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Africa: AIDS Conference Reports

AfricaFocus Bulletin
Jul 17, 2004 (040717)
(Reposted from sources cited below)

Editor's Note

At the International AIDS Conference just concluded in Bangkok, the U.S. AIDS program came in for sustained criticism on several fronts. In an interview with the BBC, UN Secretary-General Kofi Annan chided the U.S. in particular for failing to keep its promises to support the international war against AIDS.

But while the U.S. was the primary target of criticism, prominent leaders as Annan and Nelson Mandela called for renewed efforts from all parties to address a war that is now being lost. Acknowledging that new resources are flowing and that the need for treatment as well as prevention is now on the agenda, conference attendees were also made acutely aware that the world's collective efforts were still falling well short of a winning strategy. In fact, UNAIDS noted in its annual report released just before the conference, [ http://www.unaids.org/bangkok2004/report.html], the estimated number of people living with AIDS increased from 35 million in 2001 to 38 million in 2003, despite some 3 million deaths from AIDS in 2003.

In sub-Saharan Africa, UNAIDS estimated that at the end of 2003, 25 million people were living with AIDS, and 2.2 million died of AIDS in 2003.

A host of policy reports and proposals were released at or around the Bangkok meeting. Among these, this AfricaFocus Bulletin includes excerpts (1)from a summary of the event from the Global Fund Observer, (2) from a report from the U.S. Government Accountability Office on the U.S. global AIDS program, and (3) from a New York Times article on implementation of the U.S. program in Mozambique. Another AfricaFocus Bulletin sent out today highlights several other reports, particularly one from Physicians for Human Rights highlighting the key role of human resources and the exodus of medical professionals from Africa to wealthy countries.

Other related reports released recently may be highlighted in future bulletins.

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

International AIDS Conference Roundup

Excerpts only. Reproduced from the Global Fund Observer Newsletter <http://www.aidspan.org/gfo>, a service of Aidspan.

Issue 30 16 July 2004.

The International AIDS Conference, which takes place every two years, ended today. Based this year in Bangkok, the conference was attended by 19,000 people. The Global Fund featured prominently. Thanks in large part to criticisms of President Bush's $15 billion PEPFAR initiative, the Fund was widely and somewhat simplistically portrayed by many as the knight on a shining white horse that could do no wrong.

The conference began with the release of some disturbing new data from UNAIDS: a record 5 million people were infected with HIV last year, and the cost of responding to the epidemic, including prevention, care, and treatment, will rise to an estimated $12 billion a year by 2005. But at the conference itself, whose theme was "Access for All," session after session took up the question of how, in practical terms, to expand treatment access to the millions in need of antiretrovirals and prevention access to the hundreds of millions most at risk for HIV. And the three most significant global AIDS initiatives the World Bank, the President's Emergency Program for AIDS Relief (PEPFAR), and the Global Fund were at the center of debates over how best to "scale up" the response.

The World Bank was criticized in some sessions for the role debt to the Bank plays in leaving national health programs under-funded; most prominently, UNAIDS executive director Peter Piot, in his speech during the closing ceremony, declared that "Africa's crippling debt must be relieved the $15 billion annually that disappears down the money pit. That is four times more than is spent on health and education the building blocks of the AIDS response." But throughout the conference the approach of the other two main players, PEPFAR and the Fund, were discussed and debated much more widely by protesters, panelists, government officials, and global leaders in the fight against AIDS.

Criticism was constant of PEPFAR on three main fronts: for setting its own agenda, rather than responding to country priorities; for putting ideological constraints on prevention dollars (particularly by earmarking funds for abstinence and by prohibiting funds that are used for harm reduction programs for injection drug users or that could be construed as empowering sex workers); and for its refusal to pay for generic medicines that have not received approval from the US Food and Drug Administration (none have), leaving its grantees able to purchase only patented drugs, often at many times the cost of generics. The United States' own Government Accounting Office (GAO) released a report on PEPFAR during the conference that confirmed these concerns. In GAO interviews with 28 USAID officials involved in implementing the initiative, all 28 identified coordination challenges and 25 identified PEPFAR program constraints especially limitations on the purchase of ARVs as primary obstacles to successfully implementing the program.

