HIV, Public Health and Development

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HIV, Public Health and Development

• A Question of Balance
• VK Barbiero, PhD, MHS
• George Washington University
• 202-416-0097
• vkb_at_gwu.edu

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Missed Opportunities

• He who refuses to embrace a unique opportunity
  loses the prize as surely as if he had failed.
   William James
• A missed opportunity in public health is
  inexcusable and the ultimate responsibility of
  all public health professionals vkb

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On Equality
I believe in equality for everyone, except
reporters and photographers. Mohandas K.
Gandhi
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Making Sense

• many other public health needs in developing
  countries are being ignored.
• The fact is, spending 50 billion or more on
  foreign health assistance makes sense, but only
  if it is not limited to HIV/AIDS programs.
• Daniel Halperin 1/1/08

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The 600lb Gorilla in the Room
Which one do we want?
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HIV Facts and Figures

• Global HIV Infections 33M (40m)
• HIV Annual Deaths 2.5M (3.0m)
• Non-HIV
• Investments DO NOT balance with need
• HIV can be a development engine or a development
  impediment
• Balanced investments are imperative for
  successful health foreign assistance including
  HIV /AIDS prevention, care and treatment

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Global Success National Programs, GFATM PEPFAR
Source PEPFAR, 2008. Power of Partnerships
http//www.pepfar.gov/press/95911.htm
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PEPFARs Impressive Results

• 1,445,500 men, women and children treated with
  ARVs (1,358,500 in Focus Countries)
• Prevention of MTCT to more than 10 million
  pregnant mothers
• ARVs to 827,000 women
• 157,000 infant infections prevented
• 61.5 million reached through community outreach
• 520,000 trained or retrained
• 4,863 service outlets and 3,848 blood safety
  outlets supported

Source PEPFAR, 2007. http//www.pepfar.gov/about
/c19785.htm
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The HIV/AIDS Dilemma

• The power of HIV programming is impressive
• Success is clearly demonstrated
• Millions have been saved and protected
• BUT
• What of the opportunity costs
• What of the impact on other development programs?
  
• What of the pull of staff, resources, time,
  effort?

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Approximately 9.7 Million Children Die Annually
(70 From 5 Major Causes)
Undernutrition 36-56
Birth Trauma Neonatal Deaths Tetanus Fever Low
Birth Weight
Source Lopez, et. al., 2006
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AIDS/TB/Malaria Child Mortality

• Child Deaths from AIDS 3-500,000
• Child Deaths from TB 0
• Child Deaths from Malaria 1,500,000
• Total Child Deaths ATM 2,000,000
• Total
• Total Child Deaths ATM 2,000,000
  _________
• Deaths Remaining 7,700,000

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HIV and Public Health - Overview

• Comparative annual resources 5B vs 1B
• Balance of investments - out of whack
• Objectives and outcomes to confined
• Impacts - Millions of PLWAs saved
• Outcomes HIV prevention weak
• Lost opportunities - millions of children still
  die
• Opportunity potential millions more lives could
  be saved

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Balancing PCT

• Globally, treatment has been successful
• Care both for adults and vulnerable children has
  expanded
• Prevention remains problematic
• estimates of infections averted are difficult
• HIVs natural history requires personal
  perception of risk
• Circumcision holds promise, but is difficult to
  deliver
• ABC is a solid strategy, but is limited by its
  vertical nature
• Revised balance with PCT is in order

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Presidents 2009 Budget RequestSubmitted
February 9, 2008
Total Budget 3.1 Trillion 39B/3.1T
1.26 7.1B/39B 17.9 18x1.26 0.23 of
Total Budget for Global Health!
Billions of USD
HIV 5B/year 2008 Up to 10B/yr 2009
Source Global Health Council, 2008, vkb, 2008,
extrapolation
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Acute Infection
Mathematical models estimate the average
probability of malefemale transmission of HIV-1
per unprotected coital act to be between 0.0005
and 0.003 during chronic HIV infection, which in
itself would not sustain an epidemic. -Pao
et al, AIDS (2005)
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(No Transcript)
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Total US Contribution HIV/AIDS
18.8B since 2004
Source PEPFAR, 2008. http//www.pepfar.gov/press
/80064.htm
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USG Global Health FundingFY 2007
Source www.thomas.gov/, GHC, 2007, PEPFAR, 2008
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Kenya PEPFAR Approved FY 2007 Funding
Source PEPFAR, 2008. http//www.pepfar.gov/abou
t/82463.htm
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USAID Program Account Summaries FY 2007
Millions USD
Source USAID, 2007. USAID Budget
usaid.gov/policy/budget/cbj2007/
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Verticality and Sustainability

