Scaling Up Treatment for the Global AIDS Pandemic Challenges and Opportunities (2005) / Chapter Skim
Currently Skimming:
2 Opportunities and Challenges
2 Opportunities and Challenges
Pages 32-61
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; U.S. funding for global HIV/AIDS efforts, in particular the President's Emer BOX 2-1 The Global AIDS Pandemic at a Glance · Leading infectious cause of adult death in the world · Leading cause of death in adults aged 1559 · First case of AIDS recognized in 1981 · 40 million persons now living with HIV/AIDS, 50% of them women · More than 70% of HIV-infected persons living in Africa · 14,000 new infections daily · Sexual transmission responsible for more than 85% of infections · 6 million in need of immediate treatment and fewer than 8% receiving it SOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b.
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The final section examines the ethical issues and challenges at both the local and international levels. CURRENT EFFORTS The Global Fund: Scale-Up of Antiretroviral Therapy in Action The Global Fund to Fight AIDS, Tuberculosis, and Malaria, sponsored by the United Nations (UN)
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Many are concerned that the Global Fund monies have been slow to roll out and that, despite agreements being in place, some countries do not yet have the promised funds or ARVs. Total global funding budgeted for the fund in 2003 for HIV/AIDS was an estimated US$4.2 billion (including funding from all donor governments and UN agencies and disbursements from The World Bank, foundations, and major nongovernmental organizations [NGOs]
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In mobilizing resources, the Global Fund operates as a financial instrument to attract, manage, and disburse funding to fight HIV/AIDS, tuberculosis, and malaria worldwide through a competitive grant support mechanism. It seeks to fund projects that will form new or innovative alliances with governments, civil society, the private sector, and affected communities, which in turn will create local ownership of programs.
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: · Satisfactory evidence of a strategic approach to HIV/AIDS, developed in a participatory manner · Existence of a high-level HIV/AIDS coordinating body, with broad representation of key stakeholders from all sectors, including people living with HIV/AIDS · Government commitment to quick implementation arrangements, including channeling grant funds for HIV/AIDS activities directly to communities, civil society, and the private sector · Agreement by the government to use multiple implementation agencies, especially NGOs/community based organizations
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Kaiser Family Foundation, 2004b)
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multilateral support. The President's Emergency Plan for AIDS Relief On May 27, 2003, President Bush signed Public Law 108-25, the United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003.
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Operational Plan for Comprehensive HIV and AIDS Care, Management, and Treatment for South Africa Of the more than 5 million HIV-infected South Africans, 400,000 to 500,000 are eligible for ART based on the WHO guidelines, indicating one of the largest AIDS burdens in the world. Fully 12 percent of the general population is infected with HIV.
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Examples include providing clean water to 8.4 million new South Africans, providing access to electricity for 3.8 million households, building 1.46 million formal houses, increasing literacy, increasing the number of children in school, and increasing the number of people involved in an integrated nutrition program.
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Also in the early 1990s, the South African government developed its first strategic plan for HIV/AIDS. In terms of expenditures, the national response to the HIV epidemic was initially quite inadequate, with only US$4.4 million (2004 exchange rate)
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A task team was convened and, with the assistance of up to 40 technical consultants from the Clinton Foundation, an operational plan was written; this plan was endorsed by the Cabinet on November 19, 2003, without reservation. On January 23, 2004, the first patient received treatment.
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In recognition that some 80 percent of South Africans have recourse to traditional healers and take traditional medicines, the plan includes efforts to destigmatize traditional medicine and ensure that health professionals are aware of possible interactions and other issues surrounding the use of such medicines. During the development of the plan, as with ART scale-up in general, human resource deficiencies were identified as the principal constraint (see Chapter 5 for further discussion)
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COORDINATING THE GLOBAL RESPONSE The ambitious ART roll-out goals of the PEPFAR initiative, the South African government, WHO, and a considerable number of countries and organizations worldwide represent a desperately needed global response to a devastating human tragedy (see Table 2-3)
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SOURCE: Henry J Kaiser Family Foundation, 2004a,b.