The criticisms of PEPFAR exploded onto the global stage on Wednesday afternoon, when PEPFAR's leader Randall Tobias, who had canceled at least two scheduled appearances earlier in the week and canceled a press conference after his speech, finally addressed the conference in a special lecture. As soon as he stepped up to the microphone, he was disrupted by activists condemning PEPFAR's policy on generic drugs, an event covered widely in the press.

The Global Fund, on the other hand, received broad support at Bangkok. While panelists and participants in several sessions spoke about in-country implementation problems, such as non-inclusive CCMs and significant delays in disbursement from Principal Recipients to implementing organizations, participants overwhelmingly expressed support for the Fund's nondirective approach to funding, which supports countries' national plans, the involvement of civil society, and sets no restrictions on drug purchasing or prevention interventions. Activists with Fund The Fund, a loose network of AIDS NGOs from donor nations, distributed some 5,000 leaflets to conference participants reading "Round 5 Now. Stop Killing the Global Fund. Fund the Fund" that were held up in plenary sessions, while street activists from the US-based Health GAP, the South Africa-based Treatment Action Campaign, the Thai AIDS Treatment Action Group, and others held street demonstrations with the same demand. ...

Princess Mabel van Oranje of the Netherlands, an economist, presented the results of a study by the Open Society Institute at the opening plenary, which found that the Global Fund was better positioned than other funding mechanisms to scale up the AIDS response, harmonize national efforts, and support a comprehensive approach to AIDS that integrates development concerns and addresses the needs of marginalized communities. She said she had set out to ask "how donors could get the best bang for their buck," and concluded that, "based on the early evaluations I would put my money in the Global Fund."

Messages throughout the conference from prominent figures such as UN Special Envoy for AIDS in Africa Stephen Lewis, French President Jacques Chirac, UN Secretary General Kofi Annan, and former President of South Africa Nelson Mandela echoed this growing confidence in the Fund: ...

After mentioning the Global Fund only in passing in his speech at the Conference's opening plenary, UN Secretary General Kofi Annan issued an unexpectedly strong statement of support for the Global Fund in a Tuesday interview with the BBC. He expressed disappointment that so little of the $15 billion promised by President George W. Bush to tackle HIV/AIDS is going to the Global Fund. "The Global Fund is ready to go," he said. "If individual governments begin to set up their own initiatives, they start from scratch, it takes longer, the money that they hold will not be spent for a long time." He went on to encourage the US to contribute $1 billion a year to the Fund, asking Europe to put in another billion. With additional resources raised elsewhere, "the Fund could have assured and sustained support through the next five years or so," Annan said. ...

The US delegation began the conference by mounting a vigorous defense of PEPFAR. USAID sponsored a Sunday satellite session featuring research in support of PEPFAR's preferred "A B C" (abstain, be faithful, use condoms) approach, and PEPFAR chief medical officer Mark Dybul claimed at various sessions that PEPFAR was disbursing funds much more rapidly than the Fund, because of USAID's 20-year history of HIV-related aid. He said that within PEPFAR's first four weeks, $850 million had been programmed, and that a total of $2.4 billion would be programmed by the end of September. He also said that within four weeks of PEPFAR's launch, people with HIV in rural Kenya were already receiving PEPFAR-funded ARVs. ...

But when conference participants continued to criticize PEPFAR and the level of US support for the Global Fund, Tobias lashed out. In an interview with the San Francisco Chronicle after his speech, Tobias said that "the United States is urging the Global Fund to slow down." He said the Global Fund, which has raised $3.5 billion, already had "a large pipeline'' of approved grants. "If we put more money into the Global Fund right now ... that money is going into an account at the World Bank,'' he said. "I believe they have adequate resources on hand.'' He added, "I think the president's budget request for $200 million [for the Fund] for next year is just fine."

