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HIV's Tenuous Funding Road

Interviewee: Laurie Garrett, Senior Fellow for Global Health
Interviewer: Toni Johnson
June 8, 2011

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The UN General Assembly is holding a high level meeting June 8-9 to decide on a next course for HIV/AIDS funding, a decade after its breakthrough commitment on AIDS funding in May 2001. CFR's Laurie Garrett notes that discovery of the virus was the beginning of what we now consider to be global health. But because the virus was discovered thirty years ago in a group of gay men in San Francisco and then subsequently in other stigmatized populations, the world health community was slow to respond, allowing HIV to get out of control and representing "the single greatest defeat in the history of public health," she says. Garrett says there while there has been progress--particularly on funding and treatment, the community started far behind. She notes there have been tremendous new breakthroughs on prevention, but that will require double the current commitment. "[A] lot of the discussion we're going to hear this week is going to be about how not to have HIV be the Peter that robs Paul, [and the need to] align more and more programs so that whether we call it money to treat HIV, or call it money to treat children with malaria, it's raising all of these ships at once," she says.

June 5 marked the thirtieth anniversary of acquired immune deficiency syndrome, a debilitating and deadly disease that would become known worldwide as AIDS. If you had to look back on the biggest challenges in fighting the disease--was it stigma, money, science? And what are your concerns going forward?

Our biggest challenges were all of the above. The stigma, clearly, was the overriding challenge in the beginning, and still is an enormous issue today. But in the early days, it was stigma that was not against AIDS, but against homosexuals. And then IV drug users, and then Haitians just put blinders on political leaders all over the world, so that they really refused to acknowledge how bad this problem was, how many millions of people were going to die, and what it was going to mean in their societies.

Every country, with the possible exception of the Scandinavians, reacted the same way to the arrival of HIV inside their borders. First the reaction was: "There isn't any HIV in our country--period, full stop. And therefore, there's nothing we have to do about it." Second reaction: "Oh, there's HIV, foreigners brought it. It's not our people, it's them. So, we have to start screening people at the airport, and restricting the movement of foreigners. Fill in the blank: somebody you don't like.

Then, the third reaction: "Oh, it's not just foreigners. It's in the country, but it's this group we all really hate." Fill in the blank: homosexuals, prostitutes, IV drug users, marginalized ethnic groups, what have you. By the time you actually got to the point that the leadership was ready to take a deep breath and confess, "We have an epidemic," it was already all over the place. This was especially true in countries where the primary means of transmission was heterosexual.

How has this disease transformed global health?

The whole concept of "global health" came because of AIDS. The legacy of the colonial era was this notion of tropical diseases that reflected the notion of sequestering certain kinds of disease threats in the category of exotic, because white Europeans and North Americans didn't get them commonly. The arrival of HIV [showed] that all the systems had failed, all the assumptions were wrong. AIDS was first noted in the United States, not in some obscure place.

Initially, obviously, it made sense that the World Health Organization (WHO) should take the leadership. But WHO found the whole idea of getting involved in this thing with homosexuals abhorrent, and stayed away from the disease entirely for three years. Then they created a global program on AIDS, nested inside of WHO. It was very modest. By then, we estimate, the epidemic had already infected two hundred thousand or three hundred thousand people worldwide, though most of them were [not yet symptomatic].

Without a doubt, the fact that HIV got out of control is the single greatest defeat in the history of public health, and represents a total failure on the part of every single actor that should have had a primary role to try to control the disease.

All of a sudden, nobody could deny that this was a) transmissible, b) a really nasty virus of a kind that had never really been seen circulating in human beings before--a class called retrovirus for which we had no cure, no treatment, no vaccine, nothing. And everybody kind of woke up and recognized that if this was being transmitted sexually, we were about to face a grim change in the entire ballgame. And that is of course what happened.

There are an estimated thirty-three million people living with AIDS/HIV, twenty-two million of whom are in sub-Saharan Africa. There's also somewhere in the neighborhood of 2.6 million new infections a year. Do these statistics suggest failure?

