News from the AIDS World

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June 2008

MILESTONES: Though Two Years Later Than Target, WHO’s “3 by 5” Goal Is Reached
Gains In Antiretroviral Access: About one million people in developing countries gained access to antiretroviral drugs in 2007, according to a report released by UNAIDS, UNICEF, and the World Health Organization (New York Times, 06/03/08). A total of about three million people in developing countries now have access to the drugs (Los Angeles Times, 06/03/08). In addition, the approximately one million additional people who gained access to antiretrovirals in 2007 represent a 42% increase compared with 2006 (UNAIDS Release, 06/02/08).

Ambitious Goals: According to the 3 by 5 website, the “initiative, launched by UNAIDS and WHO in 2003, was a global target to provide three million people living with HIV/AIDS in low- and middle-income countries with life-prolonging antiretroviral treatment (ART) by the end of 2005. It was a step towards the goal of making universal access of HIV/AIDS prevention and treatment accessible for all who need them as a human right.” “Reaching that target even two years late is quite a remarkable achievement,” Kevin De Cock, director of WHO's HIV/AIDS Department, said (Los Angeles Times, 06/03/08). “In retrospect, maybe [the target] was excessively aspirational,” De Cock added. But he said that in battling the AIDS epidemic, “aspiration is necessary" (San Francisco Chronicle, 06/03/08). According to De Cock, when UNAIDS and the WHO set that goal in 2003, less than half a million people were receiving treatment (Los Angeles Times, 06/03/08).

Challenges Remain: Peter Ghys, chief of UNAIDS' Epidemiology and Analysis Division, said, “It is important to note that despite these successes, there were 2.5 million new HIV infections last year. If new infections continue at this rate, it will be impossible to sustain the treatment scale-up successes we are seeing today.”

“This report highlights what can be achieved despite the many constraints that countries face and is a real step forwards towards universal access to HIV prevention, treatment care, and support,” UNAIDS Executive Director Peter Piot said, adding, “Building on this, countries and the international community must now also work together to strengthen both prevention and treatment efforts" (UNAIDS Release, 06/02/08).

Funders Can Help: The report cited several major challenges the international community can still help to address, including “weak health systems; a shortage in health workers; a lack of sustainable long term financing and weak information systems.” It “underlines the urgent need for enhanced political commitment, better coordination and additional research” to address some of these challenges. “Three million people on treatment is an important milestone and an incredible achievement,” said Elhadj As Sy, Director of Partnerships and External Relations at UNAIDS. “It shows that scale-up is happening and that momentum now needs to be sustained" (UNAIDS Release, 06/02/08). Funders can focus on UN recommendations, funding programs with long-term focus and the ability to expand as needs expand.

INTERNATIONAL: India On Track For Sustainable HIV/AIDS Treatments.
Reaching New Populations: India, one of the world’s emerging “global hot spots” for new HIV infections (Economic Times, 02/21/08), has been implementing strategies to speed treatment to many affected populations, and extend prevention methods to often overlooked at-risk groups. For example, female condoms are being marketed to women in the eight most-affected provinces of India, where they will begin being distributed and sold in the coming months (CNNMoney, 06/10/08). In an effort to encourage sex workers to receive screenings for HIV/AIDS, the sex workers may now sign up for government-run life insurance specifically targeted at them. The only condition for the insurance is that the women undergo a routine medical check-up, which includes an HIV screening (AFP, 05/19/08).

Expanding Care and Fighting Discrimination: Since tuberculosis kills over 60% of HIV infected Indians, the government there has integrated its tuberculosis and AIDS programs, and will soon begin a program which offers no-cost HIV tests to people diagnosed with TB (Times of India, 06/13/08). Additionally, advocates are pressing the Indian government to pass a bill aimed at solidifying the rights of HIV/AIDS patients. According to Kaiser, the measure “would appoint health officials in all districts in the country to address HIV/AIDS-related stigma and discrimination. The bill in its current form includes measures such as the right to equality, autonomy, privacy, health, safe working environments, and information (Kaiser Daily HIV/AIDS Report, 05/27/08).

Update: Addressing Rural AIDS Sufferers: As FCAA reported in our March newsletter, AIDS has been spreading quickly to rural areas of India. Patients have to make long and costly trips to regional treatment centers, and though antiretroviral drugs are free, they cannot afford the transportation or the physical strain of travel (Reuters, 06/03/08). To that end, the Bill & Melinda Gates Foundation is funding a $100 million treatment center in rural Asansol. The center will treat 100 HIV/AIDS patients, as well as providing them with counseling and entertainment. The Global AIDS Awareness Organization, an affiliate of the International AIDS Society, will run the center, and will also be opening similar centers in other rural areas (Business Standard, 05/28/08). And in an effort to reach these rural populations, state-run literacy centers are providing educational materials regarding the dangers of HIV/AIDS. Posters and storybooks employing simple language and colorful pictures will be published in many regional dialects as an effort to educate illiterate or neo-literate migrant workers and other at-risk populations (Thaindian News, 06/01/08). In Bihar Province, barbers are being recruited to help educate. The barbers will chat with their customers about the facts of HIV/AIDS, as well as sell condoms (ExpressIndia, 06/04/08).

Funders Can Help: Funders should keep these programs in mind when considering not just India, but the Global South as a whole. Creative and progressive solutions are needed in these areas of the world, and it’s vital that funders continue to keep in mind solutions that are tailored to the target community—and the challenges that community presents. By encouraging creativity and openness, educational programs in particular can successfully be extended to difficult-to-reach communities—as in these examples from India.

