Canada Reneges on Global Health Promises

ALAN WHITESIDE AND JAMIE COHEN
(as seen in The Globe and Mail)

On Nov. 28, Parliament sent a deafening message to the world about the value it places on global health. Bill C-398 aimed to make the Canadian Access to Medicines Regime (CAMR) easier to apply. The CAMR is a mechanism for providing generic drugs to the world’s poorest countries. It is so complex that it has hardly been used.

The bill was defeated and this means there will be fewer lives saved and more new infections. It presented an opportunity for change: This has been lost.

Antiretroviral (ARV) drugs allow HIV-infected individuals to have long and healthy lives; without them, illness and death are virtually inevitable. Over the past year, it has become apparent the drugs also help prevent transmission and are a key part of the armamentarium for halting the AIDS epidemic. Since the development of highly-active antiretroviral therapy was announced in Vancouver in 1996, drugs have become cheaper and more effective.

Global precedent has been set around the ability to lower the price of ARVs through direct negotiations and innovative financing mechanisms, such as the Medicines Patent Pool. In July of this year, the Clinton Health Access Initiative (CHAI), with generic drug manufacturers, announced price reductions of up to 30 per cent. This brought the cost of tenofovir-based regimens down to $125 per patient per year in the 70 CHAI procurement countries.

Access to low-cost ARVs is critical for health care in developing countries, many of which depend on foreign aid for health funding and drug procurement. Tanzania, for example, receives 49 per cent of its health-care funding from abroad. Of Malawi’s $558-million health funding for 2012-2013, the Ministry of Health provided only $132-million (24 per cent).

ARV price reductions help developing countries take greater financial responsibility for drug procurement and graduate from donor dependency. These investments are essential to save lives and will bear fruit in the future: healthy populations are crucial for sustainable growth and development.

On this World AIDS Day, on the heels of US Secretary of State Clinton’s release of the Blueprint for an AIDS-Free Generation, there is a renewed sense of optimism. We believe we are at a turning point in the 31-year epidemic. Science has delivered the tools and knowledge and will continue to develop new technologies. The biggest obstacle is implementation.

In our country, South Africa, which runs the world’s largest treatment program, only 58.3 per cent of eligible adults and children are receiving ARVs. In 2010, with help from CHAI, the Department of Health was able to negotiate a 53 per cent price reduction in drug prices, saving almost $250-million. This will enable South Africa to reach its treatment goals.

The defeat of Bill C-398 could have broad and far-reaching implications for global health delivery and particularly for HIV and AIDS. It may signal a shift in the momentum towards ‘ending the epidemic’ that began at the International AIDS Conference in July, 2012, in Washington, DC. All people everywhere deserve access to lifesaving treatment and care. Sadly this is now more difficult to achieve.

Happy Thanksgiving!

A very South African Thanksgiving

It has been over two months since I last posted. In that time…

• I attended the Opening and Scientific Symposium for the launch of the KwaZulu Natal Research Institute for Tuberculosis and HIV (K-RITH), a groundbreaking collaboration between the Howard Hughes Medical Institute (HHMI) and University of KwaZulu Natal, which is housed in a world-class laboratory facility at the UKZN Medial School campus. As a Caprisa fellow, I am lucky enough to sit in the K-RITH building! The energy and scientific rigor presented at the K-RITH symposium was inspiring, with a wide range of presentations, including Bruce Walker, Eric Goosby, Tony Fauci, and Nobel Prize laureate Peter Agre.
• President Obama was re-elected (!!), which allows the global health community to sigh a breath of relief and get back to work. Center for Global Development has mapped the top five global health items that should be on the President’s agenda over the next four years.
• Proposition 37 was defeated in California by 53.1% to 46.9%. The ballot measure, which was bankrolled by $47 million in campaign contributions from biotech companies such as Monsanto, would have made California the first state to require labels on foods containing genetically modified organisms. This disappointing result marks a major setback for the food movement.
• The Phase III trial of the RTS,S malaria vaccine showed only 31% efficacy in children, disappointing results after the Phase II trial results showed higher efficacy.
• UNAIDS released its Global Epidemic Annual Report, which details an increase in the number of people worldwide on antiretroviral therapy and a decrease in new infections. However, the pace of ART scale-up does not match the decrease in HIV incidence, with 2.5 million people becoming newly infected last year, while only 1.4 million received treatment for the first time.
• Hurricane Sandy devastated the Eastern seaboard.

