May 31, 2007
Here's a Good Idea
Southern African nations are organizing to launch a joint effort to produce antiretrovirals. In the wake of several countries offering compulsory licenses to produce generic versions of AIDS drugs, this step would be another way that the developing world can take some control over the way it treats AIDS. It also could do more to disrupt the current drug distribution and patent hegemony.
May 30, 2007
Ryan White Redux
Housing Works has some details on the impact of Ryan White restructuring on New York City. Though the city's HIV services groups planned for a shortfall, they were apparently not expecting it to hit $20 million. They are appealing to the city for help, but it remains to be seen whether the backlash is strong enough to prompt a response. Whether federal money could be made available on an emergency basis is also not clear.
In other news, this year's NYC AIDS Walk was the most successful ever, raising $6.9 million for AIDS organizations here. Not that it fills the gap, but perhaps there is appetite for private fundraising.
In a Rose Garden press conference, President Bush has announced he'd ask Congress to "double" the budget for his global AIDS plan over the next five years. That would be $30 billion from 2008 to 2013. But if you're keeping track at home, you've noticed that PEPFAR won't be reauthorized until next year. And since budgets are made on an annual basis, it's hard to make sense of a request of $30 billion over five years, just as it was hard to make sense of his original $15 billion request for PEPFAR's first five years. (Congress will have provided about $18 billion.)
Bush, of course, will be out of office in 2009, 2010, 2011, 2012 and 2013, and presumably he won't be hanging around lobbying Congress come budget season in each of those years. Also, he didn't say where Congress should come up with the money. And as with any budget request, Congress could ignore Bush and chart their own course.
So why the press conference? The Washington Post says: "But administration officials said he wants to make the announcement in advance of next week's [G8] summit, during which Bush is likely to take criticism for his administration's positions on climate change. Also, [Robert] Zoellick's appointment is expected to stir opposition among nations weary of U.S. leadership of the World Bank." As John Donnelly puts it: Bush is looking at his legacy.
Many AIDS groups criticized the request as being too paltry to keep up with the spread of HIV. The New York Times says: "Administration officials concede that point and say the White House is hoping Mr. Bush's announcement will prod other Group of 8 countries, as well as nations that have growing economies, to make spending commitments of their own." Perhaps this will be one of PEPFAR's lasting effects, to normalize high spending on HIV overseas.
It's worth noting that you can't go from zero to 60 instantaneously. Even if money suddenly became available to pay for every request under the sun, countries couldn't absorb it or spend it efficiently.
Guidelines for Expanded Testing
The World Health Organization now advises making an HIV test a part of routine care in parts of the world hardest hit by AIDS. Evidence suggests that making tests more regular goes a long way to cutting down the vast majority of infected people who do not know it. "Those who do not know they are infected are more likely to infect others and less likely to seek early treatment, experts said. That means it costs more and takes more effort to save them with antiretroviral drugs," writes Sharon LaFraniere in the New York Times.
"Still, some human rights advocates have argued that because of the stigma of AIDS, no one should be pushed to take a test that could lead to the loss of their employment or abandonment by their families," she writes. Others argue that normalizing testing will go a long way to normalizing HIV.
The real rub is here, however: "... the new policy would likely depend on hiring and training more low-level health care workers because there are far too few doctors or nurses in low-income countries to handle the task."
Drug Access = Drug Profits?
Turns out that the lobbying push for better access to HIV medicines in Canada perhaps had a profit motive. If your national health care system will pay buy the drugs you make, it gives you a regular revenue stream. This is not unheard of and it's probably going to crop up in a lot of places. Last year I covered a Abbott Labs-sponsored buffet dinner for poor AIDS patients in New York, and I couldn't figure out why the company was wining and dining them. Then it hits me: New York has a very comprehensive health care system for the poor -- which would cover the new version of Abbott's Kaletra, the drug that was the subject of the dinner's PowerPoint presentations and postprandial entertainment.
