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GlobalPost's John Donnelly and a team of reporters investigate what experts are calling a 'turning point' in the global fight to reduce HIV infection rates. Successes in southern African countries have produced valuable lessons on effective approaches to fight AIDS, lessons that need to be learned in US cities where infection rates remain persistently high — particularly among African-Americans. Meanwhile a political confrontation looms in Washington over critical funding which could threaten gains already made.

Kenya HIV AIDS PEPFAR
HIV/AIDS activists, some of them living with the virus, yell during a demonstration April 25, 2012 in Nairobi on the sidelines of a joint conference sponsored by the US embassy here and Kenya's vision 2030 about health and reducing mortality in the East African nation. The activists demanded that the US HIV program, PEPFAR, and the Kenya government work together to utilize some $500 million of unspent funds to get desperately needed HIV treatment to more Kenyans. (Tony Karumba/AFP/Getty Images)

Activists question Obama's AIDS plan

Part One: Many perceive a disconnect between the president's big promises and a proper strategy.

WASHINGTON — The global fight against AIDS is a high-wire act these days, teetering between the Obama administration’s lofty promise of an “AIDS-free” generation and the grounded realism of those who fight the epidemic and say they just don’t see the commitment needed to deliver on such a promise.

In the middle of this tightrope, the end of AIDS appears closer than ever because of new scientific discoveries that could dramatically reduce new HIV infections all over the world. But at the moment, there’s new danger of falling because political leaders in the United States as well as the developing world may have lost their sure-footedness for the way ahead, no longer talking about AIDS as a pressing matter of life and death and putting crucial funding in jeopardy.

“On one side is the end of the epidemic, defeating a disease that has plagued us for 30 years,” says Paul Davis, the Nairobi-based director of global campaigns for Health Gap, an AIDS activist group. “But at the same time, we are equally as likely to fall back off the other side … by not doing enough. We are so close and yet it feels as far away as ever.”

In July, Washington will host the International AIDS Conference, the first such conference on US soil in 22 years, bringing to the US more than 20,000 AIDS activists from every corner of the world and drawing global attention to whether the historic commitment made by America in the past to fight the deadly virus can ramp up sufficiently to reach the next bold goal.

More from GlobalPost: Talking about the end of AIDS

“The Obama administration has turned out to be a big disappointment.”
~Gregg Gonsalves, Yale University

While President Obama announced new ambitious goals for the end of next year, many activists do not detect urgency on behalf of his administration nor do they see a detailed roadmap of how to get to an “AIDS-free generation,” as Secretary of State Hillary Clinton described the administration’s broad goal in a speech late last year. For these activists and critics, the urgent push against AIDS that sprung forth from the Bush administration, the architects of the President’s Emergency Plan for AIDS Relief, or PEPFAR, has mostly not materialized in a government led by someone in whom they had great hope.

“The Obama administration has turned out to be a big disappointment,” said Gregg Gonsalves, a longtime AIDS activist now at Yale University. “They talk big but they have no new money behind it. They talk about an AIDS-free generation, but they cut the PEPFAR budget.”

In this first of a series of stories over the next two months, GlobalPost will examine several key issues in the Obama administration’s approach to fighting AIDS. This includes looking at whether the US government can effectively deploy new tools to prevent infections, including: Expanding treatment, which has been proven to prevent new infections in 96 percent of cases; rapidly expanding male circumcision, shown to reduce female-to-male infection by more than 60 percent; and trying to end all mother-to-child infections of infants during birth and breast-feeding.

They are ambitious goals for sure, but many critics believe there is less force of will in the Obama administration than George W. Bush showed in his historic initiative to fight AIDS around the world. When Bush announced the creation of PEPFAR in 2003, roughly 50,000 people in the developing world — a large number of them in Brazil — were taking AIDS antiretroviral drugs. Today the US government supports more than 4 million people on AIDS medications.

Looming over this turning point in the global fight against AIDS is the global economic crisis and a deeply divided political landscape in Washington where serious questions are emerging about US funding. The Obama administration, despite its lofty goals, is recommending that Congress cut its own AIDS initiative by $550 million. While many advocates first blamed fiscal austerity for the decrease in funding, the real accounting reveals a complex set of facts that critics say has been kept quiet for too long. That is, the US has $1.5 billion backed up in a pipeline of funds to African countries, and wants to spend that already allocated amount down before asking for another increase.

More from GlobalPost: Kenyans want AIDS windfall to stay in country

Beyond the intricacies and shifting parameters of accounting for such a vast and sprawling global effort, there is a clear question on the minds of experts and advocates around the world: If a proposed cut is approved by Congress, will the United States be able to fund the fight against AIDS at levels necessary to meet Obama and Secretary Clinton’s big promise for an “AIDS-free” generation?

Many fear not and, with the Global Fund to Fight AIDS, Tuberculosis and Malaria facing uncertain fiscal support, they see a future in which the medical tools to effectively fight AIDS are becoming available just at the point when the world decides it may not be able to pay for them.

The leader of America’s global effort to fight AIDS, US Ambassador Eric Goosby, remains optimistic. Goosby said in an interview with GlobalPost that Obama’s goals of America supporting the treatment of 6 million people and performing 4.7 million male circumcisions by the end of next year are reachable. The other target announced by the administration: Ending newborn and infant infections by 2015.

“We will achieve all the goals that President Obama and Secretary of State Clinton referred to,” Goosby said in an interview in his Washington office recently. “We will hit a home run here.”

He wouldn’t say exactly how the goals will be reached. Advocates say the details of the administration’s plans are critical at a time when they see a turning point in the US response to the AIDS epidemic: Either America is turning away from the earlier ambitious focus on AIDS and focusing on more broadly based health care goals, or it’s turning toward the fight against AIDS with a sense of heightened purpose and renewed energy.

More from GlobalPost: A Q&A with Eric Goosby

But with so much of the Obama administration’s emphasis on its Global Health Initiative, which includes the AIDS fight and has struggled to show results in its three years of existence, few see the AIDS fight taking off toward an AIDS-free generation.

“There is not a huge commitment to global health in this US administration,” Gonsalves said. “Global health is sliding out of the limelight.”

Goosby said that PEPFAR country coordinators have set goals on treatment, circumcision, and preventing newborn infections, and that some funding to scale up the efforts is coming from new savings from cheaper drugs and other efficiencies. In addition, he said, new revenue will be coming from increased contributions from developing countries.

The new approach to funding AIDS, according to Goosby: Building up two other large pots of money — from both developing countries and the Global Fund, which is supported by a wide array of donors, including the US — while keeping the third pot, PEPFAR funding, strong.

“That has been a profound change in countries actually realizing that these are their populations, they are ministries of health, they are the ones responsible for people’s care, and us realizing that an unrealistically fat system of care in place is not helping,” he said. “We’ve created a dynamic now to give the country an opportunity to address the unmet need fully with our pot, the Global Fund pot, and their pot. But we are going to demand (that developing countries) are going to oversee it and that they contribute to it monetarily and increase that contribution as resources allow them to.”

http://www.globalpost.com/dispatch/news/health/120530/activists-question-obamas-aids-plan