth in single-interest groups, such as environmental groups and HIV-related NGOs, which are the core of a nascent civil society. The Chinese government is unable to contain the development of participatory interest groups, and has begun to even discern its own self-interest in encouraging this phenomenon in some sectors, including public health. This is not to say that democracy is just over the horizon, but government and politics in China are becoming more responsive to popular demand. Like the SARS epidemic, the HIV/AIDS and STD epidemics in China are a form of peaceful evolution. Although this peaceful evolution comes at a huge cost in human lives, it is transforming society indirectly.
Jeffrey Sturchio
Merck & Co., Inc.
Large research-based pharmaceutical companies' primary role in the fight against the HIV/AIDS epidemic is to develop and discover breakthrough medicines to advance patient care. We consider this to be our role for a number of reasons. First, we engage in HIV/AIDS research and the manufacture and provision of AIDS drugs because we can. This is one of the worst epidemics in human history, and all people share a responsibility to help in any way they can. Second, we believe that health makes wealth. Emerging markets around the world are being hit by this epidemic, and it is in our interest to help these countries survive and develop, until they become mature markets like those of North America and Western Europe. Simply put, it is a humanitarian response that makes business sense.
Merck's HIV vaccine research program is the largest and most intensive in the company's history. A promising vaccine candidate is now in early human trials in eighteen cities around the world. Nonetheless, discovery is fundamentally a matter of serendipity. Although Merck and other large pharmaceutical companies will continue their research despite recent developments, it is in the best interests of AIDS patients to preserve the economic incentives for AIDS research so that the smaller companies remain in the business, too.
Merck and other large pharmaceutical companies are committed to making their medicines accessible to as many people as possible. Public-private partnerships provide one important means of doing so. They draw on the expertise of all the stakeholders to develop a comprehensive, multisectoral approach across the spectrum of prevention, care, support, and treatment. With strong political leadership, a comprehensive and coordinated approach across the entire spectrum of care, investment in healthcare infrastructure, and the training of healthcare providers, they are an important component of plans to scale up the response to the AIDS epidemic. These partnerships are a tremendous cause for hope, which can also be found in the front-line efforts people are making on the ground daily, in the new resources that are coming into the fight, and in scientists' research efforts for the development of new medicines and a vaccine.
Keynote Speech
Tommy G. Thompson
Secretary, U.S. Department of Health and Human Services
AIDS is a global epidemic that has claimed the lives of millions, from Africa to America. The Bush administration is committed to fighting AIDS at home and abroad. Drawing on the expertise Americans developed in our domestic efforts to combat the disease, the United States is doing a great deal to prevent and treat AIDS in Africa and around the globe. The Bush administration has dedicated $15 million over five years to the cause, drug companies are providing drugs to African countries, and private investors are also contributing. Visits to countries such as Botswana, Uganda, and Mozambique reveal that these efforts are producing positive results both in terms of combating AIDS and boosting morale.
One of the core PEPFAR initiatives is the prevention of HIV transmission from mother to child during childbirth and infancy through the use of nevirapine and ARVs. Although it focuses on Africa and the Caribbean, PEPFAR also provides for the strengthening of U.S. bilateral programs around the world, such as those in India and China, and for developing new relationships in countries like Russia and the Ukraine. As PEPFAR is implemented, the U.S. policy on patents and AIDS drugs will remain firmly committed to supporting intellectual property rights of pharmaceutical companies. We will continue to press companies to make their products available at the lowest possible prices, recognizing that failure to respect intellectual property rights will stifle innovation and ultimately be counterproductive. Collective drug purchasing can efficiently provide ARVs to people living in countries that otherwise couldn't afford AIDS medicines.
Three years ago, President Bush and UN Secretary General Kofi Annan announced the Global Fund, a UN initiative to provide access to medication for AIDS, tuberculosis, and malaria. The US has utilized the Fund's structure to build stronger relations with countries threatened by AIDS, and PEPFAR also provides for continuing U.S. contributions to the Global Fund. Congress has capped those donations at 33 percent of the Global Fund's total budget, to encourage other countries to contribute equally generously. Even in my role as chairman of the Global Fund, I support this limit on U.S. funding because the United States cannot win this war on its own.
Whether collaborating with Indian scientists on vaccines, educating China's leadership about the benefits of transparency when dealing with AIDS, or working with Russian leaders to reduce risky behavior among its people, promoting good health makes wonderful foreign policy. The United States is home to the best doctors, researchers, and scientists in the world. Our foreign aid strategy should take advantage of this area of expertise. "Doctor diplomacy" works extremely well: you need not share a man's faith, or speak a woman's language, to save his or her life, or those of their children. Furthermore, when we help others, we are not just saving lives. We are also spreading respect and love for America and Americans, the importance of which cannot be underestimated in today's geopolitical context.
AEI research assistant Heather Dresser prepared this summary.
