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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.

Activists question Obama's AIDS plan

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

Wanted: More country contributions

Goosby said this sharing of financial responsibility is a “big change” from the start of PEPFAR, and “it moves us closer to being able to ensure these programs will be there for the next 30 years.”

In 2010, international donors disbursed $6.9 billion to fight AIDS in developing countries, down from the $7.6 billion that the wealthiest countries gave in 2009. That marked the first time in a decade that there has been a major cut in funding.

Of that $6.9 billion in 2010, the US contributed 54 percent, according to one study. When all contributions are considered, including large amounts spent by developing countries, the US portion decreases to 24 percent of all AIDS funding, which nearly matches its 23 percent portion of the global GDP.

Some developing countries have pledged to contribute more money in light of the global fiscal turbulence. Nigeria, which has 500,000 people on AIDS treatment, pledged last year that it would fund 50 percent of the cost of universal access to AIDS treatment by 2015. Other countries contributing more include Zambia, an extraordinarily poor country, which paid $5 million for antiretroviral drugs last year. Kenya agreed to a 40 percent increase in its health budget and set a goal of putting 1 million people on treatment, up from 460,000 currently. South Africa also committed to use more funds to fight AIDS.

Nigeria pledging to pay more

“Nigeria is stepping up,” said Dr. John Idoko, director general of the Nigeria’s National Agency for the Control of AIDS. “We have been concerned because of the global economic crisis, and we realize that we have to take more responsibility to set priorities and fund our programs.”

Many activists remain concerned that the fiscal crisis, though, will cause cuts so deep that more contributions from developing countries won’t make up the difference.

“I actually feel fairly positive with the ways things have been going, but the financial crunch genuinely imperils the momentum that has been created,” said Stephen Lewis, the former United Nations special envoy for HIV/AIDS in Africa and co-founder and co-director of AIDS-Free World, an advocacy group.

But other issues concern activists as well.

The first is whether the Obama administration will reach the target of supporting 6 million people on treatment. One source of doubt is whether the United States is poised to start taking credit for putting people on treatment even if it has done little to help them.

For instance, a memo written by a team of PEPFAR officials earlier this year recommended that the US claim it is supporting 277,000 people on treatment in the southeastern African country of Malawi. The United States has never claimed credit in Malawi before because the vast majority of AIDS funding in Malawi is from the Global Fund.

The PEPFAR document claims the US could claim credit for several reasons, including that it funds quarterly visits to check in on treatment sites and that it helped “prepare” the first edition of the “Malawi Integrated Guidelines for Clinical Management of HIV in Children and Adults.”

“They are trying to go from zero people treated to 277,000 treated without a single additional dollar to Malawi and without giving a single pill to anyone,” Davis said. “It’s ridiculous.”

A second concern is the disclosure the US government has had trouble spending its money in some African countries, running up a $1.5 billion pipeline of funding that has been stalled in the US Treasury for 18 months or more. Many activists had heard rumblings about the backlog of funds, but did nothing about it until the GlobalPost broke the story in April.

In the last six weeks, Goosby and his senior team have met with staff members in Congressional offices and activists in Washington and Nairobi to explain the predicament. Many fear that the disclosure could lessen support in Congress for AIDS programs. Others believe the administration should have been more forthright in acknowledging the rising backlog of unspent money, which was first identified internally two years ago.

“It’s an absolute failure of the activists,” Gonsalves said. “We should have been screaming bloody murder a year ago about this when we first heard something about it. We should have made it much more visible.”

A third issue is building up health services.

“The public health systems are still very weak — not as weak as pre-PEPFAR or Global Fund, but still weak,” said Dr. Paul Farmer, co-founder of Partners in Health, the quarter-century-old NGO based in Cambridge that provides health care for the poor in six countries. “You need to put the supplies and drugs into the hands of the right people, from the community health workers to the physicians. It requires going that final mile.”

Rwanda provides good example

Farmer explained further that Rwanda was a good example of improving the system, including the training of community health workers. In 2004, the country had almost no one on AIDS medication. Today it has more than 9,000, and it is one of two countries in Africa (Botswana is the other) regarded as securing treatment for 95 percent of those who are eligible.

Inside the US Office of the Global AIDS Coordinator office, which is housed in a nondescript brick building five blocks west of the White House on Pennsylvania Avenue, senior officials are looking for ways to find savings in many programs as well as deciding where to ramp up funding in order to try to dramatically reduce the number of new HIV infections.

But activists say they have long heard about how efficiencies are saving money and new prevention schemes will be ramped up, but they don’t see evidence of either. They also don’t see a long-term strategic plan.

“What’s the goal for 2015? Or 2020?” said Paul Zeitz, vice president for policy at Act V, an advocacy group that brings in celebrities to push the AIDS fight. “What’s the long-term US strategy? I don’t think they’ve figured that out yet.”

Caroline Ryan, the director of technical leadership in the global AIDS office, said the office feels “pressure” from all sides.

“We have a lot of pressure from the Hill (Congress) and OMB (Office of Management and Budget) that we can get more impact for the same amount of dollars,” said Ryan, who has been the office’s chief scientific adviser for the last eight years, nearly since PEPFAR’s inception. “We also have pressure from the countries not to slow down. The only way to do that is to get efficiencies and to be very analytical on how you get impact.”

Ryan and others in the office express hope that countries will start seeing results once these new prevention strategies are ramped up.

“It’s sort of like it all came together at the right time,” Ryan said. “Now we have results (from clinical trials) and it’s up to the programs to do the implementation. How do you take the discoveries from the bench desk to the bedside? That’s the exciting part of PEPFAR. It’s a living lab for bedside science.”

But how does PEPFAR do it?

That’s the key question. But their answer, for now, remains a secret.

Officials in the global AIDS office refused requests from GlobalPost to turn over its country-by-country roadmap of the HIV prevention strategy ahead. Their reason: The numbers are constantly changing. 

GlobalPost's reporting on global heath is made possible in part through a partnership with the Henry J. Kaiser Family Foundation as part of its U.S. Global Health Policy program.