A Helpful Reminder
Doctors Without Borders has a new report setting down in painful detail the lack of health care workers in southern Africa, and its effect on medical treatment there, especially around AIDS. The health-worker crisis is pushing its way onto the global AIDS community's radar, albeit slowly. Last year at the International AIDS Conference in Toronto, protesters interrupted one of Bill Clinton's speeches to call for more doctors and nurses. Clinton said something to the effect of "Actually, I agree with them."
Now that drugs are more widely available, the barriers to access are increasingly about infrastructure and personnel. Malawi, the report says, has two doctors for every 100,000 people -- that's 260 for the entire country of 13 million.
There are a few causes here. The New York Times recently pointed out the problems with Africa's crumbling universities. Students I met in both Mozambique and Ghana were good-naturedly waiting out strikes and political strife to return to class. But Google "brain drain Africa" to see what happens when countries produce highly skilled workers like doctors. If they are trained abroad, they tend not to come back -- at least in particular in the medical fields.
May 29, 2007
DC IDU HIV
The New York Times reviews the way in which the federal government uses Washington DC as a social-policy laboratory by way of the ban on needle exchange programs. The degree to which that ban worsens DC's HIV epidemic -- growing 10 times as fast as the national average -- is not clear, but it cannot be helping. Now that Democrats control Congress, however, some influential members are saying they'll get rid of it. A moral battle will no doubt ensue.
May 25, 2007
Innocent Until Tested?
The New York Times explains a fight over a state bill to require anyone indicted for rape to undergo an HIV test. The rationale behind the bill: If someone who is raped is at risk for exposure, he or she should know. If exposed, the victim could take a prophylactic course of ARVs, a treatment that often keeps the virus from taking hold. The current law requiring a test only on conviction of rape does not allow the victim to start the drugs fast enough. There are a couple of sides to this one:
Why not give ARVs to any rape victim, just to be safe? That would alleviate the concerns of those who point out that tests can sometimes show up falsely negative if the rapist had only recently been infected. Well, the bill's backers say, ARV treatment is quite toxic and not without side effects. Best not to put people through that unless it's necessary.
The civil-liberties types say that it sets a disturbing precedent to test someone who is merely accused of a crime, particularly if the results become public. But given the huge number of infected people who don't know their status, any excuse to test seems like a good one, especially set against the many other indignities the accused suffer regardless of whether they are ultimately convicted.
The bill touches on a broader debate about testing: Because of the stigma that remains around AIDS, even some patient advocates argue for limits on testing. And most say that testing must be accompanied by proper counseling, education and referrals. Still, no one argues against more people getting tested and knowing their HIV status.
May 24, 2007
Set the Bar Lower
The CDC's new target for reducing HIV infections is 10 percent -- a number some advocates call too low to inspire the necessary response, according to Poz. The old target had been 50 percent, which was perhaps unrealistic in the other direction. Take your pick.
Ryan White Cuts Still Raw
The San Francisco Chronicle reports on millions in cuts the Bay Area faces as a result of last year's Ryan White law reauthorization. The changes prompted Speaker Nancy Pelosi to write to HHS seeking an explanation.
As the Chronicle notes: "Among the programs bracing for cuts are meal deliveries, emergency housing, legal assistance, benefits counseling and emergency financial aid. The council voted to maintain Ryan White funding for core services such as primary medical care, mental health and substance abuse, home health care and case management."
The new law was meant to spread the money better between historically hard-hit areas and others getting big HIV populations for the first time. One might argue that a cutback in secondary services in San Francisco might mean more primary services for the rural South, but it's a debate we'll see across the country as states get their Ryan White money.
May 21, 2007
In Other News...
Catching up on a few items:
|| Some new reports:
The WHO reports on treatment progress worldwide.
DATA, Bono's organization, evaluates the follow-through on promises of aid to Africa. (Curious? The New York Times says it's not pretty.)
ActionAid says the world is far from on track to guaranteeing universal access to ARVs. (Reuters on the report.)