DOMESTIC: Nation’s Capital In Need Of Sustainable Solutions
AIDS-Related Deaths Vastly Underreported In Already-Highly-Infected DC: According to a new analysis in Washington, DC, the District has underreported AIDS-related deaths by more than half. Of the 2,460 deaths from AIDS-related illnesses during the six-year period, 1,337 had not been reported because the city's system for tracking the toll of the disease was inadequate, according to the analysis by the D.C. Department of Health and the federal Centers for Disease Control and Prevention.

At least 12,500 District residents are HIV positive—one of the highest rates in the country. Officials estimate that between three and five percent of people in the District are infected, and the new analysis indicates that the AIDS epidemic may be taking a far greater toll on the city than officials had realized.

The city has initiated several efforts aimed at improving the system, including a mass mailing in January to about 4,000 doctors and laboratories to try to increase the number of diagnoses reported to the city. Officials also have begun routinely reviewing death records, and launched a campaign to increase HIV testing to try to identify more people before they contract or die from the disease (Washington Post, 06/14/08).

DC Hospital Starts First-In-Nation Hospital-Wide HIV Screening Program: In the first step toward curbing the high HIV rate in Washington, DC, one hospital has implemented a hospital-wide screening program. Under the program, anyone arriving at the hospital for urgent or routine care is offered a free oral HIV test. So far, about 13,000 people have volunteered, and about 260 have shown signs of infection. But there are worries. “[T]he question of sustainability remains. Many insurers don't cover the tests in these settings,” the article notes. "If I didn't get the [testing] kits from the D.C. Dept. of Health, I could not do it," said Dr. Celia Maxwell, who developed the program. "If I did not get staff that is funded through the CDC, I couldn't do it. There are true barriers" (American Medical News, 06/23/08).

Funders Can Help: There are a wide variety of funding opportunities in Washington, DC. Washington is an important case for funders because of two difficult realities: it has among the highest rates of HIV infection in the country, and its local government has little control over the city’s programmatic budget. Even the vital fledgling screening program mentioned above could be subject to a budgetary axe. Thus, it is crucial that funders patch up wide holes in governmental funding by encouraging sustainable, long-term programming in the District on all fronts—from education and prevention to screening and treatment.

POLICY: Despite Bush’s Support, No Agreement Yet On PEPFAR

Still Much Disagreement In Senate: As FCAA reported in our March newsletter, PEPFAR has been controversial since its early stages. In March, members of the House and Senate were clashing over the so-called abstinence clause—a clause requiring at least 33% of funded programs to promote “abstinence only” as a means of protection. On that issue, the legislators have reached a compromise, but recently, the debate has been related to the cost of the program. PEPFAR’s price tag has significantly increased from previous years- $50 billion as opposed to the $30 billion President Bush Requested (Kaiser Daily HIV/AIDS Report, 06/30/08).

U.S. AIDS Funding Is Key To Leveraging International Donations: The bill's supporters had been hoping to pass the legislation before Bush leaves for the Group of Eight industrialized nations summit. The House passed its version of the measure in April. Bush has said he would like the Senate version to be approved so he can use it as leverage to ask other countries at the summit to make larger contributions to the program (Kaiser Daily HIV/AIDS Report, 06/27/08).

Funders Can Help: While the new legislation has the potential to alleviate concerns over the Bush administration’s emphasis on abstinence education spending, the ban on organizations supporting sex-workers remains unchanged, which means that an important population continues to be ignored by U.S. policy. This funding-gap remains a key opportunity for funders. Additionally, if the House and Senate do not resolve the differences between the respective bills before the August 2008 recess, it is unlikely for the reauthorization to be approved this year. Though funding would likely continue, it would do so under the original 2003 rules until new legislation could be approved. Advocacy funders should consider supporting efforts to keep PEPFAR reauthorization moving, yet do so in the name of a bill that reflects a progressive compromise. Funders with grantees in PEPFAR countries should also consider ways that they can work with PEPFAR to leverage funds or fill gaps that PEPFAR does not address (FCAA March 2008 Newsletter).

March 2008

POLICY: PEPFAR Funding Boost, Debate Over Abstinence

President Bush’s mid-February Africa tour coincided the start of the reauthorization process for PEPFAR, the major federal HIV/AIDS program and an essential source of support for PLWHA in Africa and the Global South. The House Foreign Affairs Committee and the Senate Foreign Relations Committee have recently approved new legislation for PEPFAR, though full votes are not expected to be held until after the March recess. The House and Senate bills approve significant increases in PEPFAR funding over the next five years, as well as eliminate the requirement of the 33 percent abstinence-until-marriage education funding earmark. Some differences exist between the two versions of the bill.

The new House bill would increase total funding to $50 billion, $20 billion more than Bush’s requested amount, which itself doubled the initial $15 billion committed with PEPFAR’s launch in 2003. Democratic and Republican committee members clashed over the inclusion of PEPFAR’s original “abstinence clause,” which required that one-third of all HIV prevention funds be spent on abstinence programming. The committee reached a compromise, replacing this clause with a directive that the administration promote “balanced funding for prevention activities.” Abstinence-only education funding is not entirely gone from PEPFAR, however; the administration would be required to issue a report to Congress if spending on “abstinence and fidelity” programs dropped below one half of funds devoted to the prevention of sexual transmission of HIV, a sub-appropriation of the larger prevention budget. The House Committee bill does not change the 2003 provision requiring funding recipients to oppose sex work (David Brown, Washington Post, 2/28/08).

