Obama Launches HIV Cure Initiative, Ups Pledge For Global Health.


 

President Obama walks into an auditorium in the Eisenhower Executive Office Building Monday for a speech about World AIDS Day.

President Obama walks into an auditorium in the Eisenhower Executive Office Building Monday for a speech about World AIDS Day.

Carolyn Kaster/AP

 

Commemorating the 25th World AIDS Day a day late, President Obama announced an initiative Monday to find a cure for HIV infections that would be funded by $100 million shifted from existing spending.

 

“The United States should be at the forefront of new discoveries into how to put people into long-term remission without requiring lifelong therapies — or better yet, eliminate it completely,” Obama said at a meeting in the Eisenhower Executive Office Building next to the White House.

 

The initiative reflects a growing optimism among scientists that it may be possible to get patients’ immune systems to control HIV without drugs, or even to eliminate the virus from their systems. A feat like that seemed impossible not so long ago. The moneywill come from expiring AIDS research grants over the next three years, the administration said in a statement.

 

The president also pledged $5 billion over the next three years to the Global Fund to Fight AIDS, TB and Malaria if other countries contribute twice that amount. The Global Fund is holding its fourth replenishment meeting this week in Washington, with a goal of topping the $9.3 billion pledged three years ago.

 

And he signed legislation enacted last month to extend the 10-year-old President’s Emergency Program for AIDS Relief, or PEPFAR, started by President Bush.

 

Obama boasted that PEPFAR has exceeded the goal — thought to be ambitious when he set it on World AIDS Day two years ago – of getting anti-HIV treatment to 6 million people in developing countries. “Today I’m proud to announce that we’ve not only reached our goal, we’ve exceeded our treatment goal,” he said. “We’ve helped 6.7 million people receive life-saving treatment, and we’re going to keep at it.”

 

Obama also noted that the waiting list for treatment under the federal-state AIDS Drug Assistance Program last week fell to zero, from a peak of 9,310 in the fall of 2011.

 

Apart from that domestic bright spot, however, a report card on how America is doing with its own HIV epidemic reveals only slow progress.

 

In a panel discussion following Obama’s remarks, Dr. Chris Beyrer of Johns Hopkins University pointed out that when PEPFAR and the Global Fund began, AIDS experts were betting it would be easier to combat HIV in targeted populations in America than to get millions of HIV-infected people in sub-Saharan Africa into treatment.

 

But the opposite has happened. “African-American men are about half as likely” to have their HIV infection under control as non-Hispanic white men, Beyrer says. “And two-thirds of new infections are among men who have sex with men.”

 

The White House report is thin on promising results, as one section puts it, and heavy on challenges.

 

For instance, a 2010 National AIDS Strategy set a goal of reducing new HIV infections in this country by 25 percent. But the incidence “remains unacceptably high,” the latest report says. And, in fact, new HIV infections increased 12 percent among men who have sex with men in the most recent figures – 22 percent among the youngest males, from 13 to 24 years old.

 

The strategy aimed to increase the percent of HIV-infected who know their status to 90 percent. But the most recent figures indicate undiagnosed HIV decreased by only 9 percent between 2006 and 2010. And fewer than half of those between ages 13 and 24 years are aware of their infection.

 

When it comes to effective anti-HIV treatment, fewer than half of Americans at highest risk – men who have sex with men, blacks and Latinos – get sufficient antivirals drugs to keep their HIV under control.

 

Still, there’s evidence that concerted efforts to combat HIV can pay off in the most heavily affected places. The report cites impressive gains in New York City, the District of Columbia and San Francisco.

 

“All three have made care and treatment very available, have ramped up testing and needle exchanges,” says Chris Collins, policy director of amfAR, the American Foundation for AIDS Research. “When you do that, you see infection rates fall.”

 

For instance, when Washington, D.C., increased publicly funded HIV testing from 400 tests in 2007 to 120,000 in 2011, newly diagnosed cases went down by almost half. Newly diagnosed cases have also fallen by half in New York City and San Francisco.

 

The proportion of HIV-treated people whose virus was suppressed has gone steadily up in New York City, especially after the health department recommended that all newly diagnosed patients should be offered anti-retroviral treatment. By the end of last year, nearly 8 in 10 were virally suppressed.

