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Viral Strain: In AIDS Fight, Ambitious Goals
Meet Hard Realities --- Millions of Ill in Poor Nations Fail to Get Drugs as
Funds, Medical Systems Fall Short --- Attention Shifts to Terror
By Gautam Naik in London; Mark Schoofs in Johannesburg, South Africa and Sarah
Lueck in Washington
2,307 words
1 July 2004
The Wall Street Journal
A1
English
(Copyright (c) 2004, Dow Jones & Company, Inc.)
Four years ago, the United Nations, governments of wealthy countries and major
foundations committed for the first time to bring drugs to the millions of AIDS
sufferers in poor countries. No longer, it was declared, would the life-saving
medications proven effective in the mid-1990s be restricted to rich nations that
could afford to spend thousands of dollars a year per person.
Today, however, the major global programs are falling short -- either in getting
funding, reaching treatment targets, or both. According to the World Health
Organization, more than 93% of the six million AIDS patients in the developing
world who urgently need drugs aren't getting them. As many as 40 million more
people world-wide have the virus that causes AIDS, a number that rose by an
estimated five million last year. Controlling the epidemic will be the top issue
at the International AIDS Conference in Bangkok starting July 11.
There are two major campaigns against AIDS. One is the Global Fund to Fight
AIDS, Tuberculosis and Malaria, a brainchild of U.N. Secretary General Kofi
Annan. He originally envisioned the fund as a $10 billion-a-year effort. But its
executive director now says pledges look likely to peak at about $3 billion a
year in 2008, of which a little more than half will be spent on AIDS. He says
that's not enough to stem the tide of the disease.
In the U.S., meanwhile, President Bush pledged $15 billion over five years for
AIDS and related programs overseas in his State of the Union address in 2003. So
far, the U.S. is close to being on track to meet its funding commitment, but far
from its goal of treating two million people by 2008. Mr. Bush's global AIDS
coordinator, Randall Tobias, says 200,000 people will have received the drugs by
next year under its programs. One reason for the slow progress, according to
critics: The Bush administration is blocking access to cheaper versions of AIDS
drugs and insisting on rules that favor big pharmaceutical companies. The
administration says it's opening the door to cheaper drugs but wants to ensure
their safety.
The U.S. isn't the only target of criticism. Many European governments are
giving less to the AIDS cause than the U.S. relative to the size of their
economies. Amid the fight against terrorism, AIDS has lost the status it held
four years ago as the compelling global issue of the day.
The World Health Organization, which provides on-the-ground support for many
AIDS programs, said last December that it hopes three million people will be
receiving AIDS drugs in the developing world by the end of 2005. The current
figure is less than one-sixth of that. "In my heart of hearts, I worry we won't
make it," says Charles Gilks, a WHO official, noting the challenge of
distributing drugs in remote places and training thousands of doctors and
nurses.
To be sure, the programs now under way will vastly multiply the number of people
in Africa and other poor regions getting drug treatment, and officials both in
the U.S. and abroad say they hold out hope of reaching their targets. Mr. Tobias
asserts that the U.S. plan is off to a "fast start" and adds: "I think we're
building some momentum, and I'm very confident."
Although cocktails of AIDS drugs were shown to prolong life in 1996, at first
there wasn't any major attempt to distribute the drugs in poor countries. In the
absence of drug-company discount programs or generic drugs, it cost about
$10,000 to treat a patient for one year -- far too much for governments or
charities to pay. It was also widely believed that health-care systems in poor
countries would have difficulty getting reliable supplies of the drugs and
teaching people how to take them.
A turning point came in June 2000 at the World AIDS Conference in South Africa.
Nelson Mandela declared that AIDS on his continent was "claiming more lives than
the sum total of all wars, famines and floods." World leaders and the media
began to take notice of AIDS's enormous toll.
A call by Mr. Annan, the U.N. secretary general, for $10 billion a year to fight
AIDS, tuberculosis and malaria developed into the Global Fund. It was set up in
January 2002.
Despite its origins, the fund isn't part of the U.N. It is financed largely by
direct contributions from Western governments as well as private donors such as
the Bill and Melinda Gates Foundation. Rather than directly giving sick people
medicine, the fund receives proposals for grants from individual countries and
awards money to them if a panel of experts thinks the proposals are workable.
In 2004, more than 80 countries sought a total of $2.8 billion from the Global
Fund, of which $968 million was approved. Since donor countries committed $1.5
billion for 2004, there was more than enough money this year to pay for every
proposal judged workable.
But next year looks tougher. The fund has long planned for a major ramp-up in
2005 and beyond, so that it can fund new programs while continuing to give drugs
to AIDS patients who started treatment in earlier years. (The drugs must be
taken for life.) Based on its analysis of likely grant proposals, it believes
that it could put $3.3 billion to good use in 2005. But donors have made pledges
so far of only $900 million.
To stem the AIDS epidemic, the Global Fund believes it needs to raise -- and pay
out -- $7 billion to $8 billion a year from 2007 onward. But the fund's
projections suggest that contributions at their peak will reach only $3 billion
per year. The fund has made "extremely rapid progress in the right direction,"
says its executive director, Richard Feacham. "On the other hand, it's nothing
like enough."
One reason for the shortfall is that many donor nations only commit funds year
by year. Some, such as France, have agreed to give as much in 2005 as they did
this year. But that leaves the fund far short of the goals set in 2000-01 when
the world's attention was focused on the AIDS crisis.
Overall, many wealthy nations gave less to the global AIDS fight in 2003 than
the U.S. when donations are considered relative to the size of each nation's
economy, according to the Kaiser Family Foundation, a Menlo Park, Calif.,
health-care research group. By this measure, France committed half as much as
the U.S. and Japan about a third, says the foundation.