PEPFAR is the major U.S. program for international HIV/AIDS funding, and directs funds primarily to 15 “focus countries”, 12 of them in Africa. The new House bill also adds 14 Caribbean countries to this list. (Associated Press, 2/27/08).

Both chambers are expected to have floor votes on their respective bills after the March recess. According to Jamila Taylor, Legislative and Policy Analyst for the Center for Health and Gender Equity–CHANGE/PEPFAR Watch (PEPFAR Watch is an initiative of CHANGE, www.pepfarwatch.org), the House floor vote will likely be held under a “closed rule” in which no amendments would be permitted. It is still unclear as to the rules that may be applied during a Senate floor vote. The Senate Foreign Relations Committee passed its version of the PEPFAR bill by a vote of 18-3 on March 13, 2008.

While the new legislation has the potential to alleviate concerns over the Bush administration’s emphasis on abstinence education spending, the unchanged ban on organizations supporting sex-workers means that an important population continues to be ignored by U.S. policy. This funding-gap remains a key opportunity for funders. Additionally, if the House and Senate do not resolve the differences between the respective bills before the August 2008 recess, it is unlikely for the reauthorization to be approved this year, according to Taylor. Though funding would likely continue, it would do so under the original 2003 rules until new legislation could be approved. Advocacy funders should consider supporting efforts to keep PEPFAR reauthorization moving, yet do so in the name of a bill that reflects a progressive compromise. Funders with grantees in PEPFAR countries should also consider ways that they can work with PEPFAR to leverage funds or fill gaps that PEPFAR does not address.

DOMESTIC: Growing Awareness of the Southern Epidemic in the U.S.
The U.S. South is gaining increasing attention as the domestic region hardest hit by HIV/AIDS. As revealed by recent FCAA research, the U.S. South receives a small share of philanthropic commitments for HIV/AIDS relative to the epidemiological crisis. Both POZ Magazine and Ford Reports covered the U.S. South in recent issues. IN mAy 2008, FCAA will release an in-depth report on HIV/AIDS and philanthropy in Alabama, the first of a series of Spotlight reports focused on key locales in the domestic epidemic.

According to the Centers for Disease Control, the U.S. South currently accounts for 45 percent of all new U.S. HIV infections, and 50 percent of all U.S. AIDS deaths (Briggs, Jamie. “The South Shall Rise Again.” POZ, Nov 2007). However, in 2006, the South as a region received only 19% of U.S. domestic philanthropic commitments to HIV/AIDS (Funders Concerned About AIDS, U.S. Philanthropic Commitments for HIV/AIDS: 2005 & 2006. Funders Concerned About AIDS, New York, NY: 2007).

A recent article from the Ford Foundation found that the Southern HIV/AIDS epidemic is “exacerbated by heightened factors in the region, including a health care delivery system in crisis; a significant stigma surrounding the disease; high rates of poverty; the prevalence of racism, sexism and homophobia; and high incarceration and immigration rates.” The article also emphasized the impact of the epidemic on minority populations; HIV/AIDS is a leading cause of death for African Americans, 54 percent of whom reside in the South. (Ford Foundation, “Combating HIV/AIDS: The Southern Strategy.” Ford Reports, No. 2, 2007).

In addition to these factors, specific crises such as Hurricane Katrina continue to stress the response to AIDS in the region. POZ reports that, following the hurricane, “half the community-based prevention contractors” in the city “went out of business” and many patients returning later found their medical coverage “lost or in disarray.” According to the Henry J. Kaiser Family Foundation, Hurricane Katrina directly affected more than 21,000 people living with HIV/AIDS in Alabama, Louisiana and Mississippi (Henry J. Kaiser Family Foundation, HIV/AIDS Policy Fact Sheet: Assessing the Number of People with HIV/AIDS in Areas Affected by Hurricane Katrina, September 2005.)

The South presents numerous opportunities for HIV/AIDS funders looking to make impact in the epidemic. For instance, Ford Foundation and the Elton John AIDS Foundation are supporting the National AIDS Fund’s new Southern REACH (Regional Expansion of Access and Capacity to Address HIV/AIDS) initiative.

in May 2008, FCAA will release a report focused specifically on the private philanthropic response to HIV/AIDS in Alabama, one state facing challenges common to the region.

INTERNATIONAL: Prevention, Testing, and Treatment in the Global South
It has been obvious from the start of the international HIV/AIDS epidemic that the regions hardest hit are located in the Global South—the term increasingly used by economists for the “Third World.” A vast range of diverse factors is at play in this dynamic, but some of the problems stem from geographic and historical factors similar to those in the U.S. South. For instance, rural geography, combined with poverty, impact HIV/AIDS prevention education and access to care.

In India, there is increasing evidence that HIV/AIDS awareness messages are not reaching rural areas. The rural population accounts for 40 percent of HIV cases, and calls are being made for increased funding and attention to these regions (The Hindu, 1/8/08). The Los Angeles Times reported in 2006 that rural Indians may travel hundreds of miles to reach cities where work is available, staying for months at a time. Men who migrate for work may get HIV from urban sex workers and then bring the virus back to their wives in the villages, as reported by the Times (Los Angeles Times, 12/21/06). As in the U.S. South, rurally dispersed PLWHA often encounter barriers to access and care thanks to daunting transportation requirements and stigma in communities that have not been reached with AIDS awareness programs.

