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PEPFAR’S Annual Report to Congress: Success on Numbers has Consequences

June 27, 2011

This month, PEPFAR submitted its Seventh Annual Report to Congress. At the end of 2010, it reported that:

  • over 3.2 million people were on ARV treatment, an increase of more than 700,000 over the previous year;
  • and more than 600,000 pregnant women were provided with drugs to prevent mother-to-child transmission of HIV, resulting in 114,000 babies who were born free of this disease in 2010.

PEPFAR comments that

“when one reflects that each of the numbers represents a real person—with a story, a family, a community—the impact of this work is too vast to comprehend through numbers alone”.

All true, compelling, and a tribute to PEPFAR’s consistency of effort. The numbers do indeed reveal a remarkable achievement in combating a disease which many thought an impossible undertaking just a short decade ago.

Yet, since AIDS is a life-long chronic disease once ARV treatment is initiated, two questions arise:

1)      What are the clinical outcomes of patients under treatment?

2)      What are the long term costs as patients proceed along life’s path, particularly from new born children to aged adults?

Neither PEPFAR nor the Global Fund to Fight HIV/ADS, TB and Malaria ever provide any clinical outcomes. UNAIDS reported that between these two organizations, 5.2 million AIDS patients were under treatment at the end of 2010 (Report in PDF).

Numbers are important in public health; clinical outcomes are a critical component in chronic care—they inform us of a patient’s progress and response to treatment over time.  The global health community is now into its 8th year of rapid scale-up on AIDS and it is committed to universal coverage of approximately 15 million by 2015.

This goal is being pursued in the absence of scant clinical knowledge on whether, for instance, ARV ‘x’ has a higher viral suppression level than ‘y’; of mortality rates after 6 months on treatment, 18 months after treatment, etc.; of the onset of drug resistance and its reasons; of co-morbidities and their timing; of primary causes of mortality, e.g., TB, malaria, diabetes, schistosomiasis, CVDs, etc.; of the reasons for treatment failures; and of the long-term costs for salvage therapies, e.g., specialty care, hospitalization, etc.

In terms of the second question, data from the U. S. provides ample evidence of rising societal costs as AIDS patients’ age. For those that were initiated into treatment in the late 1980s at mid-life, they are now approaching the transfer point between coverage by Medicaid and Medicare. The former has an ample record of treatment costs and it can be a guide as to what PEPFAR can anticipate in the years ahead as its covered population ages, especially because it is several orders of magnitude higher than the US.

In the report to Congress, PEPFAR provides a country listing of the numbers receiving various forms of assistance. For China and India on Prevention of Mother- to-Child Transmission it is 258,000; for prevention it is 635,200; for ARV treatment it is 8,400; for Orphans and Vulnerable Children it is 67,900; and, for Care and Support it is 89,900.

In total, 1+ million patients are beneficiaries of PEPFAR in these two countries.

Both China and India have intercontinental nuclear launch capabilities and can obliterate entire nations in a nano second. They are also among the largest economies in the world, ranked 3rd and 10th in terms of GDP, respectively, enjoying economic growth rates exceeding 6% per annum over the past decade.  India is the global leader in the provision of ARV therapies to the developing world, mainly to Africa; is the epi center of a multi-billion dollar Medical Tourism Industry; has a Middle Class larger than the entire population of the U. S.; and, along with China, it is a Charter Member of BRIC (Brazil, Russia, India, China).

Given the fact that Washington D. C. has the highest HIV/AIDS infection rate in the U.S., and is unable to provide annual immunizations for 20% of its primary and secondary school population, it might reasonable be asked: why has our government accepted a life-long fiscal responsibility for the care and welfare of so many citizens of China and India? These countries expend billions on weapons that can destroy whole populations external to their own borders, but are unwilling to provide needed healthcare for the few thousands within those borders.

There can be no doubt that PEPFAR has been a remarkable success in moving 3.2 million AIDS patients into life-extending treatment, and providing for the direct care of thousands of orphans and vulnerable children.  Or that the United States, as the main financial supporter of the Global Fund, has materially assisted in boosting global coverage of AIDS patients to 5.2 million, of which some of the additional 2 million reside in China and India.  In the annals of public health, there is no other comparable accomplishment in such a compressed period of time.

Yet, numerical success in the attainment of public health goals has its consequences when a disease migrates to a chronic condition. Does our Congress fully understand that if the universal goal of treating 15 million AIDS patients by 2015 is achieved, then the greater proportion of them will become permanent wards of U. S. taxpayers for the remainder of their natural lives, even as China and India continue their ascendancy to become the predominant global economic powers? This disconnect on priorities is occurring at a time when our government isn’t able to provide adequate access to therapies for AIDS patients here at home, prompting “a national response [that] will once again become an area of shameful neglect”. (See James Driscoll, We can change the reality of AIDS, The Washington Post, 6/25/11).

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