Meeting fund-raising goals isn't the only problem for the Global Fund. Finding
worthy recipients is a challenge too, since the fund can only give money to
countries that write workable proposals -- a difficult task for poorer
countries.
Kenya, home to 2.5 million patients infected with HIV and some 900,000 AIDS
orphans, asked this year for $92 million from the Global Fund to pay for
antiviral drugs. It was turned down because the "use of funds wasn't clearly
stated," says a person familiar with the decision. The fund's technical experts
found similar faults in proposals from some other hard-hit countries, including
Nigeria, South Africa and Zimbabwe, and these proposals were also rejected.
Still, the fund encourages most of the rejectees to try again and advises them
about the details needed for a successful proposal, such as who will distribute
the drugs and how many doctors and nurses are available to prescribe them.
Officials are confident that over time many countries will figure out how to
devise proposals -- and programs -- that work. Countries hit hard by AIDS "are
falling over themselves to get going and every day we lose is unnecessary," says
Stephen Lewis, the U.N.'s special envoy for AIDS in Africa.
Evidence to date suggests that even very poor countries can use the Global
Fund's money effectively to deliver drugs to AIDS patients. For example,
Honduras has put 40% more patients on AIDS drugs than it originally targeted
when it got a Global Fund grant in 2003, according to a fund-raising official
for the fund. Haiti exceeded its goal of treating 1,200 patients by 67%, even
though it was in the midst of a civil war. Audits of the fund's first 25
recipients showed that only five were failing so badly that they were at risk of
losing their grants.
One reason the Global Fund needs so much money is that it's expensive to shore
up health systems that are short of trained medical personnel. For example,
thousands of South African nurses desperately needed at home to deal with a
rising tide of AIDS patients have been wooed away by the higher pay in England.
Mozambique is considering importing doctors from Brazil, India and Cuba.
South Africa's North West Province recently advertised for a doctor to run the
HIV/AIDS program in Taung hospital, located about 125 miles from the provincial
capital. But no one applied for the job because, says health department official
Calvinia Sebekedi, "people wouldn't like to work in this remote area."
The Global Fund's struggles are playing out alongside the other big effort in
global AIDS: the Bush administration's $15 billion, five-year commitment.
The Bush plan, which includes small amounts for tuberculosis and malaria
programs, officially got started in the fiscal year that began in October 2003.
Mr. Bush proposed spending $2 billion for the fiscal year and Congress raised
the amount to $2.4 billion. While $547 million of that went to the Global Fund,
most is going to America's own programs. For the fiscal year beginning this
October, Mr. Bush has proposed spending $2.8 billion and Congress is expected to
approve that amount.
In order to meet Mr. Bush's $15 billion pledge, the U.S. will have to boost
spending to more than $3 billion a year for each of the plan's final three
years. Mr. Tobias, the U.S. global AIDS coordinator, and a former Eli Lilly &
Co. executive, says the acceleration in spending is exactly what was planned
from the beginning. Starting with smaller amounts allows aid recipients to
prepare facilities and staff, and lets U.S. officials identify the wisest
investments, he says.
"Let's be sure we're going to use this money as efficiently and effectively as
we possibly can," says Mr. Tobias, adding that he's confident the U.S. will make
good on its full $15 billion pledge.
(MORE)
The bigger controversy is over how the money is being spent. Countries and
charities that work with Global Fund money have slashed drug costs by using
generic copies, even though the original brand-name drugs still enjoy patent
protection. AIDS groups have been pushing Washington to let organizations
receiving U.S. grants buy two Indian-made drugs that each combine three
medications in a single pill. The pills cost as little as a quarter of the price
of the three brand-name medicines they are replacing. And patients only have to
take two pills a day instead of six.
The World Health Organization has judged the Indian drugs and some other copies
as safe and effective under a program that "prequalifies" the drugs for purchase
by poor countries and charitable groups. But Washington has prohibited groups
that receive U.S. money from buying the copies, insisting that they stick to
drugs that are approved by the Food and Drug Administration.
"We've never had any hesitation about buying copy drugs per se. The hesitation
is about buying drugs for which there is no evidence of safety and
effectiveness," Mr. Tobias says. "A lot of very, very well-intentioned people
have taken a very simplistic view -- that we have got to get drugs out there
fast without knowing whether they're safe and effective."
In June, Mr. Tobias points out, the WHO removed two copy anti-AIDS drugs from
its prequalified list because their maker, Cipla Ltd. of India, hadn't proved
they were equivalent to the original drugs. Cipla, which also makes one of the
three-in-one pills, says it is redoing tests for the delisted drugs and will
submit new documentation to the WHO. Defenders of the WHO say its action
demonstrates the rigor of its quality-checking process.
In May, the U.S. said it would set up a fast-track program for makers of generic
copies to get the FDA's seal of approval for their safety and quality. U.S.
grant recipients for global AIDS programs could then buy drugs from these
approved makers. Mr. Tobias says he expects that U.S.-funded groups will be able
to buy copy drugs "fairly quickly," provided that manufacturers apply. Until
that happens, though, grant recipients such as Catholic Relief Services and the
Elizabeth Glaser Pediatric AIDS Foundation must buy brand-name drugs.
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Spreading Disease
Some facts on AIDS as of the end of 2003:
-- People infected with AIDS virus: 34 to 46 million
-- People newly infected in 2003: 4.2 to 5.8 million
-- Deaths from AIDS in 2003: 2.5 to 3.5 million
-- Worst hit region: Sub-Saharan Africa, about 60% of total cases
-- Percentage of Sub-Saharan Africans with HIV: 8%
-- Percentage of North Americans with HIV: 0.6%
Source: World Health Organization estimates
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