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Duplication of effort and generation of redundant data may create unnecessary additional work for those responsible for collecting and managing monitoring and evaluation data. Role of National Governments The role of the governments of affected countries will be crucial to a coordinated response, since NGOs and universities, which serve as valuable sources and concentrations of expertise, do not have the mandate to scale up.
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Box 2-5 describes one example of an assessment tool. Of note, based on its experience assessing program readiness, the Clinton Foundation has repeatedly identified human resource capacity as the major limiting factor.
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SOURCE: Hirschhorn et al., 2002. Importance of Engaging the Private Sector and Nongovernmental Organizations Although the tendency when discussing and planning ART scale-up is to focus on the public sector, nongovernmental and private-sector programs may provide innovative, creative mechanisms for getting programs-including ART programs -- off the ground more rapidly and operating more efficiently.
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This and other human resource and infrastructure issues surrounding the management of ART scale-up are discussed in greater detail in Chapter 5 and in Appendix E Finally, as important as assessing readiness may be to introducing ART programs in the manner most likely to achieve maximal ARV coverage, it is equally important that scale-up efforts be able to proceed without having every detail in place.
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A recent economic analysis of 83 countries showed that achieving high ARV coverage by 2015 will require additional annual spending of an estimated $US6.8 to 9.2 billion, including 25 percent for infrastructure (additional annual costs for prevention and care total more than an estimated $8.5 and $5.5 billion, respectively) (Kumaranayake et al., 2002)
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In Zambia, a 2003 report on the per-patient costs and human resource requirements for scaling up ART in that country concluded that, at a perpatient annual cost of US$480, the current ART budget allows for provision of therapy to only about 10,000 people (Kombe and Smith, 2003)
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The Clinton Foundation uses WHO's prequalifying Procurement Quality and Sourcing Project (WHO, 2004b) criteria as accepted by the South African Medicines Control Council (Medicines Control Council, 2004)
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Need for Continuous Funding Not only will the sustainability and success of ART scale-up depend on long-term funding, but it is vitally important that such funding from external donors be continuous while upstream issues such as debt and trade rules are being addressed in ways that could reduce the long-term dependence of developing countries on this philanthropy. In some countries, uncertainties in funding are already putting ART programs at risk of failure by interrupting the procurement and timely delivery of drugs.
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At the same time, national governments in coun tries severely affected by HIV/AIDS must begin to invest in and develop priorities for prevention and treatment programs to ensure those pro grams' long-term sustainability and effectiveness. ETHICAL ISSUES As ART programs are scaled up throughout the developing world, many difficult decisions will be necessary, and in many cases, both local and institutional/international ethical issues will be faced.
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· To be eligible for Médicins sans Frontières' pilot ART program in South Africa, patients must meet certain biomedical, adherence, and social criteria, in cluding residence within a certain geographic area, number of dependents, health status, income, and level of activism in seeking improved access and care for individuals suffering from HIV/AIDS. SOURCE: Wasunna, 2004.
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In the latter context, researchers identified the importance of seeking multiple perspectives on the problem under review, ensur ing transparency and honesty in the decision-making process, identifying potential conflicts of interest, and achieving consensus. A recent detailed qualitative study of how the framework of accountability for reasonableness can be applied to ac cess to intensive care units for neurosurgical patients provides evidence that such a process improves the fairness of priority setting.
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How should such countries be treated by the international community? What are the ethical issues surrounding the provision of funds and resources to countries without ethical decision-making processes in place?
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. It is imperative that ART programs be strategically situated within existing health care systems so that funding for HIV/AIDS can contribute to building a sustainable health care infrastructure that can benefit all people in need, whether they suffer from HIV/AIDS, TB, malaria, or some other health complication.
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Henry J Kaiser Family Foundation.
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. Office of the United States Global AIDS Coordinator.
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. South African National Treasury.
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