[Ip-health] Mission Crash: The Intolerable Policy Incoherence in US AIDS Policy, Global and Domestic

Baker, Brook b.baker at neu.edu
Wed May 18 02:31:04 PDT 2011

Mission Crash:  The Intolerable Policy Incoherence in US AIDS Policy, Global and Domestic
For the past three years, US global health pundits in the White House have been calling for greater efficiencies, for a renewed focus on prevention rather than treatment to turn the tide of new infections, and paradoxically for reduced expectations because fiscal realities and budget reductions are the order of the day.  They have bemoaned the HIV/AIDS treatment mortgage and espoused unmet needs in other priority global health arenas, like child and maternal health, neglected diseases, and even chronic conditions.  Their talking game is strong.  When jobs are lost at home, when formal unemployment hovers near 10%, when an entire generation of young people look forward to dimming job prospect, why shouldn't we turn inward, protect our own, and hunker down into a bunker mentality? When federal deficits soar, we we continue to spend, individually and collectively, more than we earn, when our excesses are subsidized from creditors abroad, some of whom may jump currencies and call in their loans if our national debt becomes too onerous, why shouldn't we cut back, deep and hard, anywhere and everywhere we can?
Even during these atavistic periods of national introspection, some people, including government-sponsored scientists, just carry on.  They look to the future, they hear the cries of those without medicines and those most at risk of disease.  They try to discern the razor-edge path to better programming, more effective treatments, and to health interventions that will beat back the tide of disease.
Just this week, scientists employed by and supported by US tax dollars reported a stunning, though not wholly unexpected finding in a randomized trials of AIDS treatment as HIV prevention.  They had planned a long-term study, extending until 2015, to study whether starting heterosexual people, living in partnership with an uninfected person, could reduce their risk of onward transmission by starting antiretroviral therapy early, before their CD4 cell counts (a measure of immune system strength) plummeted to 250 CD4 per mm3. Alternatively, they explored whether starting early had little or no discernible effect on infectivity and onward transmission of HIV, whether early treatment might just benefit the patient but not the community. 
When scientists first unblinded the study (looked at the interim results on infection of sex partners), they were stunned.  Compared to patients who started treatment at 250 CD4 cell counts, the patients who started early had a 96% reduction in risk of infection.  To put it in clearer mathematic terms, instead of 27 partners becoming HIV-infected only one partner became infected in the early treatment arm.  The results were so compelling that the scientists stopped the study in its tracks.  They found it ethically unjustified to continue to research something that had such strong evidence of an unequivocal benefit, not only for the patient but for the health of the patient's lover.
This is a stop-the-presses kind of moment.  If you can test people for HIV and start them early on treatment rather than when they show up sick, or pregnant, or worse yet in a wheelbarrow, you might save and extend their lives (because early treatment has numerous benefits in preserving patient longevity and well-being) and you might prevent new infections, even in steady relationships where condom use is less likely.
In a rational world, US politicians one both sides of the aisle and White House officials would catch their collective breathe and say:  "Hey, this is important; this is a game changer; this has promise to help defeat HIV/AIDS both at home and abroad."
Instead, we get something that feels like a yawn, a cynical "We're too broke to think" response.  So politicians and bureaucrats will let ADAP wait lists grown (ADAP is a federal/state program that provides AIDS medicines for people in the U.S. who are uninsured and too poor to pay for medicines out of pocket).  Likewise, they will flat-fund or even reduce funding to global AIDS initiatives like the President's Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria, initiatives that provide AIDS medicines for the vast majority of people living with HIV who are on treatment.  They will turn their backs and withhold the promise of treatment for those waiting in line.
And waiting in line they are.  Ten million people are eligible for treatment under WHO guidelines based on their well-being alone.  But many people living with HIV would like to save the lives of their sex partners and loved ones as well.  They might want to start even earlier in order to protect others, and might be willing to do especially since most of the evidence to date shows that earlier treatment initiation is better for them not just their partners.
What is our government saying to these people desperate for treatment and eager to protect others?  They're saying "We can't commit to achievable expanded ARV coverage because ... "  No real finish to the "because," except perhaps, "We have a large deficit; come back when we're flush."
These are the same politicians and White House officials who can give a $700 billion dollar tax break over ten years to the richest people on earth.  These are the same people who can find trillions of dollars to pay for protracted wars and armaments under a mantle of deceit.  These are the same people who found hundreds of billions of dollars to bail out banks, banks that are now reaping their highest ever profits just three years later.
So, the money excuse - the we're broke excuse - falls flat on its face.
But stop, US policy incoherence doesn't stop here.  At the same time that the US is signaling that it will regrettably ignore science, and at the same time that it spends money hand-over-fist for to preserve the interests of rich people, bankers, and military contractors, it is also negotiating trade agreements that will ultimately raise the costs of medicines needed in the life-and-death struggle against HIV/AIDS, TB, malaria, heart disease, diabetes and cancer.  The US insists on protecting the corporate interests of the hugely profitable pharmaceutical industry by demanding higher levels of protection for the patent and data monopolies of Big Pharma and for more stringent enforcement measures to enforce those enhanced rights.  All of these intellectual property and trade efforts have the predictable impact of raising the prices of new and improved medicines that fight AIDS and of delaying the introduction of generic competition that drives prices down.
This short-sightedness, this callous disregard, this intolerable policy incoherence must stop - it must be opposed by all rational people.  Forced over time to respond to demands for AIDS treatment at home and abroad, the US solemnly promised a mission to halt, reverse, and eventually eliminate the pandemic - it promised universal access to comprehensive prevention, treatment, and care.  Instead of all speed ahead, especially in light of new breath-taking research, the US is engaging in mission crash.  The cost of disinvestment is paid in the lives of our brothers and sisters, fathers and mothers, and sons and daughters, here and abroad.  As the mission crashes, the lives lost are not those of politicians, who have plenty of insurance, thank you very much, but of people who can't afford treatment on their own, and who certainly cannot afford the even higher costs of patent monopolies.
Expert communities in medicine, law, and development should be beating down doors to the White House and Congress.  People living with HIV/AIDS and their allies should be taking to the streets.  Proponents of human development, social justice, and global equity should be shouting "Enough is enough."  All of us live in a world of political choice and political action.  In the promising light of science, the new wages of silence are even more death.
Professor Brook K. Baker
Health GAP (Global Access Project) &
Northeastern U. School of Law, Program on Human Rights and the Global Economy
Honorary Research Fellow, Faculty of Law, Univ. of KwaZulu Natal, SA
400 Huntington Ave.
Boston, MA 02115 USA
(w) 617-373-3217
(c) 617-259-0760
(f) 617-373-5056
b.baker at neu.edu

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