One answer to rural dispersion is mobile testing and treatment programs. In Zambia, one such program is showing success. Zambia’s Mpika district is the largest in the country, and home to 165,000 people but only one government hospital, UNICEF reports. “There are no decent roads into the district, and no one has transportation anyway,” said one care worker quoted in the article. UNICEF donated a mobile testing van, which now visits 19 health posts across the district. Collaboration with the William J. Clinton Foundation and PEPFAR brought low-cost antiretroviral (ARV) drugs to the effort, which is directed primarily towards women and children at risk for HIV/AIDS (Bahringer, Christyne. “Mobile testing and treatment fight HIV/AIDS in Zambia’s Mpika District.” UNICEF Newswire, 3/11/08).

Funders should remember that the challenges common to the Global South are not restricted to the broad region. Recent research in Japan, for instance, indicates that people with HIV in rural areas are more likely to have already progressed to AIDS at time of diagnosis than are their urban counterparts (Kaiser Daily HIV/AIDS Report, 10/12/07). The rural AIDS epidemics of first-world nations continue to need funder awareness and attention, as the United States’ own example demonstrates.

EPIDEMIOLOGY: Latinos in Los Angeles and the Southern U.S.
Awareness is building around the HIV/AIDS epidemic among U.S. Latinos, who represent more than 17 percent of people living with HIV/AIDS and 18 percent of new cases, despite making up 15 percent of the population. In areas frequented by migrant workers, the statistics are both more severe and less easily obtained. Migrant workers face a range of challenges that increase their vulnerability to HIV, and are often harder to reach with prevention and care efforts than more stable domestic populations.

Nationally, in 2005, Latinos had the second highest AIDS case rate among major U.S. ethnic groups (Henry J. Kaiser Family Foundation, HIV/AIDS Policy Fact Sheet: Latinos and HIV/AIDS, July 2007). In certain regions, such as Los Angeles County and many Southern states, Latinos are even harder hit, due to factors related to language, awareness, and migration.

In Los Angeles County, according to a New American Media report, as of 2006 Latinos made up 40 percent of the people living with AIDS. Latinos in L.A. County have a late detection rate; 44 percent of Latinos diagnosed with AIDS and interviewed between 2000 and 2004 were diagnosed with AIDS within one month of learning they were HIV positive. The same was true for 33 percent of African-Americans and 20 percent of whites (Gomez, Cynthia. “Who Has AIDS in L.A. County?” New American Media, 2/17/08). Dr. Amy Rock Wohl, chief epidemiologist at the Los Angeles County Department of Public Health’s HIV Epidemiology Program, noted that the dynamic “may be due to language barriers, fears of revealing immigration status and a lack of understanding” about risk for HIV infection. Funders can play a critical role in educating their grantees about the needs of Latino populations in their communities and providing resources to meet those needs.

An accompanying story discussed the issue of Latino day laborers being offered money for sex. One study found that out of 450 day laborers interviewed, nearly 40 percent indicated that they had been solicited for sexual services. Day laborers generally know how to protect themselves from HIV transmission, but infection levels are driven by “social isolation and lack of support.” (Flores, Adolfo. “Day Laborers Offered Money for Sex.” New American Media, Feb 16, 2008). Another article explored an even darker dynamic, wherein day laborers are recruited for work only to find that they are actually wanted for sex; some are drugged and raped. Notes Anel Flores of the Los Angeles Legal Aid Foundation, “The day laborer will not present the charges formally before a judge. There is not one case like this in the courts. These immigrants are afraid that they’ll be accused of being gay on their work corners or that they’ll be deported, and it’s very difficult to change that mentality. They can’t see that what happened to them is a crime.” (Núñez, Claudia. “Male Day Laborers Turn to Prostitution.” Translated by Elena Shore. La Opinion, 12/22/07).

While other areas may not have Los Angeles’ concentration of migrant workers, the nature of the problems faced may be similar. A study in North Carolina recently found higher AIDS case rates among Latinos than the state average. Bilingual education campaigns are one response; as a local county HIV/STD program manager said, “the Latino community is not afraid to get tested… Where they have difficulty sometimes is in accessing services where someone understands their language” (Perez, Lorenzo. “New Drive to Inform Latinos About HIV.” The News & Observer, 1/24/08).

Funders should consider supporting efforts to increase outreach to at-risk Latino populations and ensure legal advocacy for victims of sexual exploitation.

December 2007

INTERNATIONAL: China faces epidemiological challenges, but philanthropy is active

Rates of new HIV/AIDS cases in China have increased to more than 3,000 per month, with a growing proportion attributed to sexual transmission.  In total, the deputy director of the Chinese Centre for Disease Control and Prevention, Wang Ning, estimated that about 220,000 people in China have contracted HIV, with a quarter having developed AIDS.  According to Reuters, the United Nations puts the total number of PLWHA in China at around 650,000 (Reuters, 11/06/07).

In a separate announcement, the director of the Chinese Association of STD & AIDS Prevention and Control warned of increasing HIV/AIDS rates across the country and cited several factors hampering treatment and prevention efforts, including, as Xinhua reported, “inadequate publicity and funding, inefficient health care facilities in rural areas and ineffective control on floating populations” (Xinhua, 11/10/07).