 

THE TWIN EPIDEMICS: HIV AND TB CO-INFECTION.


Setting the Scope

An estimated 2 billion people – one-third of the global population – are infected with tuberculosis (TB), and each year, 8.7 million people develop TB disease. TB kills more than 1.4 million people each year and is economically devastating to families and communities worldwide. Although TB is a global problem, its geographic distribution is drastically disproportionate. Ninety-five percent of all TB cases and 98 percent of all TB deaths occur in developing countries. TB is one of the top killers of women and is responsible for 500,000 of their deaths each year. TB is a major killer among women of reproductive age and the leading cause of death in HIV-positive individuals. Only 22 high-burden countries (HBCs) account for 80 percent of the global TB burden, with half of these countries located in Asia. In Africa, 40 countries have an estimated TB prevalence rate greater than 100/100,000 compared to an estimated prevalence rate of <5/100,000 in the United States.

The global resurgence of TB has been fueled by a combination of factors, including increasing rates of HIV/AIDS and multidrug resistance, inadequate investments in public health infrastructure, insufficient political commitment, limited awareness of TB, disparities in access to and quality of health care services, and inadequate investments in new tools, including drugs, diagnostics, and vaccines. The disease threatens the poorest and most marginalized, disrupts the social fabric of society, and slows or undermines gains in economic development.

Progress on the Stop TB Partnership and DOTS Expansion

Significant progress has been made since the Stop TB Partnership was launched in 2000. The Amsterdam Ministerial Conference on Tuberculosis and Sustainable Development, held in March 2000, established global targets of 70 percent TB case detection and 85 percent treatment success rates in smear-positive pulmonary TB cases to be achieved by the year 2005 in the 22 HBCs. The first Global Plan 2001–2005 served to catalyze governments and donors to address TB. The number of countries implementing DOTS (directly observed treatment, short-course), the most effective strategy available for the treatment and control of TB, increased from 112 in 1998 to 184 by 2006.

Building on this momentum, in January 2006, the Stop TB Partnership launched the Global Plan to Stop TB 2006–2015, which includes the Millennium Development Goal target of halting and beginning to reverse the incidence of TB by 2015, as well as the more ambitious Stop TB targets of reducing TB prevalence and deaths by 50 percent by 2015, relative to the 1990 baseline. TheGlobal Plan describes the actions and resources needed to combat the epidemic and achieve these targets. The World Health Organization (WHO) and other Stop TB partners also launched a more robust technical approach known as the Stop TB Strategy, which builds on DOTS. There is strong global commitment to combat TB and to collaborate on that effort: The Partnership has grown to more than 1,000 members, including endemic countries, donors, nongovernmental organizations (NGOs), research organizations, and other institutions.

To date, much progress has been made in achieving these goals. New cases of TB have been declining each year and fell to >2 percent between 2010 and 2011. The TB mortality rate has decreased by 41 percent since 1990 and is on track to reach the global target of 50 percent reduction by 2015. However, the job is far from done, with an estimated 8.7 million new cases and 1.4 million deaths annually.

HIV and TB Co-infection

HIV/AIDS and TB co-infection present special challenges to the expansion and effectiveness of DOTS programs and the Stop TB Strategy. TB accounts for one-quarter of AIDS deaths worldwide and is one of the most common causes of morbidity in people living with HIV and AIDS (PLWHA). Currently, approximately 34 million people are infected with HIV, and at least one-third of them are also infected with TB. The dual epidemics of TB and HIV are particularly pervasive in Africa, where HIV has been the most important contributing factor in the increasing incidence of TB over the last 10 years. In some countries in sub-Saharan Africa, up to 80 percent of individuals with active TB disease are also HIV-positive. The dual epidemics are also of growing concern in Asia, where two-thirds of TB-infected people live and where TB now accounts for 40 percent of AIDS deaths. Eastern Europe and the former Soviet Union have the fastest growing HIV epidemic in the world, a factor further exacerbating the expanding problem of the multidrug-resistant TB (MDR-TB) epidemic in these regions. The overlap of TB-HIV co-infection with MDR-TB and extensively drug-resistant TB presents a tremendous challenge and threatens progress in controlling TB and HIV and AIDS and in eliminating the mortality associated with these diseases.

