Global fund to fight AIDS, tuberculosis and malaria

It's hardly news that the best intentions of governments and the expertise of public health and infectious disease researchers have not succeeded in containing the AIDS epidemic in Africa and other parts of the developing world.But in April 2001, when UN Secretary General Kofi Annan called for the establishment of a global fund on AIDS and health, hopes rose that the addition of a third critical element — major investment of funds in a coordinated international effort — could promote the integrated goals of controlling HIV and two major related diseases, tuberculosis and malaria.In October 2001 in Baltimore, Maryland, the Johns Hopkins University Center for AIDS Research hosted a two-day conference that shed some light on whether this hope is warranted. Given that the UN has estimated the cost of preventing and treating AIDS alone in the developing world at 7 to 10 billion dollars annually, and that the Global Fund to Fight AIDS, Tuberculosis and Malaria currently has a commitment of only one and a half billion dollars from a handful of countries, the quick answer, at least for the present, is no. But, the charge of the conference was not to pronounce judgment or even to make recommendations but to provide a briefing document on methods "to decrease the epidemic in developing countries using available, feasible, and cost-effective technologies," as Chrispis Kiyonga, National Political Commissar of Uganda and chair of the transitional working group for establishing the fund, wrote in his brief to the conference organizers.Johns Hopkins is ideally suited to such a task, as it boasts the world's largest research enterprise on HIV and AIDS, supported by grants totalling more than 80 million dollars annually. It also runs 11 HIV programs in the developing world."[The Fund's] major interest is in stemming the epidemic," said John Bartlett, chief of infectious diseases at The Johns Hopkins School of Medicine. "But it is not reasonable to implement a major prevention program without a treatment plan" to fight what he calls the 'three epidemics' of new HIV infections, complications and comorbidity in existing infections, and the "epidemic of death." So, is the answer to bend to pressure to slash the prices of antiviral drugs and supply them to sub-Saharan Africa, which has 80% of HIV/AIDS cases in the developing world, as well as to other affected countries such as India and China?On the surface this would seem to be one of the cost-effective technologies the Fund is looking for. But the success of HART therapy in Europe and the United States will not translate to the developing world for myriad reasons, some of which are very basic and have already stymied other efforts at prevention and treatment. For example, "if there is no electricity, you can't protect the blood supply," said Bartlett. Similarly, if there is no infrastructure to distribute drugs, train physicians to prescribe them and health care workers to instruct patients on how to take them, or monitor if and how they are working, the drugs will go to waste. But, he also pointed out that the biggest bang for the buck in the short term might indeed come from providing drugs for prevention of mother-to-child transmission of HIV. "It's the easiest to prevent and has the most impressive results," he suggested, citing evidence of the effectiveness of just a few doses of drug therapy at delivery.Bartlett also emphasized the importance of treating opportunistic infections, the 'second' epidemic. Better treatments would result in better quality of life, which in turn might at least allow people to continue to work and thus prevent further unraveling of social and economic structures, he said. Again, however, he cautions against applying to Africa data on treatment outcomes from the United States and Switzerland. What is needed, he says, is a cohort study, even as comparatively small as 100 out of 1,000 treated people in a longitudinal analysis of adherence, resistance, complications and mortality. As for prevention, there is no data to point to — applicable or not — showing the success of prevention programs in the West. "We still have 40,000 new cases of HIV infection per year in the U.S.; it's the epidemic of death that has declined."For now, says the Hopkins panel (and it has been said many times before), the main focus should be on using the Fund to improve public health programs and health care services. Such improvements would be left to the discretion of localgovernments, and in some cases, would not necessarily be aimed directly at HIV/AIDS. Measures to control tuberculosis, which was a public health problem in this part of world even before AIDS gave it a firmer foothold, and malaria, which appears to upregulate HIV infection, must also be considered. If it is more practical to clean the water in a certain area or concentrate on mosquito control in another, then those efforts should be viewed and supported as part of an overall public health strategy, concluded Bartlett.But what about the money? The call has gone out to governments and the private sector in industrialized countries as well as to the affected countries themselves. It takes time, though, to mobilize institutions, not to mention entire governments whose budgets must be rearranged to reflect new priorities. For now, the United Kingdom, the United States, France and Credit Suisse are carrying the load, with some help from the International Olympic Committee and Secretary-General Annan himself (who donated his Nobel Peace Prize winnings). Instructively, according to Bartlett, a 15-year-old boy in Botswana today has an 85% chance of dying of AIDS.The briefing document from the Hopkins conference arrives on Kiyonga's desk this week. "We have told [him] what we know, what we don't know, and what constraints exist," said Ronald Gray, Professor of Population and Family Health Sciences at Hopkins's Bloomberg School of Public Health. When asked if he thought the Fund could achieve its goals with its current resources, Gray replied, "I'm pessimistic."

Global fund to fight AIDS, tuberculosis and malaria

An international conference calls for substantially increased funding to undertake basic research and start to fight the scourge of AIDS in the developing world.

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