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Truth and Reconciliation: President Obama's Global Health Initiative and HIV/AIDS -- Raising the Bar

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Dr. Ezekiel Emanuel, special advisor for health policy in the Office of Management and Budget, published an op-ed in The Huffington Post responding to criticisms made by the global health community that the Obama administration is flat-lining HIV/AIDS treatment funding. Contrary to op-eds written by Archbishop Desmond Tutu in The New York Times and my own in The Huffington Post, Dr. Emanuel asserted that President Obama has "steadily increased" support for the President's Emergency Plan for AIDS Relief (PEPFAR). Surprisingly, despite recent scientific evidence, Dr. Emanuel also stated that President Obama's Global Health Initiative recognizes "we can't treat our way out of the HIV/AIDS epidemic."

Dr. Emanuel claims that President Obama has "steadily increased" support for PEPFAR by "proposing an 8% increase in global health funding... including a historic $7 billion request for PEPFAR" in the President's 2011 budget. Indeed, Dr. Emanuel is correct but only in that he is misrepresenting the complete picture.

In 2008, the United States Congress authorized the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act providing $48 billion over 5 years ($9.6 billion/year) to PEPFAR. However, President Obama's $63 billion Global Health Initiative allocated $51 billion over 6 years ($8.5 billion/year) resulting in an overall decrease in PEPFAR funding while allocating $12 billion towards other global health initiatives including maternal and child health. By not providing "new" money towards maternal and child health, President Obama has in de facto pitted HIV/AIDS funding against other global health priorities.

In rare occasion, Republicans and Democrats in both houses of the United States Congress issued strong bipartisan criticism of the Obama administration's retrenchment in financial commitment towards HIV/AIDS treatment (Congressional Letters of Concern: Senate Letter (dated Dec 12 2009); House of Representatives Letter (dated Dec 15, 2009); GOP Senate Letter (dated April 30, 2010). Sadly, the funding decisions made by the Obama administration resulted in the devastating "rationing" of antiretroviral treatment in Uganda as reported in The Boston Globe and The New York Times.

The claim made by Dr. Emanuel that "we can't treat our way out of the HIV-AIDS epidemic" is incorrect, in light of new scientific evidence that emerged last week from the International AIDS Conference in Vienna. Results by Dr. Julio Montaner published in The Lancet demonstrated that provision of antiretroviral therapy in British Columbia halved the rate of new infections. The Economist writes the study by Montaner is "the strongest confirmation yet that treatment and prevention are two sides of the same coin."

Treating our way out is indeed possible.

In our recent article in AIDS, Sarah Leeper and I demonstrated the unique dynamic-reciprocal relationship that HIV/AIDS, TB, and Malaria have on maternal and child health and vice-versa in the resource limited setting. I salute Dr. Emanuel for forwarding the dialogue on global health and advocating for comprehensive, integrated, cost-effective models of care that advance not just HIV/AIDS but other important health priorities including maternal and child health. Given that the provision of antiretroviral treatment can actually lead to prevention, eradication of new HIV infections is possible if the world community remains fully committed to funding cost-effective antiretroviral treatment initiatives.

HIV/AIDS organizations, including Médecins Sans Frontières, Partners in Health, The Clinton HIV/AIDS Initiative, and The AIDS Healthcare Foundation (AHF) have pioneered cost-effective approaches. In particular AHF- the world's largest HIV/AIDS organization- under the leadership of Michael Weinstein has led the charge towards cost-effective care.

AHF proposes:

  1. PEPFAR should spend no more than $350 per person per year for treatment.
  2. Restore PEPFAR funding to levels originally authorized by the Lantos-Hyde legislation ($48 billion over 5 years)
  3. Remove waste by limiting administrative overhead for contractors to 10% and all indirect costs to 20%.
  4. Require that 75% of all PEPFAR funds be spent on AIDS treatment

Senator Tom Coburn MD (R-OK) has recently introduced the HIV/AIDS Saves Lives First Act of 2010 that builds upon many of the cost-effective solutions advocated by AHF. President Obama should endorse the Coburn bill to save an additional 2 million lives.

HIV/AIDS remains an emergency and warrants an exceptional response. Colleen Denny and Dr. Emanuel's innovative and seminal Mother and Child Campaign recognized an important area in global health, and President Obama was correct to enact polices that addressed maternal and child health. As Dr. Emanuel correctly writes "patients don't come to doctors with one disease or condition, and our response shouldn't focus on one as well." However, President Obama needs to fully fund both PEPFAR and maternal and child health initiatives.

President Obama has achieved great things for this country including: domestic healthcare reform, Wall Street reform, and re-emphasizing multilateralism in US foreign policy. Now the President has the opportunity to significantly improve global HIV/AIDS (and maternal and child health), saving millions of more lives in the developing world, and building upon the success of President George W. Bush and PEPFAR.

I urge President Obama to embrace the AIDS Healthcare Foundation's proposal to improve HIV/AIDS delivery in a cost-effective manner, restore PEPFAR funding to the levels originally authorized by the Lantos-Hyde Act, and strongly endorse Senator Coburn's bill.

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In 2005, Anand Reddi was a Fulbright Scholar assisting the Sinikithemba HIV/AIDS clinic at McCord Hospital in Durban, South Africa. Mr. Reddi serves on the board of directors of the AIDS Healthcare Foundation (AHF), the largest HIV/AIDS organization in the world. Mr. Reddi is currently at the University of Colorado, School of Medicine.