Politics and Policy

House Passes $516B Spending Bill With Global Health Provisions

[Dec 18, 2007]

The House on Monday voted 253-154 to approve a $516 billion fiscal year 2008 spending bill that combines 10 unfinished spending measures with the FY 2008 foreign operations spending bill (HR 2764), the New York Times reports (Hulse, New York Times, 12/18). The measure would fund the Department of State, USAID, and other global health and international aid programs. It also affects the Millennium Challenge Corporation, which aims to encourage economic and political reforms in developing countries, CQ Today reports.

The proposed bill would provide $6.5 billion for U.S. and global health activities, which is $1.4 billion more than in 2007 and $796 million more than President Bush's request, including emergency spending, according to the House Appropriations Committee. Five billion dollars in foreign operations spending would go to the President's Emergency Plan for AIDS Relief -- at least $1.2 billion more than the program received last year -- CQ Today reports (Graham-Silverman, CQ Today, 12/17).

According to the Washington Post, conservatives "in and out of Congress criticized" the bill, including a provision that would "sever[e] overseas AIDS relief from abstinence-education mandates" (Weisman, Washington Post, 12/18). By law, at least one-third of HIV prevention funds that focus countries receive through PEPFAR must be used for abstinence-until-marriage programs (Kaiser Daily HIV/AIDS Report, 11/30).

Under the bill, the Global Fund To Fight AIDS, Tuberculosis and Malaria would receive about $841 million. The amount includes $546 million in the State-Foreign Operations section and $295 million in the Labor-HHS-Education section of the bill. Bush had requested $300 million for the Global Fund, all of which was allocated in the Labor-HHS bill, CQ Today reports (CQ Today, 12/17).

In addition, the measure would provide $1.8 billion for global health and child survival programs, including $347 million for HIV/AIDS programs. Funding for maternal and child health programs would increase by $101 million, and malaria and TB funding would increase by $101 million and $72 million, respectively (House Appropriations Committee release, 12/16). The measure would reduce funding for MCC to $1.54 billion -- about half of Bush's requested $3 billion. MCC is "cut below the president's request because of the availability of unobligated balances," the Appropriations Committee said. A proposal to change the way MCC funding is dispersed was dropped, according to CQ Today (CQ Today, 12/17).

The measure also would increase funding for AIDS Drug Assistance Programs -- federal- and state-funded programs that provide HIV/AIDS-related medications to low-income, uninsured and underinsured HIV-positive individuals -- by $19 million to $809 million, CQ HealthBeat reports (Reichard, CQ HealthBeat, 12/17). In addition, the measure would lift a ban on needle-exchange programs in Washington, D.C.

Reaction

"I'm pleased to report that we're making some pretty good progress toward coming up with a fiscally sound budget -- one that meets priorities, helps on some emergencies and enables us to say that we've been fiscally sound with the people's money," Bush said Monday.

Some Republicans in the Senate and House called on Bush to veto the final measure. Even Democratic leaders were "only mildly supportive" of the compromise measure, the Post reports. "In an adult world, win, lose or draw, we have an obligation to complete our work," House Appropriations Committee Chair David Obey (D-Wis.) said, adding, "In an adult world, we have an obligation to compromise and move on" (Washington Post, 12/18).

The measure now goes to the Senate, where Republicans are expected to add funding for the war in Iraq. The White House on Monday said Bush would sign the bill only if Iraq funding is included, CQ Today reports (Wayne, CQ Today, 12/17).

Senators, HIV/AIDS Advocates Call for PEPFAR Reauthorization at Senate Committee Hearing

In related news, senators and HIV/AIDS experts on Thursday at a Senate Foreign Relations Committee hearing called on Congress to promptly reauthorize PEPFAR, CQ HealthBeat reports. Sen. Robert Menendez (D-N.J.), who chaired the hearing, said the challenges the U.S. faced when PEPFAR was created in 2003 remain as "relevant and as devastating as ever."

Nils Daulaire, president and CEO of the Global Health Council, said "expedient and thoughtful" reauthorization is critical over "the next several months." Helen Smits, vice chair of the Committee for the Evaluation of PEPFAR Implementation at the Institute of Medicine, said that if the program is not reauthorized quickly, nongovernmental organizations working in recipient countries might be forced to lay off employees.

