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United States Global Health Policy: HIV/AIDS Treatment Funding At Risk Under President Obama

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This week, the XVIII International AIDS Conference is convening in Vienna, Austria. The diminishing commitment by the Group of Eight (G8) countries, including the United States, towards HIV/AIDS treatment funding is a major topic at the Vienna AIDS conference. The global economic recession and the de-emphasis of HIV/AIDS treatment in favor of other global health initiatives threatens to undermine the impressive results achieved thus far in treating HIV/AIDS in the resource limited setting.

In 2003, President George W. Bush authorized the President's Emergency Plan for AIDS Relief (PEPFAR) with a 5-year, $15 billion commitment towards HIV/AIDS prevention and treatment. In 2008, due to the tremendous success of PEPFAR, President Bush and the United States Congress reauthorized PEPFAR for an additional 5-years allocating $48 billion. As of September 2009, PEPFAR has: prevented HIV transmission in an estimated 77.6 million people, prevented 340,000 babies from contracting HIV, provided 2.4 million patients with life-saving antiretroviral treatment, and supported the care of 11 million people including 3.6 million vulnerable children. These impressive results warrant the doubling, or even tripling, of PEPFAR's budget. Despite these successful outcomes PEPFAR is under attack.

In May 2009, President Barack Obama unveiled a new global health initiative. The architects of the Obama administration's global health initiative, namely Dr. Ezekiel Emanuel (a healthcare advisor to President Obama), recommend funding maternal and child health initiatives at the expense of future funding increases for PEPFAR. Dr. Emanuel in an article in The Journal of the American Medical Association claims that PEPFAR "is not the best use of international health funding," and "fails to address many of the developing world's most serious health issues."

Recent articles in The Boston Globe and The New York Times have reported evidence of a retrenchment in PEPFAR treatment funding for new patients in Uganda. In South Africa, an estimated 3,000 deaths occurred due to a recent antiretroviral scale-up moratorium. The Office of the United States Global AIDS Coordinator in the Department of State claims that PEPFAR is, "moving from its initial emergency focus to a heightened emphasis on sustainability, and serving as a platform for expanded responses to a broader range of global health needs." Sadly, the perception that HIV/AIDS is no longer an emergency is misinformed.

Only one-third of patients who qualify for antiretroviral therapy in resource-limited settings are able to access it. Recently the World Health Organization revised guidelines for antiretroviral initiation; an estimated 5-million new HIV-infected patients now qualify for treatment. Flat-lining PEPFAR funding increases would, in essence, constitute "treatment rationing" for the millions of patients dying of this entirely treatable illness.

Polices that de-emphasize PEPFAR threaten to undermine, rather than support, maternal and child health in countries with high HIV/AIDS prevalence. A recent article in AIDS reported that in the five countries with the highest adult HIV prevalence worldwide, HIV is the leading cause of mortality in children under the age of five. A recent study in The Lancet estimated that in the absence of HIV, there would have been a 17.9% reduction in maternal mortality in 2008 suggesting the importance of providing HIV treatment to women.

Sarah Leeper and I in the journal AIDS argue: "The idea that differing global health initiatives must compete with each other lacks not only ethical legitimacy but also scientific merit. Maternal and child health, need not to be framed in opposition to PEPFAR. Confronting illness in isolation -- whether by funding PEPFAR at the expense of programs that target maternal or child health or vice versa -- cannot be our way forward. We should be advocating for funding both PEPFAR and maternal and child health together instead of favoring one program over another."

In this current climate of government bailouts for the financial and automotive industries, exorbitant budgets for the wars in Afghanistan and Iraq, and stimulus spending (together amounting in excess of $1 trillion), allocating the appropriate funds towards global health initiatives is a moral imperative for the United States in the spirit of Tikkun Olam. I urge President Obama to reaffirm his presidential campaign promise of expanding PEPFAR "by $1 billion a year in new money over the next five years," while also supporting maternal and child health.

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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.