However, Chinese officials and AIDS workers have some cause for encouragement, too.  The Bill & Melinda Gates Foundation on November 13 announced a new partnership with the Chinese government and an initial commitment of $50 million towards supporting both governmental and nongovernmental HIV-prevention efforts among high-risk populations (Xinghua, 11/15/07). As reported by the Seattle Times, the Gates funding would equal one-third of China’s total public spending on HIV/AIDS this year (Seattle Times, 11/14/07).

The Gates announcement is not the only recent philanthropic headline in China.  An in-depth article in The Australian reported earlier in November that Li Ka-shing, chairman of the Hong Kong conglomerate Hutchison Whampoa and Asia’s wealthiest man, has announced plans to give a third of his fortune (approximately $10.9 billion) to the Li Ka Shing Foundation, founded by Li in 1980.  The pledge would give the Li Ka Shing Foundation an endowment rivaling that of the Ford Foundation.  According to The Australian, the move would create a new precedent in China, where philanthropy has traditionally been discouraged and lacks the established identity and transparency of Western institutional giving (The Australian, 11/3/07).  More information about the Li Ka Shing Foundation’s activities is available at its website, www.lksf.org.

DOMESTIC: Baltimore AIDS crisis fueled by sex work and drug addiction

As reported in the Baltimore Sun on November 4, though Baltimore is not always associated with the domestic HIV/AIDS epidemic, the city’s rate of AIDS diagnoses was, at last count, nearly three times that of the nation, and far higher than that of New York or San Francisco.  A report in the Sun explored the links between sex work and drug use that are helping to fuel an explosion of HIV infection, describing an at-risk population caught in a desperate cycle of drug addiction.  While heroin injection is most obviously linked to HIV risk, crack addiction, widespread among the women interviewed by the Sun, works to increase vulnerability by prompting people to engage in risky sex in exchange for money or drugs.  Many do not, or find they cannot, insist on condom use by partners.  Susceptibility is further increased by existing sexually transmitted infections, such as syphilis, gonorrhea, and chlamydia (Baltimore Sun, 11/04/07).

The city is planning a new response to this population of “core transmitters” that will focus on evaluating outreach efforts and formulating new recommendations for policy interventions.  In addition, the state’s attorney’s office is planning to implement a prostitution court which will connect sex workers with services and refer them to counseling. (Baltimore Sun, 11/09/07).  Philanthropy can assist these efforts by amplifying its support to needle exchange clinics, methadone clinics, and support services for at-risk women in the Baltimore area.

HEALTH & RIGHTS: Rates of TB/HIV coinfection increase in sub-Saharan Africa; in Cape Town, drug-resistant patients quarantined

The 38th Union World Conference on Lung Health opened on November 8 and sparked coverage of an expanding AIDS and tuberculosis (TB) co-epidemic in sub-Saharan Africa.  AIDS and tuberculosis form a deadly combination—of the 33 million PLWHA worldwide, one third also have TB, and the death rate for people infected with both is five times higher than that of tuberculosis alone.  Nine out of ten people harbor dormant TB bacteria, but HIV-positive people are more likely to develop active TB.  There were 4.3 million new HIV infections in 2006 and over twice that many new TB infections.  The heart of the co-epidemic is in sub-Saharan Africa, where AIDS-related illnesses account for 40 to 60 percent of all deaths and drug-resistant TB is spreading rapidly (AFP, 11/02/07).

Delegates to the conference charge that existing funding levels for TB research are drastically insufficient, and some say that the scope of the epidemic is not fully appreciated.  Most of the drugs used to fight TB are decades old, and lack of innovation has led to the emergence of highly lethal drug-resistant strains of the disease (Associated Press, 11/07/07).  Prior to the conference, one expert stressed the combined nature of the HIV/TB epidemic, urging collaboration in response efforts by HIV and TB organizations (IOL, 11/06/07).

Extremely-drug-resistant tuberculosis, or XDR-TB, presents difficult choices to public health workers. In Cape Town, South Africa, some patients with XDR-TB are being kept under enforced quarantine, a move made reluctantly in light of the severe public health threat of XDR-TB and the lack of viable treatments. Many of these patients have HIV/AIDS as well, and quarantine introduces new concerns for treatment as well as human rights—challenges the director of the related hospital characterized as “without answers.” (Associated Press, 11/11/07).

One response is to increase funding to research and treatment programs aimed at XDR-TB and its intersection with HIV/AIDS. Private philanthropy and pharmaceutical funders were responsible for some of the increase in global TB funding from 2005 to 2006, however, overall funding levels are falling short of previous goals and projections (Kaiser Family Foundation, 11/09/07).  Funders should consider ways that they can address HIV and TB coinfection in their grantmaking and how they can play a key role in spearheading innovative responses to the HIV/TB epidemic.

RESEARCH: Recent announcements prompt new perspectives on global epidemic

Two November developments emphasized the dynamic, evolving nature of the HIV/AIDS epidemic, and the diversity of global situations and perspectives, and both inform practical next steps for funders.

On November 13, the M•A•C AIDS Fund released a new international study documenting perspectives from nine countries on the nature of HIV/AIDS as a disease and a global threat.  Among its findings, the report reveals that nearly half of people do not view AIDS as a fatal disease, that many believe there is a cure for HIV, that people overestimate the availability of treatment, and that stigma and shame continue to exclude PLWHA from their mainstream societies (PR Newswire, 11/13/07).  Funders should stay tuned to opportunities in supporting global education, prevention programs, and programs that address stigma. Click here for more information on this report.