On a personal level…

• I applied to graduate school (!!)
• I signed up for my first marathon (!!)
• I planned my boyfriend’s trip to South Africa and have watched the countdown go from 97 to 33 days (!!)

Today is Thanksgiving, a uniquely American holiday. I am living thousands of miles away from my family and the traditions of Thanksgiving that I grew up with and endlessly adore.

It’s funny how Americans living abroad instinctively seek each other out in late November–they crave the company of other Americans, the taste of Turkey and mashed potatoes, sounds of football on TV and in the backyard. But the values of Thanksgiving are universal–being thankful for family, friends and health. Family, friends and health relate to each other in such important and interconnected ways, and nowhere is that more clear than in Durban, South Africa.

Take TB for example, which correlates highly with HIV infection. South Africa has a 70% HIV/TB co-infection rate. Both TB and HIV are closely related to your social network: how many sexual partners you have, whether you are using a condom, being faithful, what type of work environment you’re exposed to, and the list continues. Your health and well-being is then again intricately related to your friends and family and the support they provide you in your care and treatment. Whether you are willing to disclose your HIV status to your partner is a powerful indicator for your treatment success or failure and loss-to-follow-up. Friends, family, and health (and in the South African context, community as well) reinforce each other in positive and negative ways through a powerful feedback mechanism. Any response to TB or HIV must consider the social and behavioral factors** that drive the epidemic.

Tonight I will feast on local sweet potatoes and butternut squash (yes, there will be Turkey, but I am a vegetarian) in a truly South African Thanksgiving. When I look around the table, I will see my South African family, made up of beautiful faces I have come to love. We will carve new Thanksgiving memories and traditions that will live on in the Durban soil.

**For post food-coma reading, check out the Center for Global Development’s publication by Saugato Datta and Sendhil Mullainathan on the ways that behavioral economics can and should be used to inform better policy design.

Study: Take TB drugs to the patient

Last week I discussed South Africa’s exponential growth in TB incidence over the past two decades and hypothesized, with support from the literature mind you, that HIV is the confounding factor that has thrown South Africa so radically off-track.

Veloshnee Govender has a different, though not mutually exclusive, explanation. The UCT health economist identifies weaknesses in South Africa’s public health care system as a reason for the rise in TB incidence. A study** in South Africa that looked at barriers patients face in taking their TB treatment consistently identified taking treatment at a clinic as the key variable. According to The Guardian article on Govender’s presentation at the Strategies to Overcome Poverty & Inequalities conference,

Taking treatment at a clinic was the key variable that determined whether someone missed their daily dose. Patients who missed treatment at clinics said the reasons they did so included the cost of transport, their distance from facilities and the conflict between taking medication and meeting work and other domestic responsibilities.

These findings call for more research and pilot projects focused on patient-centered and community-based TB treatment delivery: to measure adherence, health outcomes, costs and cost-effectiveness. Perhaps the model of TB treatment delivery can and should move closer to diabetes and HIV/AIDS treatment delivery?

**The study is currently under review for publication.

The elusive quest for an AIDS vaccine

The elusive quest for an AIDS vaccine is the topic of a four-day conference hosted by the Global HIV Vaccine Enterprise that begins today in Boston. The annual conference comes at a very exciting time in the HIV prevention landscape, and makes the conversation all the more interesting.

The development a vaccine, while progressing, remains in the very distant future, for reasons that only a real scientist can articulate. There are some exciting and game-changing tools such as microbicides and other forms of pre-exposure prophylaxis on the horizon with the potential to dramatically alter the shape of the epidemic and change the gendered power dynamics that fuel the epidemic.

If you take a cold hard look at the statistics, the fact remains that despite enormous progress, for every person who is initiated onto lifesaving ART, two more people are infected with HIV. While countries like South Africa are making huge strides in bringing new people onto treatment, they still are struggling to keep pace with the rate of new infections and are missing a large portion of people in need of treatment. According to the World Health Statistics 2012 report, South Africa is reaching just 55% of people with advanced HIV infection with ART. This leads people to the conclusion that it will not be possible to treat our way out of the epidemic and makes the elusive quest for an AIDS vaccine all the more critical; until recently, many argued that a vaccine was the only tool that will ever “end AIDS”.

