Applauding the New US Commitment to an AIDS-Free Generation
Authored by John Barnes
Last week FCAA launched our latest edition of resource tracking – U.S. Philanthropic Support to Address HIV/AIDS in 2010 – which found that total disbursements among U.S.-based private funders decreased by 7% in 2010 to $459 million. And, since 2005, we’ve seen a 30% drop in the number of “top AIDS funders”, organizations giving $300k or more to HIV/AIDS in a given year. With these narrowing trends, it is essential for us to monitor the field and identify opportunities for philanthropic action in the global response to HIV/AIDS.
On Nov. 8th U.S. Secretary of State Hillary Clinton addressed a gathering at the U.S. National Institutes of Health (NIH) to announce the official new goal of the United States in achieving an AIDS-Free Generation. The speech was inspiring and encouraging … two sentiments in short supply these days.
Secretary Clinton pointed out in her speech that the possibility of an AIDS-Free Generation exists thanks largely to scientific advances in utilizing ARVs to stem the spread of infection – but she was quick to point out, and to emphasize repeatedly, that these modalities will be utilized as part of what she deemed “combination prevention” strategies.
Leading researchers at the World Bank’s Nov. 11th session on the game-changing advances in “treatment as prevention” (TasP) seemed to concur with this assessment. In spite of the intended debate style of their presentations, all four presenters seemed to concur that the right approach to HIV prevention moving forward will be employing the right mix of evidence-based approaches, including an emphasis on ARV-based prevention.
The World Bank debate – the sixth in a series co-hosted by USAID and the World Bank – pitted Wafaa El-Sadr (Columbia University) and Sten Vermund (Vanderbilt University) supporting the proposition to spend a majority of what is likely to be declining HIV prevention resources on TasP against Stefano Bertozzi (Bill & Melinda Gates Foundation – the world’s largest private funder of HIV/AIDS) and Myron Cohen (University of North Carolina – and lead investigator on HTPN 052) who argued against such a strategy.
Team Yes (El-Sadr and Vermund) made some compelling arguments:
- Historic prevention efforts have been unsuccessful, we know what doesn’t work and we need to stop funding what does not work (e.g. abstinence based messages, female condoms and mass media campaigns)
- We must use evidence to inform our strategy and there is no stronger evidence of an effective intervention than 96% efficacy seen in the HTPN 052 study
- Per person cost of treatment is at an all-time low ($335 pp/annually) and dropping quickly
- We have developed significant health infrastructure for treating PLWHA and can leverage that infrastructure to deploy TasP
- There is a long history of success in preventing disease through treatment (e.g. tuberculosis, STDs)
- History has also demonstrated the mistake of diminishing efforts amidst success leading to a relapse of progress (e.g. controlling TB in India in the 1950s)
- Prevention of vertical transmission (or PMTCT) is the quintessential example of success of ARV-based prevention
Team No (Bertozzi and Cohen) also argued convincingly:
- Setting arbitrary, universal guidelines for a unilateral approach (i.e. shifting resources across the globe toward TasP) is wrong. These decisions need to be based on the context of the epidemic and unmet needs country-by-county, community-by community
- Scaling up TasP in a flat budget environment means scaling back on other important interventions (e.g. male circumcision which is also effective and important)
- HTPN 052 did NOT demonstrate the same level of benefit universally. More study is needed to determine “appropriate use.” Results to date do not suggest immediate scale-up is “ready for primetime”
- There is no benefit from TasP for people who are experience acute infection and are highly infectious
- TasP has not yet demonstrated “durability beyond two years. We know that other approaches that would be defunded in this scenario (e.g. male circumcision) are permanent and do not rely on adherence and behavioral factors
The clear message from both sides was, just as Secretary Clinton prescribed, the clear path forward MUST be one of implementing a combination of evidence based approaches. We must also have the courage to make difficult decisions about what NOT to fund. In the words of Dr. Anthony Fauci, Director of the National Institute of Allergy & Infectious Diseases, “… we must let science dictate strategy.”
This combination approach to prevention offers funders at all levels an opportunity to support evidence-based approaches that work synergistically. New biomedical approaches rely heavily on compliance and adherence of those receiving treatment. As suggested by the recent UNAIDS Investment Framework, “critical enablers” of adherence, such as transportation to medical appointments and appropriate nutrition to metabolize treatments, are two examples of opportunities for smaller funders to have real impact. Some more traditional approaches are also evidence-based and will continue to require support, such as access to condoms and clean needles. And “non-AIDS funders” also have important roles to play in establishing enabling environments in such ways as combating gender-based violence and promoting human rights.
The topic of the debate focused on how to divide a shrinking pie, but we mustn’t abandon the notion of increasing the size of the pie. AIDS advocates have a long history of driving unimaginable results, and this is no time to let up.
If we are to realize the vision of an AIDS-Free Generation described by Secretary Clinton, private philanthropy will continue to have a critical role in driving innovation, addressing marginalized populations and holding governments accountable. [Read our list of top reasons to fund AIDS – an exercise to help define both the unique role of philanthropy in the response and the urgent need for the sector’s continued, and increased, commitment].
It is critical for private philanthropy to continue to support the game-changing notion that the pie can get bigger… even in times of economic challenge. The evidence has never been clearer about the cost effectiveness of treating people with HIV to prevent AIDS. We must now also employ evidence-based advocacy to achieve evidence-based policy.
On December 5th we’ll be translating this important topic for AIDS-related philanthropy during our 2011 AIDS Philanthropy Summit. Here’ a snapshot of the session:
Session II: The Future of Treatment as Prevention
This session will serve as an exclusive forum for private funders to explore how to adapt their strategies to effectively leverage new prevention and treatment tools and help ensure their appropriate incorporation into comprehensive HIV strategies. Featuring:
· Mitchell Warren, Executive Director, AVAC
· Anu Gupta, Director, Corporate Contributions, Johnson & Johnson
· Moises Agosto, Director of Treatment Education, Adherence and Mobilization, National Minority AIDS Council
· Moderated by Andrea Flynn, Executive Director, International Programs, M.A.C AIDS Fund
Providing a diverse set of perspectives, the panel will set the stage for a robust discussion exploring the implications of these advances on our collective work, and specifically, how funders of all sizes can advance HIV prevention and treatment efforts.
Register today to take part!
John Barnes