Individuals co-infected with HIV and TB are 30 times more likely to progress to active TB disease. Infection with TB enhances replication of HIV and may accelerate the progression of HIV infection to AIDS. Fortunately, TB treatment under the DOTS programs is just as effective in individuals with HIV as it is in people who are HIV negative. In addition, clinical trials have shown that there are anti-TB regimens that can prevent or decrease the likelihood of TB infection progressing to active TB disease in an HIV-infected individual, making it an important intervention for increasing the length and quality of life for those co-infected and their families and communities.

Strategic Engagement with the U.S. President’s Emergency Plan for AIDS Relief

Within the U.S. Government, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), primarily through the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC), leads funding and implementation of HIV-TB co-infection activities. Given the importance of TB-HIV as part of a comprehensive TB program, USAID supports TB-HIV activities within the Agency’s TB programs and closely coordinates its efforts with other PEPFAR agencies. Specifically, USAID supports the threefold strategy established in 2004 by WHO to enhance collaborative efforts between TB and HIV/AIDS programs; to decrease the burden of TB in PLWHA; and to decrease the burden of HIV in TB patients.

USAID’s Three-Fold Strategy for HIV/TB

To address the first component of the strategy, USAID supports coordination of TB and HIV/AIDS services by improving collaboration among TB and HIV programs, host countries and donor agencies, NGOs, and research institutions; developing training programs for TB specialists/program managers on HIV counseling and testing and management of co-infected patients; strengthening the links between TB services and HIV testing and HIV care services; and exploring the use of alternative service delivery approaches, such as community- and home-based care and involving faith-based organizations in such approaches. Such coordination is essential in ensuring early diagnosis; appropriate referral; and prompt, quality care for each disease.

To address the second component, decrease the burden of TB in PLWHA, USAID supports improvements in TB screening, prevention, and treatment through links with facilities that provide care and antiretroviral therapy (ART) services. Identification or exclusion of active TB in individuals who are HIV positive is critical to ensuring access to appropriate services. However, in 2006, only approximately 300,000 HIV-positive individuals were screened for TB through the collective efforts of the global TB and HIV communities. By 2010, greatly expanded efforts resulted in the screening of 2.3 million, and by 2011, that number increased by 39 percent to 3.2 million HIV-positive individuals. Identification of these dually-infected individuals enabled access to critical, lifesaving TB treatment for those diagnosed with active TB, and access to preventive TB treatment for those who did not have active TB. USAID also provides assistance to programs that strengthen and expand HIV and TB surveillance to improve the quality and availability of TB-HIV-related data and to those implementing infection control measures in clinical settings with high rates of HIV and TB.

To address the third component, USAID supports programs and operations research that seeks to decrease the burden of HIV in TB patients. Support is provided to increase access to HIV testing and counseling and establish a system of referrals between TB and HIV/AIDS programs, and by training TB program personnel in HIV testing. The efforts of the global community significantly increased HIV screening among TB patients from approximately 4 percent in 2004 to 40 percent globally (and 69 percent in Africa) in 2011. USAID also supports programs to promote the use of therapies proven to diminish the morbidity and mortality associated with TB-HIV co-infection, including co-trimoxazole preventive therapy (CPT) in adults and children living with HIV and AIDS, and ART in eligible TB patients. USAID’s assistance, combined with that of our partners, led to increased uptake of CPT (from 66 percent in 2007 to 79 percent in 2011) and ART (from 30 percent in 2007 to 48 percent in 2011) among co-infected individuals. USAID also supports innovative service delivery models for reaching co-infected patients, monitors and analyzes the effectiveness of such models, and works with partners to scale up successes.