In an interview with GFO at the close of the International AIDS Conference, Global Fund executive director Richard Feachem responded to these attacks. With regard to Tobias' claim that the Fund was sitting on a large pot of money, Feachem said, "I look forward to the opportunity to sit down with Ambassador Tobias and clarify for him the financial policies of the Global Fund. These are contained in our Comprehensive Funding Policy, approved by our board with full participation of the United States." That policy says that the entire amount that a grant will cost must be in the bank before the grant agreement is signed. "All monies currently in our bank account are fully committed and programmed to the board-approved grants in Rounds 1 through 4," Feachem continued. "The Global Fund clearly requires additional finance in order to launch Round 5 at the earliest possible opportunity."

In response to Tobias' support for President Bush's 2005 budget request for only $200 million for the Global Fund, Feachem responded: "In 2004, the US contribution to the Global Fund is $547 million. This is much appreciated by all Global Fund stakeholders and represents a full one-third of Global Fund income in 2004. In 2005, the Global Fund requires $3.5 billion in order to support the renewal of programs from Rounds 1 and 2, and the launch of Rounds 5 and 6. I am hopeful that, in view of the good results being obtained in many countries through Global Fund investments, the United States will decide to maintain its one-third share of our income needs."

Feachem went on to pay tribute to the strong European commitment to the Global Fund. As of May 21, European pledges for 2004, totaling $820 million, outflanked US pledges of $547 million. (This means that US pledges constitute 36 percent of Fund income in 2004, and Europe's combined pledges constitute 54 percent.) By the same date, Europe's pledges for 2005 totaled $576 million, greater than the US pledge of $200 million; Europe's 2005 pledges constitute 69 percent of the 2005 total so far, and the US pledge constitutes 24 percent.

Feachem added, "One of the strongest messages to emerge at the Partnership Forum was the urgent need to launch Round 5 immediately following the board meeting in Arusha in November. While recognizing the need for financial prudence, I fully support this call. Without it, the rapid scaling up of prevention and treatment activity for HIV/AIDS, in addition to the urgent needs for tuberculosis and malaria, will be jeopardized." ...

GFO also asked Feachem to comment on the concerns raised by conference participants about the frustratingly slow in-country disbursement from PRs to implementers in some Global Fund recipient countries. He replied that the Global Fund's recent analysis of progress on grants from Rounds 1 and 2 [see Fund Releases Progress Report, in GFO Newsletter] shows a mixed picture. "On the one hand," Feachem said, "fully 80 percent of the 25 grants that have passed their first birthday are making good progress, and we are all very pleased about this. On the other hand, some grants have been slow to get started." ...

Former President Nelson Mandela, making what might be his last speech outside South Africa, closed the conference with a rousing call for support for the Fund. ...

U.S. AIDS Coordinator Addressing Some Key Challenges to Expanding Treatment, but Others Remain

U.S. Government Accountability Office (GAO)

GAO-04-784 July 2004

Brief excerpts from 86-page report. To view the full report, including the scope and methodology, see
http://www.gao.gov/cgi-bin/getrpt?GAO-04-784. For more information, contact David Gootnick at (202) 512-3149 or gootnickd@gao.gov.

GAO interviewed 28 field staff from the U.S. Agency for International Development (USAID) and the Department of Health and Human Services (HHS), who most frequently cited the following five challenges to implementing and expanding ARV treatment in resource-poor settings: (1) coordination difficulties among both U.S. and non-U.S. entities; (2) U.S. government policy constraints; (3) shortages of qualified host country health workers; (4) host government constraints; and (5) weak infrastructure, including data collection and reporting systems and drug supply systems (see figure). These challenges were also highlighted by numerous experts GAO interviewed and in documents GAO reviewed. ...

Although the Global AIDS Coordinator's Office has begun to address these challenges, resolving some challenges requires additional effort, longer-term solutions, and the support of others involved in providing ARV treatment. First, the Office has taken steps to improve U.S. coordination and acknowledged the need to collaborate with others, but it is too soon to tell whether these efforts will be effective. Second, to address policy constraints, U.S. agencies are working to enhance contracting capacity in the field and resolve differences on procurement, foreign taxation of U.S. assistance, and auditing of non-U.S. grantees. However, the Office's guidance did not address key issues related to the use of PEPFAR funds to buy certain ARV drugs. Third, the Office has proposed short-term solutions to the health worker shortage, such as using U.S. and other international volunteers for training and technical assistance; however, agency field officials said that using such volunteers is not cost effective. The Office is discussing with other donors certain longer-term interventions. Fourth, the Office has taken steps to encourage host countries' commitment to fight HIV/AIDS, but it is not addressing systemic challenges outside its authority, such as poor delineation of roles among government bodies. Finally, the Office is taking steps to improve data collection and reporting and better manage drug supplies. ...