On November 20, UNAIDS announced that global HIV prevalence “has leveled off” though AIDS remains “among the leading causes of death globally and remains the primary cause of death in Africa.”  The announcement reduced estimates of global HIV prevalence from nearly 40 million to 33.2 million, citing methodological advancements in data analysis.  Global HIV incidence “is now estimated to have peaked in the late 1990s” (UNAIDS, 11/20/07).

The new estimates are due largely to more accurate surveying techniques.  Previously, some surveys over-sampled populations with high HIV prevalence (such as urban clinic visitors), which inflated overall estimates when these findings were extrapolated to the national level (NY Times, 11/20/07).

A follow-up article in The New York Times characterized the announcement as “a time to rethink AIDS’ grip” and discussed how the epidemic may be winding down on global level, despite pockets of continued incidence and high prevalence (NY Times, 11/25/07).

But as the Times also emphasized, “the first thing experts are… quick to say is that it doesn’t mean anyone can relax.” According to new figures from UNAIDS, 2007 saw an estimated 2.5 million new infections, and as the M•A•C AIDS Fund study shows, worldwide understanding of the disease remains limited and mired in stigma.  Dr. Mark R. Dybul, U.S. Global AIDS Coordinator, was quoted in the Times to say, “I don’t think it radically shifts our thinking, at least not for 5 to 10 years.  We still need to prevent 2.5 million infections, we still need to prevent 2.1 million a year from dying.” Funders should keep this in mind as coverage of the UNAIDS announcement continues—the urgency of the global philanthropic response to HIV/AIDS has in no way diminished.

September 2007

Recent legislative developments highlight human rights issues

A bill that would allow nonprofit agencies to provide condoms to state prison inmates (AB 1334) was passed on September 6 by the California Senate and is now on the desk of Governor Schwarzenegger (LA Times, 09/07/07). The CDC has endorsed state-level condom-distribution programs, but an attempt to legalize them last year by the California State Legislature was vetoed by the Governor (NY Times Editorial, 07/18/07). For more analysis, see California Progress Report, 09/12/07. Legalization would not result in funds for these efforts, and would present an important opportunity for funders to implement such programs.

On September 11, Governor Schwarzenegger signed into law a bill (SB 443) that allows HIV-positive men to use their sperm in fertility treatments such as artificial insemination and in vitro fertilization, provided the sperm is “washed” to minimize the risk of HIV transmission. (LA Times, 09/10/07).

In unrelated news, care for PLWHA in state and federal detention facilities remains a troubling challenge. In a federal immigration detention facility in San Pedro, CA, Victoria Arellano, a transgender Mexican woman with AIDS, died on July 20 after having been denied AIDS medications (Washington Post, 08/15/07). Funders can make an impact in preventing similar future situations by funding advocacy efforts to ensure distribution and administration of HIV/AIDS medications to detainees, as well as supporting efforts in the ongoing struggle to reduce discrimination against transgender people and other socially-marginalized groups.

New drugs for PEPFAR

On August 13, the U.S. Food and Drug Administration (FDA) approved two generic HIV/AIDS drugs for use by PEPFAR, including a first-ever three-in-one pediatric AIDS pill for children under 12.

The pediatric pill, which combines lamivudine, stavudine and nevirapine, represents a significant accomplishment because it can be distributed and administered easily to children, in solid form or dissolved in water. The FDA approved an additional generic navirapine tablet.

Neither pill can be sold in the United States, due to patents on the drugs held by their U.S. manufacturers. But the generics, manufactured by Indian pharmaceutical companies Cipla Ltd and Hetero Drugs Ltd, respectively, will be available at lower cost for purchase and use abroad by PEPFAR (Reuters, 08/13/07).

Aging and HIV/AIDS—a growing concern

In the early days of HIV/AIDS, philanthropy’s response to the epidemic was integral to combating the disease and raising public awareness. Now, the impact of HIV/AIDS on older people is also going largely unnoticed and unaddressed, and private philanthropy is in an ideal position to advocate for and spearhead the response to this growing need.

There is a growing awareness of continued sexual activity into old age, and yet middle-aged and elderly people are rarely targeted by prevention and sexual education campaigns. A new report has found that most Americans remain sexually active into their 60s and many continue to have sex regularly into their early 70s. However, most of those surveyed had not discussed sex with a doctor since age 50 (NY Times, 08/23/07).

In 2003, the New York Times wrote on the increase of HIV/AIDS among older people and the lack of prevention messages targeted at people over 50 (NY Times, 07/08/03). The success of antiretroviral medications continues to keep older PLWHA alive, but older age is accompanied by increased medical complications. Older HIV-positive people who are not aware of their infection often remain so until they develop full-blown AIDS, and the potential conflation of early AIDS symptoms with the natural effects of aging may prevent a diagnosis until the symptoms have become more difficult to manage.

Troublingly, a recent study from the University of Pittsburgh School of Medicine found that “few older U.S. women, especially African-Americans, are interested in being tested for HIV, despite having significant risk factors for lifetime exposure” (UPI, 08/07/07).

Testing, education, and treatment programs for older people living with HIV/AIDS represent excellent opportunities for funders, as well as investment in and advocacy for research and specialized training for medical professionals to respond appropriately. Domestically, about 15 percent of all people with HIV/AIDS are age 50 and older. Regardless of gender or ethnicity, older people face a range of complications and challenges from HIV/AIDS, including increased risk of developing pneumonia or HIV-related dementia (The Body, Older People and HIV). Those who have sustained antiretroviral treatment for many years may now face drug resistance in addition the physical and mental stresses that aging adds to AIDS. Stay tuned to www.fcaaids.org for more on AIDS, aging, and the philanthropic response.

