E-drug: Lancet: A positive result for AIDS
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Lancet 2003; 316 (no 9357, 13. February 2003)
Editorial
A positive result for AIDS
The State of the Union address on January 28 by US President George Bush was
replete with grim updates from various domestic and international fronts.
But the announcement of a plan to commit US$15 billion over the next 5
years, $10 billion in new money, for AIDS relief in Africa and the Caribbean
was surprising and welcome news. 2 weeks after the dust has settled on this
initiative, what can be gleaned about the renewed commitment of the USA to
global health?
The proposal represents a tripling of US spending, which now typically
amounts to about $1 billion annually. For fiscal year 2004, the White House
plans to ask Congress for an appropriation of $2 billion, with the amount
increasing thereafter. Of that total, $1 billion is set aside for the Global
Fund to Fight AIDS, Tuberculosis and Malaria. The plan will be managed by a
Special Coordinator for International HIV/AIDS Assistance, a person who,
appointed by the President and confirmed by the Senate, will have
ambassadorial rank and report directly to the Secretary of State.
The plan comprises three initiatives: prevention of seven million new
infections through voluntary testing and counselling (to include abstinence
education and condoms); treatment with antiretrovirals for two million
people; and support and care for ten million persons infected with HIV and
for AIDS orphans. 14 countries with the highest prevalence of HIV/AIDS have
been targeted to receive most of the resources: Botswana, Namibia,
Mozambique, Zambia, Uganda, Tanzania, Kenya, Ethiopia, Nigeria, Cote
d'Ivoire, Rwanda, South Africa, Haiti, and Guyana. Cases in these countries
account for 50% of all infections worldwide, and 70% of all infections in
Africa and the Caribbean.
Anthony Fauci, Director of the National Institute of Allergy and Infectious
Diseases at the US National Institutes of Health, told The Lancet that in
June, 2002, Bush asked him and others to devise a programme that was both
"feasible and accountable". The administration had been persuaded that the
situation in Africa is especially catastrophic, and that one effect of the
geopolitical reality of AIDS is its threat to national and global security.
Fauci and other administration officials travelled throughout Africa to
investigate successful local models of AIDS prevention, treatment, and care.
The one they ultimately recommend is a layered network model used in Uganda
(with variations used in other countries). The network consists of central
medical centres, primary and secondary satellites, and mobile units, each
providing a designated level of care appropriate to the needs of the urban
or rural settings in which they are located. Standardised protocols and
prepared medication packs will facilitate efforts across the network.
Government officials in Africa and the Caribbean and AIDS activists have
responded mostly favourably to the plan. Some are, however, concerned about
competing interests. Critics charge that the Global Fund gets short shrift,
and it is unclear whether or how the Bush plan will interface with the Fund,
whose new Chair is US Secretary of Health and Human Services Tommy Thompson.
And the Global Fund is not the only possible competitor. A Senate bill that
would provide even more funding is being sponsored by a somewhat odd couple:
Bill Frist, the Republican heart surgeon from Tennessee who is now Majority
Leader, and John Kerry, a Democrat from Massachusetts who has recently
announced that he will run for President. The status of the bill, which died
in the last Congress but is being reintroduced, is uncertain. Another worry
is the plan's focus on Africa and the Caribbean, to the exclusion of
countries like India and China, where the epidemic is mushrooming.
These concerns notwithstanding, the President's plan, which appears long
considered and carefully devised by experts, is tremendously good news. The
Lancet urges the US Congress to appropriate swiftly the entire amount, so
the programme can be implemented as soon as possible. Then let other rich
nations follow suit. Ideally and ultimately, action against the epidemic
should take place in the context of a comprehensive response to the problems
of pervasive poverty, including hunger and education. The most important
reality of AIDS is that it is a global crisis, one for which all bear
responsibility, against which all must act, and act now.
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