Myron Cohen threw a wrench into that line of reasoning this past year when he published findings from the HPTN052 study, which showed that treating people with HIV with ART reduces their sexual transmission of HIV by 96 percent. Is it possible, then, that we could treat our way out of the epidemic? Cohen’s findings lend additional weight to ongoing modeling studies examining how “test and treat”—immediately putting an HIV-infected individual on treatment, despite their eligibility (measured by CD4 count)—would alter the course of the epidemic. The reasoning? As more and more people are put on medication, the epidemic theoretically should fizzle out.

In a 2009 commentary in The Lancet, Geoffrey Garnett responded to the first notable modeling study that looked at the impact of test and treat on the epidemic. He addresses the multi-faceted questions related to treating our way out of the HIV pandemic: could we, would we, should we?:

When early treatment is considered as a prevention tool, success will require substantial resources and depend on a remarkable degree of acceptance and cooperation across populations. If we could eliminate HIV this way would we, given the will needed, and should we, given the conflict between utilitarianism and individualism inherent in this strategy? 

Pilot programs are now emerging, including one in San Francisco, under the assumption that this approach works. NPR’s Shots Blog wrote a great feature piece examining some of the controversy surrounding the “test and treat” approach, including the possibility of drug resistance development and high associated costs.

Cohen’s findings do not obviate the need for a vaccine. Rather, they complicate (in a good way!) the puzzle of options available to policymakers, ministries of health, donors and other key stakeholders involved in the global AIDS response. The question remains, how do we balance the resources devoted to the elusive quest for a vaccine, when worldwide, people are still living with HIV, and in need of treatment. These questions must be answered, but who has the authority to answer them?

To stayed up-to-date on the latest happenings of the conference, check out their website, and use the conference hashtag, #AIDSVax2012 on Twitter.

Washington Post talks about TB in India, but not in South Africa

The Washington Post’s Simon Denyer wrote a very important article about India’s great effort to treat and control tuberculosis, in the face of a growing threat of drug-resistant strains of the disease. The article was paired with a graph of TB incidence over the past 20 years. India, which is highlighted on the graph, has clearly done quite well against major odds–poverty, inequality, poor infrastructure. It has decreased TB incidence by 14% over 20 years, mandated case notifications and for all of this deserves praise, case studies and much more.

The article mistakenly fails to mention the outlier in the graph–South Africa’s TB incidence has increased by over 200% over the same 20 year period, while all other countries in the graph, including the “global trend line”, have decreased.

The confounding factor is HIV. While South Africa’s TB control program benefited from the introduction of directly observed treatment short course (DOTS) in the 1990s, the same way India’s did, South Africa’s growing HIV epidemic muted these gains and led to a sharp rise in TB case notifications. South Africa now faces a 70% HIV/TB co-infection rate (Karim et al. 2009) and TB is the leading cause of death among people living with AIDS.

This graph highlights the need to address TB and HIV concurrently and with an integrated response. Check out the recently released National Strategic Plan on HIV, STIs and TB for 2012 – 2016 to learn a bit more about how South Africa is addressing its HIV and TB epidemics.

Back to school, kind of

It’s early September, and for the ultra-nerd in all of us, desperately missing our “intellectual” days (undergraduate, graduate or post-graduate, as the case may be), the Center for Global Development has once again proved to be an incredible resource. In its most recent “Back to School” newsletter, CGD published five syllabi from development/poverty/globalization-related undergraduate courses. My two favorite:

1. Inequality and Development in a Globalizing World (syllabus), taught by CGD President Nancy Birdsall at Williams College, which seeks to address the following question:

What are the effects of globalization (of economic markets) on poverty and inequality around the world, and how do those effects vary within and across countries depending on developing countries’ different characteristics and policies, and on overall global conditions?

How awesome does that sound? It reminds me of a few great classes I took at Amherst and while studying abroad on IHP.

2. Global Poverty: Challenges and Hopes in the New Millennium (syllabus), taught by Anyanya Roy at UC Berkeley, which teaches the dominant paradigms of development and welfare, introduces the field of poverty action, and reflects critically on poverty and inequality.