July 2007

IAS 2007 updates
Presentations at the 4th International AIDS Society (IAS) Conference on Pathogenesis, Treatment and Prevention reveal recent scientific developments. Delegates to IAS met from July 22-25 in Sydney, Australia. Among the many findings presented by scientists:

For more coverage of and webcasts from this conference, visit IAS or Kaiser Family Foundation.

New HIV infections are outpacing treatment
Developments in treatment and prevention were put in context by comments made by Dr. Anthony Fauci, chief advisor to President Bush on HIV/AIDS. While access to antiretroviral drugs continues to expand, and new prevention techniques such as male circumcision may have the potential to stem the tide of future infections, currently for every person put in therapy, “six new people get infected,” Dr. Fauci said. The HIV epidemic was described by Dr. Brian Gazzard of the British HIV Association as “essentially uncontrolled.” Funders have the opportunity to be crucially involved in the development of innovative prevention strategies to curb the expanding epidemic.
http://news.bbc.co.uk/2/hi/asia-pacific/6911736.stm <http://news.bbc.co.uk/2/hi/asia-pacific/6911736.stm>

MSM face difficulty accessing treatment in many regions
Men who have sex with men (MSM) face serious barriers to prevention, treatment, and care services. Globally, fewer than one in 20 MSM has access to these services, and in some developing regions, the percentage is even lower. Many prevention campaigns are aimed at the general public, and in countries where MSM continue to face stigma and criminalization, these campaigns often remain out of reach. The American Foundation for AIDS Research (amfAR) has recently begun a new global MSM Initiative which intends to address this growing crisis. More information on the challenges faced by MSM and amfAR’s MSM Initiative is available here: http://www.amfar.org/cgi-

bin/iowa/programs/globali/record.html?record=260

Four new publications of interest to funders

House lifts ban on public funding to Washington, D.C. needle exchange programs
On June 28th, the House of Representatives voted to lift a nine-year ban on using D.C. tax dollars to subsidize needle exchange programs (NEPs). Washington D.C. has the highest HIV prevalence rate of any U.S. city, and needle exchange programs have long been proven to reduce HIV transmission rates. PreventionWorks!, the district’s only NEP, currently remains funded by private donations and reaches only a third of the estimated total population of injection drug users in the city. D.C. Health Department Director Gregg Pane noted in early July that public funds could arrive as early as October if the measure becomes law.  For more on this story, read coverage here:

http://www.washingtonpost.com/wp-dyn/content/article/2007/06/28/AR2007062801878.html
http://www.medicalnewstoday.com/articles/75816.php
http://www.washblade.com/2007/7-6/news/localnews/10871.cfm
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=1&DR_ID=45920

March 2007

U.S. appellate court approves PEPFAR prostitution pledge restriction

Debate continues over President Bush’s Emergency Plan for AIDS Relief (PEPFAR), which is currently still obligated to deny funding to NGOs that do not publicly disavow prostitution and sex trafficking. In many cases this restriction limits funding for organizations that work to prevent and treat HIV/AIDS among sex-workers, a highly at-risk population worldwide, and for other key allies in promoting  proven-effective prevention strategies. In late February a federal appeals court in Washington, D.C., ruled that this restriction remains constitutional and does not violate free speech rights, as had been ruled earlier by a lower court (Int'l Herald Tribune, 02/27/07).* The Global Health Council decried this ruling as “an unjust and ill-considered expansion of government authority to limit the free speech of NGO’s receiving public funding to fight AIDS” (Global Health Council, 03/02/07). The federal ruling is unfortunate, and grantmakers should take the opportunity to focus more programming on the involvement of sex workers in prevention efforts, human rights discussions, and policy advocacy.  A  separate challenge to the prostitution pledge is pending in an appellate court in New York. A ruling by the Washington court is not binding on the New York case.

Click here to read a press statement from the Urban Justice Center and the Network of Sex Work Projects that repositions discussion of the Randall Tobias scandal to the Anti-Prostitution Pledge Tobias supported.

* Please note that registration with the relevant news source may be required to read the full text of third-party news items.

New AIDS drugs show promise

Major news for the AIDS world broke in late February, with the announcement of the clinical success of two new drugs for the treatment of HIV/AIDS (NY Times, 02/28/07, LA Times, 03/01/07). Physicians and researchers have compared the potential of these drugs, which represent the first new classes of oral HIV drugs in a decade, to that of the multi-drug cocktails from the mid-1990s.

Grantmakers should also remember the mid-90s as a time when philanthropic AIDS dollars decreased due to the excitement over new treatments. Then as now, the potential of pharmaceutical treatments should not distract from the central challenge of prevention. Grantmakers should take this opportunity to evaluate their programming on prevention and patient services, especially among populations where advanced treatment remains financially or logistically unattainable. In addition, AIDS science remains an important area for sustained grantmaker investment, as private dollars are an ideal means for jumpstarting cutting-edge research.