The fact that HIV got out of control is the single greatest defeat in the history of public health and represents a total failure on the part of every single actor that should have had a primary role [in controlling] the disease. And it was a failure that happened because--and Larry Kramer and I have an op-ed about this--the initial response in the United States was to see this as a gay epidemic. You look back now, and you laugh, but in those days, it was so upsetting.

From the very beginning, they should have realized that this is a blood disease, and it's transmitted in ways that people share blood. So, blood gets shared when you have sex. Blood gets shared when you get a tattoo with a bloody tattoo needle. Blood gets shared when you share a needle to inject narcotics. Blood gets shared when you get a medical procedure with unclean equipment. These were the ways it was spreading. In Africa, the unclean, reused needle in medical settings was a key mode of transmission that nobody talked about, because nobody was thinking about blood. So we just missed all these opportunities where the epidemic could have been contained, could have been slowed down at the very least--if not, in fact, prevented from turning into an explosion. Once you get a critical mass of humanity infected, in fact, there was no way to bring it under control without massive political commitment--which didn't even begin to appear until the epidemic was more than a decade old.

Fast forward to where we are now. What's happening on the prevention and treatment front?

Once we had a recognition of how dire this was, and that things like abstinence and "be faithful in marriage," and even distribution of condoms were not going to solve the problem [of prevention], there started to be more innovative thinking and some money tossed at the innovative ideas. The first real breakthrough [on prevention] came about eighteen months ago, [in a trial] in KwaZulu-Natal [South Africa] using a microbicide that [contained] the HIV drug Truvada. Even women who were [careless] and didn't actually use the microbicide every time they had sex had a 38 percent reduction in new infections. And among women who used those microbicide every single time, the reduction was more than 60 percent. This had people dancing on the rooftops with joy.

The next big breakthrough was [a trial] that put people who were HIV-positive on treatment drugs as soon as they're diagnosed. They actually stopped that trial early because the results were so dramatic: a 96 percent reduction in transmission of the virus. This is huge, this is vaccine-level.

What all the science is telling us is that we need a lot of money, and it is way more than the roughly $15.5 billion that's being spent this year related to HIV outside of the rich countries. We need at least to double that--immediately--and to consider even tripling that sum. It's a huge number, and frankly, if you get that many people into treatment in poor countries all over the world, the cost of the drugs is only part of the problem. We also need more healthcare workers--a lot more than we have--and that's going to greatly jack up the cost.

What this says to the world community is: It's time to put your money where your mouth is. If all along, this game was about stopping the spread of this disease and protecting the lives of people who were infected, keeping babies from being born with it, keeping women who were totally faithful in their marriage from getting the disease from their not-faithful husband--if that was really the intent, guess what? We can now deliver to you a package, a recipe book. But the recipe's really expensive.

What's got to happen to get the kind of money--this $30 billion or $45 billion--and have it not just for a year, but for the next twenty or thirty years?

That's the trillion-dollar question. Several things are happening at once to try and answer that. The first is that the current multilateral institutions that deal with distributing drugs and helping countries make their programs better clean up their act. The Global Fund to Fight AIDS, Tuberculosis, and Malaria is now in a lot of trouble because some monies and drugs have disappeared, and Global Fund purchased drugs in some East African countries that have ended up in the black market. Germany and a few Scandinavian countries have pulled their funding. Global Fund is now going through a massive clean-up operation.

The second thing happening is a kind of restructuring of the political alignments within the world health community--so the respective roles of WHO, Global Fund, five or six other major players are being sorted out, and hopefully, this will result in being able to get more done with less money. The third thing is that the biggest donor on the planet is the U.S. government. Most of the money goes through PEPFAR, because it's the emergency program for AIDS relief. The Obama administration is [attempting to align] all the health programs that we fund [as well as] our friends' programs--the UK, Japan, all of Europe, and so on--into one master plan, so that the funds it takes to set up an office and get the ball rolling are simultaneously addressed to malaria, tuberculosis, HIV, and overall health systems improvement. This is the Obama Global Health Initiative. It is being mirrored by other countries, and a lot of the discussion we're going to hear this week [at the UN] is going to be about how not to have HIV be the Peter that robs Paul, [and the need to] align more and more programs so that whether we call it money to treat HIV, or call it money to treat children with malaria, it's raising all of these ships at once. That's the goal.

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