Another great resource that fellow blogger Brett Keller flagged for me is Johns Hopkins Bloomberg School of Public Health Open Courseware, which makes available the materials of a select number of its courses. I personally have already taken advantage of the syllabus and materials of the Concepts in Economic Evaluation course, as I develop the methodology for my Fulbright cost-effectiveness study.

If you are geeking out right now, we should be friends.

Developing my research question

The first step in a research project is to develop the question you seek to answer. I thought I developed my research question many months ago. In the halls of Frost Library at Amherst College; through conversations with my advisors as I worked on my undergraduate thesis on health care delivery models in South Africa; in my New York City apartment as I refined my Fulbright Statement of Grant Purpose. I don’t want to dismiss these activities, for they will certainly have contributed immensely to the development of my research question, objectives, methods and so on. However, it was through two back-to-back visits to Vulindlela, a sub-district 150 km north-west of Durban, that I feel I have truly begun the process of uncovering my research question. 

Vulindlela is a largely Zulu-speaking rural community that is home to about 90,000 residents. The HIV prevalence rate in this rural community is astoundingly high. Just under a third of women ages 25-29 are infected with HIV, and this increases to 46.8% for the cohort of women ages 30-34 (Karim et al., 2011). Among certain age cohorts, women in Vulindlela are more likely to be infected with HIV than her counterparts in Durban (an urban city). For example, a woman between the age of 30 and 34 who lives in Vulindlela is 1.4 times as likely to be infected with HIV compared to a similarly aged woman living in Durban. Her biggest risk factors: she is poor, uneducated and unable to negotiate safe sex with her partner. See the table below for a more comprehensive set of data from the study.

(Snapshot of Table 1 from Karim et al., 2011)

Vulindlela has seven Primary Health Care (PHC) clinics where nurses provide comprehensive primary care, including family planning services, voluntary HIV counseling and testing, STI treatment, antenatal care and a whole host of other services. Caprisa has been working in Vulindlela for 10 years, providing HIV prevention, treatment and care to the community at its clinical research site.

Making your research relevant

As a result of the PEPFAR transition, all NGO’s providing PEPFAR-funded care and treatment have recently been required to down-refer their patients to department of health PHC clinics. This additional patient load will likely impose a significant burden on already overstretched and under-resourced clinics. These issues are particularly pertinent when it comes to patients on antiretroviral therapy (ART), whose health depends upon adherence to their drugs and clinical management of side effects. As Caprisa transitions its patient load to the seven PHC clinics in Vulindlela, several research questions come to mind:

• What are the human resource for health figures of the seven Vulindlela PHC clinics?
• How many NIM-ART nurses are there, and how are they balanced among the PHC clinics?
• How does the level of support to NIM-ART nurses from clinicians vary by urban versus rural facilities? Does this impact health outcomes?

Vulindlela is one community among hundreds in South Africa that is facing the dual burden of imbalances of human resources for health and high rates of HIV. While private NGOs such as Caprisa have filled a critical gap for many years, the department of health is primed to step up its responsibility for health care provision. It is the confluence of these factors and events that will help shape my research questions in the coming weeks. Stay tuned!

Same gate, new country

After traversing four European cities in 13 days, I have arrived and settled into my new home in Durban. While I have traveled to Durban numerous times before, the visible and abject poverty never fails to unsettle me each time I return. The side of the highway from the airport is littered with tin-roof shacks that house entire families. And as I pull up to 8 Musgrave Avenue—my current spacious apartment—and make my way through two sets of wrought-iron security gates, I am painfully aware of my privilege. I have a sneaking suspicion that this feeling won’t go away anytime soon.

I first arrived at this same gate just over six years ago to volunteer at the Sinikithemba AIDS Clinic of McCord Hospital. That summer, I lost my heart and soul to the spirit of South Africa. I witnessed true strength and courage in the face of enormous challenges: devoted health workers motivated by their faith and commitment to caring for others; children orphaned by AIDS and infected through vertical transmission of HIV; patients, who in the face of great stigma, never give up the will to live; and communities of “Gogos”, the Zulu word for grandmother, caring for young children. Most importantly, I witnessed the transformation that successful HIV prevention and life-saving drugs make possible.

Six years later, significant strides have been made to decrease the rate of new infections and increase access to care and treatment in South Africa. This progress was made painstakingly clear in US Secretary of State Hillary Clinton’s visit to South Africa earlier this month, part of an eight-nation African visit. On her trip she discussed the PEPFAR transition, what Reuters described as “symbolic of Pretoria’s shift from being a pariah to a global player in fighting the disease.” Secretary Clinton commended President Zuma and Minister Motsoaledi for putting the policies and systems in place to get 1.7 million people on treatment.