Significant progress in mitigating the TB-HIV epidemic has been made over the past several years through coordinated, collaborative efforts to diagnose HIV among TB patients, diagnose TB among individuals with HIV, and conduct research in new technologies and methodologies to improve both diagnosis and treatment. New diagnostics, particularly Xpert MTB/RIF, which can quickly (<2 hours) identify susceptible and resistant TB and is almost twice as accurate identifying TB in HIV-positive individuals compared with traditional methods, offer great possibilities for rapid diagnosis and treatment of those co-infected. USAID, together with its U.S. Government and global partners, is introducing and expanding access to this technology, particularly in areas of high HIV prevalence. Additionally, for the first time in many years, multiple new TB drugs and drug regimens appropriate for use in both HIV-negative and HIV-positive individuals are being evaluated and are expected to be available in the next several years. These innovations, in conjunction with advances in the delivery of care and improved partnerships with communities and the private sector, are key to further progress in reducing the morbidity and mortality TB and HIV-TB co-infection.

Source: http://www.usaid.gov

THE TWIN EPIDEMICS: HIV AND TB CO-INFECTION.


Setting the Scope

An estimated 2 billion people – one-third of the global population – are infected with tuberculosis (TB), and each year, 8.7 million people develop TB disease. TB kills more than 1.4 million people each year and is economically devastating to families and communities worldwide. Although TB is a global problem, its geographic distribution is drastically disproportionate. Ninety-five percent of all TB cases and 98 percent of all TB deaths occur in developing countries. TB is one of the top killers of women and is responsible for 500,000 of their deaths each year. TB is a major killer among women of reproductive age and the leading cause of death in HIV-positive individuals. Only 22 high-burden countries (HBCs) account for 80 percent of the global TB burden, with half of these countries located in Asia. In Africa, 40 countries have an estimated TB prevalence rate greater than 100/100,000 compared to an estimated prevalence rate of <5/100,000 in the United States.

The global resurgence of TB has been fueled by a combination of factors, including increasing rates of HIV/AIDS and multidrug resistance, inadequate investments in public health infrastructure, insufficient political commitment, limited awareness of TB, disparities in access to and quality of health care services, and inadequate investments in new tools, including drugs, diagnostics, and vaccines. The disease threatens the poorest and most marginalized, disrupts the social fabric of society, and slows or undermines gains in economic development.

Progress on the Stop TB Partnership and DOTS Expansion

Significant progress has been made since the Stop TB Partnership was launched in 2000. The Amsterdam Ministerial Conference on Tuberculosis and Sustainable Development, held in March 2000, established global targets of 70 percent TB case detection and 85 percent treatment success rates in smear-positive pulmonary TB cases to be achieved by the year 2005 in the 22 HBCs. The first Global Plan 2001–2005 served to catalyze governments and donors to address TB. The number of countries implementing DOTS (directly observed treatment, short-course), the most effective strategy available for the treatment and control of TB, increased from 112 in 1998 to 184 by 2006.

Building on this momentum, in January 2006, the Stop TB Partnership launched the Global Plan to Stop TB 2006–2015, which includes the Millennium Development Goal target of halting and beginning to reverse the incidence of TB by 2015, as well as the more ambitious Stop TB targets of reducing TB prevalence and deaths by 50 percent by 2015, relative to the 1990 baseline. TheGlobal Plan describes the actions and resources needed to combat the epidemic and achieve these targets. The World Health Organization (WHO) and other Stop TB partners also launched a more robust technical approach known as the Stop TB Strategy, which builds on DOTS. There is strong global commitment to combat TB and to collaborate on that effort: The Partnership has grown to more than 1,000 members, including endemic countries, donors, nongovernmental organizations (NGOs), research organizations, and other institutions.

To date, much progress has been made in achieving these goals. New cases of TB have been declining each year and fell to >2 percent between 2010 and 2011. The TB mortality rate has decreased by 41 percent since 1990 and is on track to reach the global target of 50 percent reduction by 2015. However, the job is far from done, with an estimated 8.7 million new cases and 1.4 million deaths annually.

