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Africa: AIDS Conference Reports
Jul 17, 2004 (040717)
(Reposted from sources cited below)
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
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
++++++++++++++++++++++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
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
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
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 email@example.com.
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
- 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
- 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
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
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. ...
AfricaFocus Bulletin is an independent electronic publication
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