AIDS Healthcare Foundation (AHF) steps up campaign to lower drug prices in Mexico
AIDS Healthcare Foundation, the largest AIDS organization in the U.S., began a campaign in late February to pressure pharmaceutical companies to reduce HIV/AIDS drug pricing for Mexico, where generic drugs may not be bought due to NAFTA restrictions. While greatly reduced prices have been achieved for Honduras and many African countries, which are considered “low income” nations in drug price negotiations, Mexican prices remain closer to those in the U.S., despite the vast gulf in average income between the two countries, because Mexico is classed as a “middle income” nation (PR Newswire, 02/23/07). In fact, the cost of AIDS drugs in Mexico nearly exceeds the average annual income there ( (AP/Forbes, 02/23/07).

Gates Foundation and microbicide research

The Bill and Melinda Gates Foundation has strongly supported microbicide research, considered a potentially significant HIV prevention measure, for several years. In early February, two clinical trials the Foundation had helped fund--which involved more than 1,300 women in various areas of Africa and India--were cancelled due to safety concerns. The Foundation, known for its emphasis on cutting edge research, is “in this unusual position where we can spend one million dollars on something we think might work and it can fail and nobody gets fired.... Political institutions can’t handle risks like that” (Bill Gates, The New Yorker, 10/24/05). Among private funders, the Bill and Melinda Gates Foundation strongly supported microbicide gel research, having provided $124 million since 2000 to microbicide research (Seed Magazine, 08/16/2006) and granting $20 million to the most recent round of trials in partnership with the Agency for International Development (NY Times, 02/01/07). Melinda Gates has emphasized the need for microbicides and other tools “that put the power to prevent AIDS in the hands of women” (Newsweek, 05/15/06). Philanthropy should continue to provide research and innovative solutions that governments cannot. The cancellation of the trials highlight the necessity for more development of vital prevention methods, especially those that can be controlled by women.

Several Phase III clinical trials for other microbicides are currently ongoing, however, with results expected by the end of 2007 (UN News Centre, 02/01/07). While this setback is unfortunate, microbicides still have highly significant potential as a means of prevention. Grantmakers should continue to invest in these and other innovative, path-breaking efforts in AIDS science.

*UPDATED* March 2007

Understanding the Ryan White Program

The Ryan White CARE Act was finally reauthorized by Congress in late December 2006, with alterations to the Act that change how federal funds are allocated to state HIV/AIDS programs. Kaiser Family Foundation recently released an updated edition of its publication comparing the prior law to that of the recently reauthorized one, now referred to as "Ryan White Program." This “Side-by-Side Comparison” is an essential resource for funders wishing to understand the potential reallocation of these federal resources, the emerging needs of grantees in certain geographic areas, and how this may create new funding gaps for essential HIV/AIDS service delivery to those in need.  Click here to download KFF’s side-by-side comparison.
 
Kaiser Family Foundation has also assembled a useful fact sheet which outlines the structure, funding, and administration of the Ryan White Program, as well as the differences between how metropolitan and non-metropolitan areas are funded. Click here to download this document.
 
After a surge in media coverage about Ryan White Program reauthorization in November 2006, the Black AIDS Institute published a statement exploring the assumptions inherent in the debate over funding formulas. Click here to read more.

Center For AIDS released a fact-sheet in Fall 2006 on Ryan White reauthorization, available for download here. This document explains the debate over the reauthorization proposals and focuses on the difference between metropolitan and rural funding via the bill’s Title structure.  

Connecticut received supplementary funding to restore some essential services. Read more here.

State-by-State

Do you know your state or territorial AIDS Director?  Prevention Director?  AIDS Drug Assistance Program (ADAP) Administrator?  To view your state’s Ryan White and Prevention profiles and contact information for your state officials, consult the directory on the National Alliance of State and Territorial AIDS Directors (NASTAD) website. Kaiser and NASTAD have also released a survey of state and territorial ADAPs available for download here.

NEW FOR FUNDERS

FCAA is happy to release its second Dialogue report, Collaborative Funding Dialogue: Ryan White CARE Act Reauthorization and California: What Funders Should Know. To learn more and download this report, please click here.

The first in FCAA’s new series of teleconferences* examined What Funders Should Know About Ryan White CARE Act Reauthorization.  It took place on Wednesday, January 24, 2007 at 2:00 pm EST. A One-Sheet Report on this event was released in May 2007.

*Open to funders only.

December 2006

HIV-Positive Russian Infants Abandoned to State Care, Problem Epitomizes Difficulties in Eastern Europe
In Russia, home to one of the fastest-growing AIDS epidemics, many pregnant HIV-positive women remain unaware of medications to reduce the risk of transmitting the virus to their babies. In addition, stigma surrounding HIV leads to the abandonment of hundreds of newborns every year to the care of the state, an article published by BBC News this February reveals. Already HIV-positive, these orphans languish further in state care, spending years in relative isolation and often growing up developmentally impaired (Simpson, BBC News 2/21/06). The rapid spread of the epidemic in Eastern Europe has been documented by several major HIV/AIDS research organizations, including UNAIDS, Kaiser Family Foundation, WHO, and the CDC. However, the Russian government, at least, has only recently begun allocating funds to HIV prevention, and stigma remains a problem.

Read full article by BBC News here.

Philanthropic Response in the Region Scant

In addition, philanthropic attention to Eastern Europe and Central Asia remains scant and disproportionate to the region's needs, as demonstrated in research by the European Funders Group and the most recent resource tracking publication from Funders Concerned About AIDS, which can be accessed by clicking here.

Funders such as Open Society Institute and Tides Foundation, among others, have focused some of their grantmaking efforts in this region.  Funders wishing to learn more and would like technical assistance on funding HIV/AIDS issues in Eastern Europe should e-mail their requests to FCAA.