HIV and TB Co-infection

HIV/AIDS and TB co-infection present special challenges to the expansion and effectiveness of DOTS programs and the Stop TB Strategy. TB accounts for one-quarter of AIDS deaths worldwide and is one of the most common causes of morbidity in people living with HIV and AIDS (PLWHA). Currently, approximately 34 million people are infected with HIV, and at least one-third of them are also infected with TB. The dual epidemics of TB and HIV are particularly pervasive in Africa, where HIV has been the most important contributing factor in the increasing incidence of TB over the last 10 years. In some countries in sub-Saharan Africa, up to 80 percent of individuals with active TB disease are also HIV-positive. The dual epidemics are also of growing concern in Asia, where two-thirds of TB-infected people live and where TB now accounts for 40 percent of AIDS deaths. Eastern Europe and the former Soviet Union have the fastest growing HIV epidemic in the world, a factor further exacerbating the expanding problem of the multidrug-resistant TB (MDR-TB) epidemic in these regions. The overlap of TB-HIV co-infection with MDR-TB and extensively drug-resistant TB presents a tremendous challenge and threatens progress in controlling TB and HIV and AIDS and in eliminating the mortality associated with these diseases.

Individuals co-infected with HIV and TB are 30 times more likely to progress to active TB disease. Infection with TB enhances replication of HIV and may accelerate the progression of HIV infection to AIDS. Fortunately, TB treatment under the DOTS programs is just as effective in individuals with HIV as it is in people who are HIV negative. In addition, clinical trials have shown that there are anti-TB regimens that can prevent or decrease the likelihood of TB infection progressing to active TB disease in an HIV-infected individual, making it an important intervention for increasing the length and quality of life for those co-infected and their families and communities.

Strategic Engagement with the U.S. President’s Emergency Plan for AIDS Relief

Within the U.S. Government, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), primarily through the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC), leads funding and implementation of HIV-TB co-infection activities. Given the importance of TB-HIV as part of a comprehensive TB program, USAID supports TB-HIV activities within the Agency’s TB programs and closely coordinates its efforts with other PEPFAR agencies. Specifically, USAID supports the threefold strategy established in 2004 by WHO to enhance collaborative efforts between TB and HIV/AIDS programs; to decrease the burden of TB in PLWHA; and to decrease the burden of HIV in TB patients.

USAID’s Three-Fold Strategy for HIV/TB

To address the first component of the strategy, USAID supports coordination of TB and HIV/AIDS services by improving collaboration among TB and HIV programs, host countries and donor agencies, NGOs, and research institutions; developing training programs for TB specialists/program managers on HIV counseling and testing and management of co-infected patients; strengthening the links between TB services and HIV testing and HIV care services; and exploring the use of alternative service delivery approaches, such as community- and home-based care and involving faith-based organizations in such approaches. Such coordination is essential in ensuring early diagnosis; appropriate referral; and prompt, quality care for each disease.

To address the second component, decrease the burden of TB in PLWHA, USAID supports improvements in TB screening, prevention, and treatment through links with facilities that provide care and antiretroviral therapy (ART) services. Identification or exclusion of active TB in individuals who are HIV positive is critical to ensuring access to appropriate services. However, in 2006, only approximately 300,000 HIV-positive individuals were screened for TB through the collective efforts of the global TB and HIV communities. By 2010, greatly expanded efforts resulted in the screening of 2.3 million, and by 2011, that number increased by 39 percent to 3.2 million HIV-positive individuals. Identification of these dually-infected individuals enabled access to critical, lifesaving TB treatment for those diagnosed with active TB, and access to preventive TB treatment for those who did not have active TB. USAID also provides assistance to programs that strengthen and expand HIV and TB surveillance to improve the quality and availability of TB-HIV-related data and to those implementing infection control measures in clinical settings with high rates of HIV and TB.

To address the third component, USAID supports programs and operations research that seeks to decrease the burden of HIV in TB patients. Support is provided to increase access to HIV testing and counseling and establish a system of referrals between TB and HIV/AIDS programs, and by training TB program personnel in HIV testing. The efforts of the global community significantly increased HIV screening among TB patients from approximately 4 percent in 2004 to 40 percent globally (and 69 percent in Africa) in 2011. USAID also supports programs to promote the use of therapies proven to diminish the morbidity and mortality associated with TB-HIV co-infection, including co-trimoxazole preventive therapy (CPT) in adults and children living with HIV and AIDS, and ART in eligible TB patients. USAID’s assistance, combined with that of our partners, led to increased uptake of CPT (from 66 percent in 2007 to 79 percent in 2011) and ART (from 30 percent in 2007 to 48 percent in 2011) among co-infected individuals. USAID also supports innovative service delivery models for reaching co-infected patients, monitors and analyzes the effectiveness of such models, and works with partners to scale up successes.