The witnesses who testified before the committee also said that the next step in fighting the HIV/AIDS epidemic would have to involve efforts to strengthen health care systems in developing countries. Sen. John Sununu (R-N.H.) said there is a need to "develop systems that can adequately address the scope of the HIV/AIDS epidemic." He also called for a health care capacity large enough to implement PEPFAR goals (Gensheimer, CQ HealthBeat, 12/17).

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Global Challenges

Los Angeles Times Publishes Articles About Partners in Health, Gates Foundation

[Dec 18, 2007]

The Los Angeles Times on Sunday published two articles on global health, one about Partners in Health and the other about the work of the Bill & Melinda Gates Foundation. Summaries appear below.

"Treating the Sick Without Bias": PIH, which "rejects narrowly targeted approaches" to address HIV/AIDS, has partnered with governments in Africa, Haiti, South America and Russia to improve health systems, the Times reports. PIH programs link medical care with nutrition, work and self-reliance for low-income people. In addition, PIH hires "accompagnateurs," or lay health guides, in communities to encourage people to seek medical care; take medication; monitor vaccinations; and look for health problems that require follow-up from a physician, nurse or social worker. The group also is training accompagnateurs to conduct home visits with pregnant women, encourage pregnant women to receive HIV tests and ensure that they give birth at a clinic. PIH next year plans to expand its program in Rwanda, which is funded in part by the Global Fund To Fight AIDS, Tuberculosis and Malaria and the Clinton Foundation. According to the Times, some officials in the Rwandan government have said that PIH programs in the country could foster dependency. "Everything for free -- we don't believe it is sustainable," Agnes Binagwaho, a top health official in the country, said. In response to such comments, PIH has helped people to form HIV/AIDS associations, provided training in farming methods and offered small loans to more than 6,000 farmers (Piller, Los Angeles Times, 12/16).

"Unintended Victims of Gates Foundation Generosity": Gates Foundation programs in sub-Saharan Africa have targeted HIV/AIDS, TB and malaria because of their "devastating health and economic effects," but the programs it has funded "have had mixed influences on key measures of societal health," the Times reports. According to the Times, by focusing on "such high-profile killers as AIDS, Gates grantees have increased the demand for specially trained, higher-paid clinicians, diverting staff from basic care." The Gates Foundation's focus on the three diseases also has "shortchanged basic needs, such as nutrition and transportation," the Times reports. The Times adds that "because of the generosity of the foundation and other donors, millions of children have been protected against scourges such as malaria and measles -- and AIDS deaths in much of Africa are finally leveling off." According to the Times, the Gates Foundation has given $650 million to the Global Fund, which has used that and other support to pay for AIDS treatment for 1.1 million people and TB treatment for 2.8 million people. Global Fund executive director Michel Kazatchkine said, "We are a global fund for AIDS, TB and malaria. We are not a global fund that funds local health." He added that the Global Fund "cannot resolve all the problems of all the people." Tadataka Yamada, president of the Gates Foundation's global health program, said that African countries need to do more to improve health. "We're a catalyzer. What we can't do is fill the gaps in government budgets," he said, adding, "It's not sustainable." (Piller/Smith, Los Angeles Times, 12/16).

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Madagascar's Response to HIV/AIDS One of 'Most Aggressive' in Africa, AP/ABC News Reports

[Dec 18, 2007]

Madagascar's response to HIV/AIDS has been one of the "most aggressive" in Africa and should serve as a model for how to prevent the transmission of the virus and improve overall health care, the AP/ABC News reports. Although less than 1% of Madagascar's population is living with HIV/AIDS, an influx of foreign workers, as well as a high rate of other sexually transmitted infections, has led the country to implement aggressive HIV prevention campaigns, the AP/News reports.

According to the AP/News, the government has established more than 100 testing clinics, increased access to condoms and has begun training teachers how to relay HIV prevention messages to their students. In addition, the country in August passed the first law in Africa that imposes fines for discriminating against people living with the disease or disclosing their status. The country also plans to distribute 400,000 HIV test kits by the end of 2007 and to provide 90% of HIV-positive people with antiretroviral drugs within five years, the AP/News reports.

