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Obama Is Criticized on Global AIDS Program
NY Times
Published: December 8, 2009

As the Obama administration slowly unveils its global AIDS plan, the drive to put more people on drugs is being scaled back as emphasis is shifted to prevention and to diseases that cost less to fight, including pneumonia, diarrhea, malaria and fatal birth complications.

AIDS advocates complained bitterly that they had been betrayed and that the Bush administration's best legacy was being gutted - and they blame a doctor and budget adviser who is also the brother of the White House chief of staff, Rahm Emanuel.

"I'm holding my nose as I say this, but I miss George W. Bush," said Gregg Gonsalves a long-time AIDS campaigner. "On AIDS, he really stepped up. He did a tremendous thing. Now, to have this happen under Obama is really depressing."

But Dr. Eric Goosby, the new global AIDS coordinator and chief of Pepfar, the President's Emergency Plan for AIDS Relief, denied that the administration's dedication to fighting AIDS had shrunk, noting that more people would still be put on treatment each year. "We're honoring our commitment, we're increasing our commitment, we will not veer from that commitment," Dr. Goosby said.

Dr. Ezekiel J. Emanuel, a bioethicist at the National Institutes of Health and an adviser to the Office of Management and Budget, rejected accusations by several AIDS advocates that he and Dr. Goosby had feuded over how many people should be treated, and denied that he had unusual influence.

"This is the president's policy and the way he wants to approach it, and no individual counselor stands in his way," he said. And, he joked, his brother rejects his advice "out of sibling rivalry."

But it was clear from Pepfar's newly released plans that treatment will soon rise more slowly than it has.

In the 74 pages of its "Five Year Strategy" handed out Dec. 1 and three supplements handed out Monday, one number stands out: the new goal is to have four million people on antiretroviral drugs by 2014.

The program has put 2.4 million on the drugs since 2004, or almost 500,000 a year on average. Adding only 1.6 million over the next five years means adding only 320,000 each year.

Some advocates for overall global health - in contrast to those lobbying for AIDS - expressed regret but said the administration was being practical by shifting to buying goods that save more lives for less money, like water filters, oral rehydration packets and generic antibiotics, rather than putting adults on antiretroviral drugs at a cost of $35 to $2,000 a year.

That was the position advocated by Dr. Emanuel in a paper he published in The Journal of the American Medical Association in November 2008, just as Mr. Obama was being elected.

Entitled "U.S. Health Aid beyond Pepfar," it argued that spending $48 billion more on the $15 billion program first proposed by Mr. Bush in 2003 was "not the best use of international health funding."

Paying for "simple but more deadly diseases, such as respiratory and diarrheal illnesses, the U.S. government could save more lives - especially young lives - at substantially lower cost," he wrote.

On Nov. 18, fearing cutbacks were coming, the presidents and deans of 37 medical schools and schools of public health wrote an open letter to the president urging that he keep expanding AIDS treatment until it reaches everyone. Right now, the problem is outrunning the solution; globally, for every two people put on treatment each year, five are newly infected.

"It's a terrible dilemma," said Dr. Martin J. Blaser, chairman of medicine at New York University Medical School and one of the signers. "Pneumonia and diarrhea are important, too, but one hates to take from one side of the pie to increase the other."

Chris Collins, director of public policy at amfAR, the AIDS research foundation., said: "We can't keep kids alive to age 13 till they die of something more expensive. Also, a high percentage of health care workers are infected; we've got to keep them alive."

AIDS advocates said they had heard that, since taking office in June, Dr. Goosby had pressed hard for treatment for five million people but had lost.

Asked about that, Dr. Goosby said that he was "advocating for numbers all over the place, above and below five million," and that he considered four million "more like a floor."

The five-year plan, written in bland bureaucratese, envisions greater focus on prevention, on stopping mother-child transmission, and on treating the sickest, pregnant women and those with tuberculosis. It endorses "sustainable, country-owned and country-driven programs."

It is nearly silent on several controversial issues: how much Pepfar will emphasize abstinence, whether and how it will get condoms to patients of the many missionary hospitals that refuse to issue them, whether it will support women's health clinics that also do abortions, whether it will support giving clean needles or methadone to drug addicts, whether it will require groups working with prostitutes to oppose prostitution, and whether it will cut off countries that criminalize homosexual sex.

Dr. Goosby said several of those issues were under discussion.

The plan also had no budget forecasts. On the campaign trail last year, Mr. Obama pledged to raise Pepfar financing by $1 billion a year, but his first budget proposed only a $165 million increase.

Advocates argued that some language was code for reducing treatment. Pledging to cover the sickest individuals, for example, signaled that the United States would probably not adopt the new World Health Organization recommendation that people get drugs as soon as their CD4 count drops below 350 rather than below 200.

"You treat the sickest first, no?" Dr. Goosby said when asked about that. "If you don't have unlimited resources, isn't that rational and ethical?"

In any case, he said, so many people are desperately ill that the average CD4 count of those seeking Pepfar's help is 138.

Right now, experts agree, about nine million people in poor countries have immune systems so suppressed that they should be on antiretroviral drugs. At the new higher W.H.O. cutoff point, that number grows to about 14 million. Nearly three million more get infected each year.

Between them, Pepfar and the Global Fund to Fight AIDS, Tuberculosis and Malaria now pay for treatment for about four million people. (Each claims about 2.4 million, but there is overlap.)

The Global Fund has never raised as much money as it hoped; earlier this year it estimated that it had $5 billion less in donations than it needed.

Dr. Goosby himself says that treating people with AIDS makes them less infectious and that not offering treatment enlarges the epidemic. "If AIDS is seen as the kiss of death, people won't get tested for it," he said.

But in the end, he said, "I see my role as making sure all decision-making is driven by science. It's up to those above me to decide what we can pay for."

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