Significant progress in mitigating the TB-HIV epidemic has been made over the past several years through coordinated, collaborative efforts to diagnose HIV among TB patients, diagnose TB among individuals with HIV, and conduct research in new technologies and methodologies to improve both diagnosis and treatment. New diagnostics, particularly Xpert MTB/RIF, which can quickly (<2 hours) identify susceptible and resistant TB and is almost twice as accurate identifying TB in HIV-positive individuals compared with traditional methods, offer great possibilities for rapid diagnosis and treatment of those co-infected. USAID, together with its U.S. Government and global partners, is introducing and expanding access to this technology, particularly in areas of high HIV prevalence. Additionally, for the first time in many years, multiple new TB drugs and drug regimens appropriate for use in both HIV-negative and HIV-positive individuals are being evaluated and are expected to be available in the next several years. These innovations, in conjunction with advances in the delivery of care and improved partnerships with communities and the private sector, are key to further progress in reducing the morbidity and mortality TB and HIV-TB co-infection.

Source: http://www.usaid.gov

 

 

How AIDS Invented Global Health.


Over the past half-century, historians have used episodes of epidemic disease to investigate scientific, social, and cultural change. Underlying this approach is the recognition that disease, and especially responses to epidemics, offers fundamental insights into scientific and medical practices, as well as social and cultural values. As historian Charles Rosenberg wrote, “disease necessarily reflects and lays bare every aspect of the culture in which it occurs.”1

Many historians would consider it premature to write the history of the HIV epidemic. After all, more than 34 million people are currently infected with HIV. Even today, with long-standing public health campaigns and highly active antiretroviral therapy (HAART), HIV remains a major contributor to the burden of disease in many countries. As Piot and Quinn indicate in this issue of the Journal (pages 2210–2218), combating the epidemic remains a test of our expanding knowledge and vigilance.

Nonetheless, the progress made in addressing this pandemic and its effects on science, medicine, and public health have been far-reaching .The changes wrought by HIV have not only affected the course of the epidemic: they have had powerful effects on research and science, clinical practices, and broader policy. AIDS has reshaped conventional wisdoms in public health, research practice, cultural attitudes, and social behaviors. Most notably, the AIDS epidemic has provided the foundation for a revolution that upended traditional approaches to “international health,” replacing them with innovative global approaches to disease. Indeed, the HIV epidemic and the responses it generated have been crucial forces in “inventing” the new “global health.”

This epidemic disrupted the traditional boundaries between public health and clinical medicine, especially the divide between disease prevention and treatment. In the 1980s, before the advent of antiretroviral therapies, public health officials focused on controlling social and behavioral risk factors; prevention was seen as the only hope. But new treatments have eroded this distinction and the historical divide between public health and clinical care.2 Clinical trials have shown that early treatment benefits infected patients not only by dramatically extending life expectancy, but by significantly reducing the risk of transmission to their uninfected sexual partners.3 Essential medicines benefit both patients and populations, providing a critical tool for reducing fundamental health disparities. This insight has encouraged the integration of approaches to prevention and treatment, in addition to behavioral change and adherence.

The rapid development of effective antiretroviral treatments, in turn, could not have occurred without new forms of disease advocacy and activism. Previous disease activism, for example, had established important campaigns supporting tuberculosis control, cancer research, and the rights of patients with mental illness. But AIDS activists explicitly crossed a vast chasm of expertise. They went to Food and Drug Administration meetings and events steeped in the often-arcane science of HIV, prepared to offer concrete proposals to speed research, reformulate trials, and accelerate regulatory processes. This approach went well beyond the traditional bioethical formulations of autonomy and consent. As many clinicians and scientists acknowledged, AIDS activists, including many people with AIDS, served as collaborators and colleagues rather than constituents and subjects, changing the trajectory of research and treatment.4 These new models of disease activism, enshrined in the Denver Principles (1983), which demanded involvement “at every level of decision-making,” have spurred new strategies among many activists focused on other diseases. By the early 2000s, AIDS activists had forged important transnational alliances and activities, establishing a critical aspect of the “new” global health.