• The lessons are clear
• Smallpox eradication
• Twin engines (ORS/UCI)
• Polio eradication
• Vitamin A campaigns
• TB control
• HIV PCT
• Need to balance results with sustainability
• Understand the opportunity costs
• Do the right things

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Monthly Incidence of Polio In India January 1998
January 2007
Number of cases
NID
NID
NID
NID
NID
NID
SNID
SNID
SNID
SNID
NID
Mop-up
NID
SNID
NID
SNID
SNID
SNID
NID
SNID
NID
5 SNIDS 2NIDS In 2006
1998
1999
2000
2004
2001
2002
2003
2005
2006
2007
NID National Immunization Day
SNID Sub-National Immunization Day
Large scale mop-up
data as on 23rd March 2007
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The Vertical DilemmaPolio and Routine
Coverage - India
Percent Immunization Coverage
92-93 98-99 05-06
Source NFHS-3, 2007
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Childhood Deaths in India
Total Worldwide Total
Source UNICEF State of the Worlds Children,
2008 India NHFW Survey, 2007
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PEPFARs Past Perception
Development
Health
AIDS
PEPFAR
With all respectthis is wrong
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The Solutions

• De-Verticalize HIV/AIDS programs
• Use PEPFAR resources more broadly
• Identify investment synergies and mutual impact
  between HIV and other system structures
• Have indicators reflect broader, integrated
  investments
• Invest in a bold vision that will achieve
  HIV/AIDS objectives AND reduce other causes of
  mortality and morbidity

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SystemsThe Deal-breaker
FP/RH
HIV Wing
Maternity
MCH
TYPICAL HEALTH CENTER
TB
EPI
Dispensary
Improved HIV PCT
Low Client Draw Improved HIV/AIDS
Services Limited MCH/FP/RH Services
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SystemsThe Deal-Maker!!
FP/RH
HIV Wing
Maternity
MCH
TB
EPI
TYPICAL HEALTH CENTER
Dispensary
Improved HIV PCT AND Improved Community Health
High Client Draw Increased HIV/AIDS
Services Increased MCH/FP/RH Services
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Program SynergiesHIV PMI AND MCH/RH/FP
HIV HIV Prevention VCT Treatment OVC/Care Blood
Safety NACP Support HRD/Tech Training Commodities
PMI ITNs IPT Treatment HRD/Tech Training Applied
Research Other
HMIS/ME Infrastructure Logistics/SCM Commodities
Equip/Supplies Mgt Efficiencies Policy
Dialogue HRD/Tech Training
MCH/RH/FP Commodities HRD/Tech Training Technical
Intervention Safe Delivery Reduced Maternal
Deaths
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The Lantos-Hyde Bill Language

• Section 4(6)(A)
• Sec. 4. PURPOSE.
• (6) helping partners to
• (A) strengthen health systems
• Title III Subtitle A Section 301(b)(1)(B)
• Title III - Bilateral Efforts
• Subtitle A - General Assistance Programs
• (b) Policy
• (1) Objectives
• (B) strengthen the capacity to deliver primary
  health care in developing countries, especially
  in sub-Saharan Africa

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New Appropriation Language for PEPFAR

• In addition to increasing the stated objectives
  of treatment, care and prevention for HIV/AIDS,
  up to 20 of PEPFAR resources will be used to
  reduce child and maternal mortality by at least
  15 in PEPFAR and Non-PEPFAR countries.
• Specifically, PEPFAR will directly reduce
  diarrheal disease, immunizable diseases and
  neonatal/perinatal causes such as trauma, fever,
  tetanus, and hypothermia.

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New Appropriation Language for PEPFAR

• Specifically, PEPFAR will reduce
  pregnancy-related deaths for women through
  improved reproductive health service delivery,
  appropriate management of pregnancy and labor,
  improved girls and maternal nutrition and
  improved girls education.

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Responsible Programming

• Put the big three in perspective
• HIV/AIDS is one of many public health issues that
  requires attention
• We have excellent tools to prevent millions of
  child deaths annually
• We cannot continue to verticalize health
  assistance
• Lantos-Hyde Leadership Bill Appropriations MUST
  embrace a bold vision

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Conclusion

• Leaders do the right thing
• Lets save 9.7 million children as well as 2.1
  million PLWAs each year
• Morally, technically and politically we cannot
  afford to triage the lives of millions of
  children and thousands of mothers worldwide
• Maximizing this opportunity is our duty
• Change is in the airthe time is now
• It is time to lead!

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Thank You