The Global Fund releases a progress report that says they've put 1 million on ARVs. (Reuters breaks it down.)
|| The Los Angeles Times continues its investigative series on the questionable investments of the Gates Foundation, which despite its humanitarian aims may have put its money into some unsavory places. This time: Warren Buffett's money may fund the janjaweed. The rest of the series.
|| One victim of the brief "D.C. madam" scandal was the head of USAID, Randall Tobias, who in his previous job as head of PEPFAR was the spokesman for the U.S. anti-prostitution, pro-abstinence and fidelity policies. John Donnelly reports on Tobias's resignation. Jodi Jacobson engages in a little schadenfreude.
|| The May/June Mother Jones has a curious if thin piece about the international black market for AIDS drugs.
|| Finally, a flap you may not have heard about at the World Bank: A high-level official allegedly ordered all references to family planning removed from a funding package to Madagascar. When family-planning and women's rights groups got wind of it they protested strongly. None other than Paul Wolfowitz stepped in to ensure the language, promoting contraception to stem the spread of HIV, stayed in place.
Earmark Delayed is Justice Denied?
The Wall Street Journal has a look at the most immediate option for removing the abstinence-only earmark in PEPFAR law: This year's foreign operations spending bill. According to the story, appropriators have enough on their mind without poking this hornet's nest, and it seems more likely that striking the earmark will have to wait until the legislation is reauthorized, probably next year.
Poz Visits Ghana, Toronto, Thailand . . .
June's Poz magazine has a story I wrote about pre-exposure prophylaxis: The idea that ARVs used to treat AIDS could actually prevent HIV transmission. A potential boon to the developing world. Difficult to test. Efficacy unknown. Read more.
May 12, 2007
Catching Up With. . . Thailand
Thailand's decision to issue compulsory licenses to allow cheap generic versions of two HIV drugs and an anti-clotting drug kicked off a chain of events in recent weeks.
(To recap: Thailand recently exercised its right under World Trade Organization rules to issue such licenses in case of "public health emergency" or "for government use." It's the wealthiest country to do this, which alarmed some trade and intellectual property advocates who claimed that going around the drug companies would cut their incentives for doing research into new drugs. These people usually don't mention that the governments issuing the licenses have to pay the companies a royalty, and that these companies aren't exactly pouring money into research on diseases that primarily affect the poor anyway.)
First, the U.S. Trade Representative announced it was putting Thailand on something called the "priority watch list." This is a warning shot that puts the country on notice it could lose its trade preferences and may not be a good investment for foreign capital. Supporters of issuing generic licenses attribute the move in part to lobbying from a shadow group called USA for Innovation. The conspiracy-minded linked the group's head, Ken Adelman, to the Edelman PR firm, whose clients include a dozen drug companies and the former prime minister of Thailand, who was deposed last fall. For good measure, they also note that Adelman is the guy on President Bush's Defense Policy Board who predicted a "cakewalk" in Iraq.
Next, Brazil followed Thailand's lead and announced it would issue a generic license on an HIV medicine. Despite several years of negotiations, they could not get a low enough price from Merck, the drug's maker. Like Thailand, Brazil's national health plan provides ARV drugs to the needy free of charge. If the name-brand drug companies were afraid that Thailand would open the door to undermining their patents, and profits, in middle-income countries, Brazil's move would provide some justification for that fear.
Then, the Clinton Foundation announced a deal to provide second-line AIDS drugs to the developing world at record-low prices. The foundation also announced it would provide a one-pill-a-day combination drug also at a new low price. The success of this deal will depend on generic licenses being issued. When asked, Bill Clinton said he supported them, and Thailand and Brazil in particular. At least in the short term, the generic companies and the developing countries seem to be winning this war.
Update, May 24: Who cares about all this stuff? UPI writes that PhRMA's fight against Thailand is meant to set an example to prevent other countries from following. It's emblematic of PhRMA's swim against the tide on intellectual property.