Furthermore, HIV triggered important new commitments in the funding of health care, particularly in developing countries. With the advent of HAART and widening recognition of HIV’s potential effect on the fragile progress of development in resource-poor settings, HIV spurred substantial increases in funding from sources such as the World Bank. The growing concern in the United Nations and elsewhere that the epidemic posed an important risk to global “security” elicited new funding from donor countries, ultimately resulting in the establishment of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. In 2003, it was joined by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which, with bipartisan support, initially pledged $15 billion over 5 years. Since PEPFAR’s inception, Congress has allocated more than $46 billion for treatment, infrastructure, and partnerships that have contributed to a 25% reduction in new infections in sub-Saharan Africa.

HIV has also attracted remarkable levels of private philanthropy, most notably from the Bill and Melinda Gates Foundation. HIV funding led to new public–private partnerships that have become a model for funding of scientific investigation, global health initiatives, and building of crucial health care delivery infrastructure in developing countries. These funding programs have fomented contentious debates about priorities, efficiency, allocation processes, and broader strategies for preventing and treating many diseases, especially in poorer countries. Nonetheless, they offered new approaches to identifying critical resources and evaluating their effect on the burden of disease. The success of future efforts will depend on maintaining and expanding essential funding during a period of global economic recession, as well as new strategies for evaluating the efficacy of varied interventions.

AIDS also spurred another related debate that continues to roil global health — about the cost of essential medicines. Accessibility of effective and preventive treatments has relied on the availability of reduced-cost drugs and their generic equivalents. A recent decision by the Indian Supreme Court upheld India’s right to produce inexpensive generics, despite the multinational pharmaceutical industry’s claims for stronger recognition of patents.

Another central aspect of the new activism was an insistence that the AIDS epidemic demanded the recognition of basic human rights. Early on, lawyers, bioethicists, and policymakers debated the conditions under which traditional civil liberties could be abrogated to protect the public from the threat of infection. Such formulations reflected traditional approaches to public health and the “police powers” of the state, including mandatory testing, isolation, detention, and quarantine. Given the stigma attached to HIV infection at the time, as well as ungrounded fears of casual transmission, affected people often suffered the double jeopardy of disease and discrimination. As a result, Jonathan Mann, the first director of the World Health Organization’s Global Program on AIDS, explained, “To the extent that we exclude AIDS infected persons from society, we endanger society, while to the extent that we maintain AIDS infected persons within society, we protect society. This is the message of realism and of tolerance.”5 Mann argued that HIV could never be successfully addressed if impositions on human rights led people to hide their infections rather than seek testing and treatment. Only policy approaches that recognized and protected human rights (including the rights to treatment and care, gender equality, and education) would permit successful clinical and population-based interventions.

These complementary innovations are at the core of what we now call “global health” — which has demonstrated its capacity to be far more integrative than traditional notions of international health. It draws together scientists, clinicians, public health officials, researchers, and patients, while relying on new sources of funding, expertise, and advocacy. This new formulation is distinct, first of all, in that it recognizes the essential supranational character of problems of disease and their amelioration and the fact that no individual country can adequately address diseases in the face of the movement of people, trade, microbes, and risks. Second, it focuses on deeper knowledge of the burden of disease to identify key health disparities and develop strategies for their reduction. Third, it recognizes that people affected by disease have a crucial role in the discovery and advocacy of new modes of treatment and prevention and their equitable access. Finally, it is based on ethical and moral values that recognize that equity and rights are central to the larger goals of preventing and treating diseases worldwide.

For more than the past decade, major academic medical centers, schools of public health, and universities have created global health programs and related institutes for multidisciplinary research and education. Thus, the institutionalization of this formulation is not only affecting services worldwide, but also changing the training of physicians, other health professionals, and students of public health. When the history of the HIV epidemic is eventually written, it will be important to recognize that without this epidemic there would be no global health movement as we know it today.

Source: NEJM