Fanjaniaina Rajoelisolo, head of the country's national AIDS office, said the country's campaign against HIV/AIDS is a "personal initiative" of Madagascan President Marc Ravalomanana, adding that the president negotiates with international donors. According to Rajoelisolo, the country also ensures that precise records of every procedure and consultation are kept to provide donors with detailed accounting of how funds are being spent. "Donors see exactly what their money is doing and are willing to contribute more," Rajoelisolo said, adding, "We compare ourselves with other countries" and "then analyze all of [the information] and plan a strategy that will fit us." Hugo Templeman, an expert in South Africa who advises Ravalomanana on HIV/AIDS, said, "On HIV and AIDS, Madagascar is the only country in Africa that is getting it right" (Leonard, AP/ABC News, 12/16).

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Opinion

Vaccine Needed To Eliminate HIV/AIDS, Opinion Piece Says

[Dec 18, 2007]

Although campaigns to prevent the spread of HIV are "critical and need more attention," a vaccine is needed to effectively "protect society as a whole and eliminate" HIV/AIDS, Seth Berkley, president and CEO of the International AIDS Vaccine Initiative, writes in a Washington Post opinion piece.

According to Berkley, prevention campaigns -- including those that promote abstinence, faithfulness to one partner, circumcision, condom use and the provision of clean needles -- are necessary, but "given human nature and the cultural and economic realities in the societies hit hardest by AIDS, these programs can do only so much." Berkley writes that to eliminate HIV/AIDS, "we need a much more powerful weapon" -- a vaccine -- because no "major viral epidemic has been defeated without one." He adds that a vaccine "holds the hope of eliminating, and not just curbing," the HIV/AIDS pandemic.

Although there were "high hopes" for Merck's experimental HIV vaccine, the trials ultimately were canceled, Berkley writes, adding that "more study is needed to find out why it failed and what implications that may have for the 30 or so experimental AIDS vaccines in trials." According to Berkley, researchers also should "build on ... insights" -- such as why a small number of HIV-positive people never progress to AIDS or why vaccines can protect nonhuman primates from infection with SIV -- adding, "We can't afford the alternative, in financial or human terms." Financing HIV/AIDS research is a "minimal investment, but it is one that will ultimately prove cost-effective," Berkley writes, concluding that a "preventive vaccine is the only intervention that could ultimately eliminate the need for all others" (Berkley, Washington Post, 12/18).

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Low Insurance Reimbursement 'Biggest Impediment' to Routine HIV Testing, Letter to Editor Says

[Dec 18, 2007]

The "biggest impediment" to routine HIV testing is not "state restrictions" or "insufficient funding," but rather "government health insurance, Medicare and managed care insurance companies," Gary Blick -- an HIV/AIDS specialist in Norwalk, Conn. -- writes in a Washington Times letter to the editor in response to a recent Times opinion piece. According to Blick, Medicare reimburses $12.14 for the $17.50 HIV test, and United Healthcare, which covers 70 million U.S. residents, reimburses $6.04 for the test, "making it impossible to routinely test anyone."

It is "ironic" that CDC recommends routine HIV testing because Medicare prevents it by reimbursing 30% below cost for the test, Blick writes. Meanwhile, the number of new HIV cases is increasing, and President Bush has "significantly" reduced "funding for HIV prevention and testing," he adds.

Blick also writes that FDA in 2004 approved the drug Sculptra for correction of facial lipoatrophy, a "serious, disfiguring and stigmatizing complication" that occurs among people living with HIV/AIDS. The disease, also called facial fat wasting, "causes severe depression" and can lead "people to divulge their HIV status to others." However, Medicare and managed-care companies "routinely deny" Sculptra for HIV/AIDS patients as a "cosmetic procedure without it having a cosmetic indication," Blick writes. According to Blick, it also is "ironic" that FDA has approved a treatment that would help "reverse stigma" so that "Medicare can deny it for irrelevant, cost-saving reasons" (Blick, Washington Times, 12/15).

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