Despite signs of progress, it’s important to not lose sight of the enduring unemployment, poverty, crime and TB, among many other factors, which compound South Africa’s HIV epidemic and hinder prevention, treatment and care efforts. These ongoing socioeconomic challenges are a critical component to South Africa’s holistic and comprehensive AIDS response.

As I arrive on the same steps as I did six years ago (and many times since then), I am keenly aware that I have returned to a very different country—economically, politically, socially and epidemiologically.

 

Goosby acknowledges role of health economists

I am currently strolling through Western Europe en route to South Africa. Therefore, in lieu of a longer post, I am linking to Amanda Glassman’s account of Eric Goosby’s speech at the recent International AIDS Economics Network (IAEN) meeting. PEPFAR administrator Goosby delivered, in my opinion, fantastic and well-timed remarks about the role of health economists in the sphere of global health and HIV.

Goosby to Economists: Step Up!
August 1, 2012

By Amanda Glassman

Economists are not global health’s most popular human resource. They usually show up to dampen enthusiasm by nattering on about budget constraints, trade-offs and incentives. In the HIV/AIDS field in particular, health economists and their work have been viewed with profound skepticism. At a recent debate, talking about choices and budget constraints was labeled “dangerous” to fundraising by one participant.

Yet a new view of the contribution of economists to global health is emerging. At the International AIDS Economics Network (IAEN) meeting earlier this month, Ambassador Eric Goosby gave a terrific overview of the policy questions that need to be addressed by the field and the role that economists need to play in improving the efficiency and effectiveness of the HIV/AIDS response. In his words:

How do policy makers decide where funds should be invested?  How do we measure value for investment in health systems in the absence of standard indicators?  Can we assess prevention benefit while accounting for the treatment benefit as well?  How do we achieve allocative efficiency—that is, putting our money where it will have the greatest impact?

These questions underscore the importance of economic analysis for the next phase of the HIV response.  Together, we need to establish and implement a research agenda for economic analysis and apply the results to the global HIV response.  We will need to adapt to these more complex intervention models and press for stronger metrics to better define value for the expenditures being tracked.  Most of all, we will need collaborative strategies to help countries collect and apply economic data for their program planning.

(…)

Economic analysis provides us with results that show us how to make programs more efficient; provides accountability for our programs to those who support this work, and supports advocacy to policy makers who have to consider the economic dimensions of investments.

(…)

You as the health economists focused on this work have an amazing opportunity, together, in dialogue with program leadership, to move this forward, to understand it better, so we can increase our effectiveness at dropping morbidity and mortality and I want to end today with a challenge to all of us to step up to it.

(…)

Those of us who have a little grey hair or lost some of it know that this is a different time. We have seen … economic pressures … push more people in policy-making positions into conversations that have brought central cost-effectiveness analysis, comparative effectiveness, looking at the variation across our implementing colleagues/partners in their ability to do the same work, the same outcome, with less money. In very many ways I think this economic severity has pushed us dramatically into what I think is the correct alignment of thinking.

Medical communities have had a lot of distrust of cost-effectiveness analysis. I know all of you in this room have butted up against your clinical colleagues who saw that every time you came with a cost effectiveness analysis, a service provision capability, a testing modality, CT scan vs MRI, suddenly those services became more difficult to access from a clinician’s perspective. And from a clinician’s perspective, seeing a body of patients in front of them, it is not the correct spot or locus of a cost effectiveness analysis. Economic analysis really needs to be part of a policy discussion that doesn’t involve or corrupt the patient-provider relationship.

So I think that we have evolved in this moment where now, from my perspective, economic analysis becomes a tool for us to preserve program and expand program to drop more morbidity and more mortality. And I really do think it’s a glimmer moment where the window has opened for you [economists] to establish your relevance but do it with compassion and consideration in how you speak about it. Cost-effectiveness analysis is not a perfect fit to a medical model; but it is an essential fit. And I think you are really at the forefront of harmonizing that integration with clinical, programmatic, and health system decision-making to preserve program and services for the population we are supposed to serve.

Enough said.