whole grains,Written by Agencies | Washington | Published: January 6
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SI: A key criticism of the past incarnation of PEPFAR is that it frequently didn’t target to the demographic of the epidemic The federal government ban on needle exchange meant that money given to Vietnam couldn’t be used for that even though they have an epidemic driven by injection drug use Other countries that had epidemics driven in part by sex workers were limited I realize that Congress stipulates these things but will that change with the new leadership EG: The simple answer is yes Those have both been targeted and prioritized in this Administration and in our office already We’re well down the road and working on moving away from any constraints put on an individual program to not engage with a population because they’re sex workers or involved in injection drug use I have spent much of my life focused on matching demographics to responses If you do not base responses to the demographics of your epidemic you will not be successful at reaching the populations who are already infected And you’ll especially be ineffective at reaching the higher risk populations that will become infected SI: How do you get around the needle-exchange ban EG: PEPFAR is not burdened by the needle-exchange ban It is a domestic-based ban Legislatively we are not restricted And we are in a dialog with the White House to try to rapidly change that position domestically given that it already is open to our international activities SI: I had always been told it was an international ban That’s inaccurate EG: That’s inaccurate SI: The Bush Administration has been praised for PEPFAR maybe more so than for any other of the programs it launched How do you view coming in to something that’s working EG: I’m grateful to PEPFAR for the work it has done putting a finger in the dike but we have by no means reached the threshold by which we can relax or view this as a job well done The job that has been done is precariously positioned to not sustain itself We need to make that the number one concern We must expect our partner countries to integrate these services into their existing public systems—or we won’t have them They’re too dependent on an NGO-based continuum of care and those systems are fragile and dependent on ephemeral funding They are not in and of the public systems that the majority of patients are accessing for their care We can’t NGO this disease off the planet That’s not to say NGOs don’t play a critical role in completing the continuum of care but we must place them in the public sector to ensure their durability SI: One criticism of PEPFAR is that it has put so much money into US-based NGOs that it hasn’t built enough local infrastructure in other countries Do you see that changing EG: I think that is the change We need to look at how to build country-based country-run country-owned delivery systems We can’t just build islands of excellence with HIV care and not address the larger health needs of that same individual That’s shortsighted The president and Secretary Clinton have been very clear about wanting all the vertical programs—HIV TB malaria immunization maternal and child health—to now look at expanding the service constellation and bringing in those broader health needs of what is a complete overlap in populations The discussion is mostly focused on using women as that access point to children husbands and partners SI: PEPFAR will have to struggle to keep supplying antiretrovirals (ARVs) to the people already on the drugs especially given the likelihood that more and more will develop resistance and need more expensive treatments Will you be able to expand the program EG: We are concerned about this too Our ability to keep up with this is going to be especially challenging in this economic downturn We’d be foolish not to open up a strategy to try and bring in other bilateral and multilateral resources We need to be smarter about how we think as funders We can’t just go in with parallel systems of intervention It is probably the biggest issue on my plate thinking about how to deal with that expanding need and how to continue the medical clinical and ethical commitment we’ve made to the patients already on drug We’re looking for efficiencies by moving to a more country-based delivery system We also need an aggressive new dialog with our global partners who have resources that can converge on this SI: Some have suggested that PEPFAR fold and give the money to the Global Fund to Fight AIDS Tuberculosis and Malaria and get rid of the redundancy What do you think of that idea EG: Right now I would not be ready to turn over the resources from PEPFAR to the Global Fund but I’d like to really move them together The Global Fund has played a critical role no doubt about it the role in many countries The Global Fund’s process is the right idea—it is more country-based—but the ability to support that country in its implementation challenges has been less than optimal It’s the combination of a PEPFAR and a Global Fund strategy that really will win the day here SI: How many people are receiving ARVs through PEPFAR now and what are your projections for the 5-year plan EG: We’re around 24 million now and climbing rapidly We have no doubt that we will meet the 3 million goal very soon We’re moving much more rapidly than we had anticipated like two to three times as fast There’s no question we’ll be increasing The question really is can we match the resources in a timely fashion to the expanding need That’s really what I spend most of my time thinking about SI: What is the estimated need EG: The legislation goal was 3 million but that’s probably about 40% of what we know is the need already so there are about 7 million people in need of antiretrovirals SI: What other issues are you facing EG: It’s a no brainer in terms of the science to use tenofovir instead of d4T [an ARV that has serious side effects] The problem is the cost The same with using the current policy of 200 CD4 cells to start treatment versus 350 CD4s as the cutoff The science has been there for a long time That’s why no else is doing 200 The United States has been at 350 forever You could argue we should be in the 400 to 500 range The science is clear What isn’t clear is how we can pay for that We need to be honest: We’re in the business of trying to find resources to cover that extraordinary expansion of need And the elephant in the room again is the second-line treatment cost going up three four times the cost of first-line for the most part That’s the final thing that keeps me up at night beginning with their ability to have an oversight function that allows for continued transparency on the fiscal level.
Chances are, shifty-eyed kid is deceiving them, wind speed.