• Nearly all agency field staff cited problems coordinating with non-U.S. groups, and slightly fewer cited problems coordinating with other U.S. government entities. Limited coordination has led to duplicate efforts, confusion regarding standards, and heavy administrative burdens.
• Field staff lacked clear guidelines for procuring ARV drugs, which made it difficult to plan treatment programs, possibly inhibiting the agencies' ability to support country HIV/AIDS treatment programs. Also, inadequate contracting capacity in the field may create delays in obtaining medical supplies and executing agreements with implementing organizations. Further, differences among agencies regarding procurement, foreign taxation of U.S. assistance, and auditing of non-U.S. grantees may inhibit the agencies' joint efforts to expand ARV treatment.
• Recipient countries faced critical shortages of qualified health workers, including doctors, nurses, and administrators, needed to expand ARV treatment.
• In some host governments, limited political commitment to addressing HIV/AIDS, poor delineation of roles and responsibilities, and slow decision-making processes hamper efforts to expand treatment.
• Many countries have weak systems for monitoring and evaluating health care programs; inadequate systems for managing drug supplies; poor linkages among programs providing HIV/AIDS services; and deteriorating physical infrastructure, including labs, clinics, and roads needed to access rural areas.

Early Tests for U.S. in Its Global Fight on AIDS

By DEBORAH SONTAG

The New York Times, July 14, 2004

[brief excerpt; for full article see
http://www.nytimes.com/2004/07/14/health/14aids.html]

The Bush administration did not consult with Mozambique last year before designating the country as a beneficiary of its emergency AIDS plan. Mozambique was simply informed that it would be one of 12 African nations, and 15 countries overall, awarded substantial financial assistance.

The pledge of big money was certainly welcome, said Francisco Songane, the Mozambican health minister; AIDS has lowered life expectancy in Mozambique to 38. But the approach, perceived by many Mozambicans as arrogant and neocolonial, was not.

Mozambique, in southeastern Africa, had spent considerable time developing a national strategy to combat its high rate of H.I.V. infection. Other international donors had agreed to pool their contributions and let the Mozambicans control their own health programs. Thus, Mozambican officials recoiled when the Americans said earlier this year, "We want to move quickly, and we know that your government doesn't have the capacity," Mr. Songane said.

The Bush administration wanted the bulk of its funding to go toward more costly brand-name antiretroviral drugs for treatment programs run by nongovernmental organizations. But Mozambique had already decided to treat its people with 3-in-1 generic pills, which were cheaper and simpler to take. Also, Mozambique did not want an American program dependent on costly foreign consultants, NGO's and the largesse of foreign political leaders, that would run parallel to its own.

There were confrontational meetings in Washington and in Maputo, the capital of Mozambique. And in the end, to the surprise of many, the Bush administration agreed to give Mozambique the kind of help it really wanted, by strengthening its laboratories, blood-transfusion centers and the Health Ministry itself - albeit indirectly, through a grant to Columbia University.

"What I witnessed in Mozambique was a disaster averted," said Dr. Steven Gloyd, an international health specialist at the University of Washington who works with Mozambique. "So, for countries like Mozambique, this may turn out to be a positive intervention, even though it could be a lot more." ...

Seventeen months after President Bush announced his five-year, $15 billion emergency AIDS initiative, the program is belatedly getting under way, and surprising some critics of what is seen as its go-it-alone approach. In some cases, the plan is proving to be more adaptive and collaborative than had been expected, especially when countries are strong enough to stand their ground.

The plan is already directing considerable money into health clinics, laboratories, testing centers and hospices, AIDS treatment, prevention of H.I.V. and care of orphans.

For every Mozambique, however, where Washington has altered its plans to meet local objections, there is a Zambia, where local officials are in the dark. ...

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