by Professor Brook Baker

Winning a commitment from PEPFAR and President Obama to treat 6 million PWAs by 2013 should have been easy – but it wasn't. Even as the President's health advisors promoted an anemic Global Health Initiative and down-played HIV/AIDS in general and treatment in particular, PEPFAR implementers and partners were achieving dramatic efficiencies in treatment costs. Sourcing nearly 95% of medicines from FDA-approved generic producers is now saving $100s of billion a year. Per person costs of those same medicines, even the improved first-line and second-line medicine has fallen dramatically over the past three years, led by 50% price decreases for tenofovir. The US started to save costs with sea and land delivery of commodities, more efficient supply chains, and more functional lab and health information systems. Finally, economies of scale from increased numbers on treatment began to kick in, lowering per person treatment costs by nearly two thirds, so that the US share of treatment costs now averages only $335/pppy.

The US getting to 4 million on treatment by the end of FY 2011 was accomplished despite adoption of policies that undermined treatment scale-up. We all remember the infamous "waiting-in-line-to-die" memo from 2009 in Uganda, but there were other setbacks as well. As confirmed by an analysis of PEPFAR Operational Plans FY2005-10 by Matt Kavanagh and Margie Thorp, absolute and relative spending on treatment began to go down between FY2008 and 2009 (adult and pediatric treatment services budget lines declined from an average of approximately 35% of all PEPFAR expenditure to 28%). This occurred at the same time that PEPFAR/Global Fund appropriations plateaued. Even more troubling, US disbursement for global AIDS actually fell from $4.4 billion in 2009 to $3.7 billion in 2010 because of new requirements established by Congress for PEPFAR (the silver lining is that this undisbursed but appropriated funds can still be disbursed in later years). Accordingly, it is clear that the continuing improvements in treatment scale up were not the result of more money, but rather more efficiency.

Even so, the US treatment scale-up is both over- and under-stated. It is over-stated because the US pays only 50% of treatment costs for the patients it says it supports. So in real terms, the PEPFAR is supporting full treatment costs for only 2 million patients. However, the number is understated, because the US is also providing major funding for the Global Fund which claims credit for supporting treatment of 3.3 million. There is approximately a 1.7 million person overlap in US and Global Fund numbers, but as a one-third funder of the Global Fund, the US can probably claim credit for an additional 1 million patients receiving partial support, the equivalent of .5 million receiving full support. So, the working hypothesis is that the US is paying full freight cost of approximately 2.5 million of the 6.6 million+ people on treatment (the number is surely closer to 7.5 million end of 2011).

Getting PEPFAR and the President to champion treatment (1/2 cost) for another 2 million PWAs between now and the end of 2013 is not actually heavy lifting in terms of affordability. It might require spending some of the accumulated undisbursed funds and a reprioritization of treatment, but calculations at PEPFAR showed that it was clearly feasible. However, even though it shouldn't have been heavy lifting, it actually took a year and a half of campaigning to get the President to state what was obvious – the US could treat another 2 million over the next two years. But if my math is right, at the end of 2013, the US will really only be paying full treatment costs for only 3.5 million PWAs, roughly 1/3 of the patients likely to be on ART at that time (10-11 million).

I agree completely that it took a strategic campaign, lots of unpopular birddogging, and an insider strategy to accomplish this important but limited goal. Our collective success was also highly dependent on long-awaited, irrefutable evidence that treatment is prevention. Even though PEPFAR should have committed to treatment "only" when it was saving otherwise disposable Africa lives, the case for treatment became even more compelling when HTPNP 052 confirmed that successful treatment reduces the risk of transmission to negative partners by 96%.

Although the US has now committed to 6 million by 2013, it may well cost more per patient to get there, if for no other reason than that the Global Fund is not going to be contributing one thin dime to treatment scale-up other than what is already programmed into Phase 2 grants. So, for the first time, the US will have to pick up the other 50% of treatment costs on some of the newly treated or it will have to try to squeeze more dollars out of the health budgets of its PEPFAR country partners.

GETTING BEYOND 6 MILLION

Everyone on this list celbrates that a commitment to 2 million more on treatment will in the short run re-engerize PEPFAR implementers and lift the gloom in high-impact countries. But the commitment from the US is being offset by the sleeping pill delivered to the Global Fund and by the reluctance of developing countries to take on long-term treatment costs in the face of dwindling donor support. Even more troubling, to get to 15 million by 2015, we will need major new investments in global AIDS.

Winning collection of the $2 billion shortfall at the Global Fund is sufficient to allow it to launch a modest Round 11, but the $11.7 billion committed to the Global Fund in the third replenishment was woefully insufficient in terms of actual growing needs. Let us not forget that the Global Fund's stagnant-progress funding need was $13 billion 2011-13, that the modest-growth funding need was $17 billion, and that more ambitious programming required $20 billion.

Let us also not forget that we are facing a treatment timebomb because of the much higher costs of second- and third-line medicines that are patent protected, that health care capacity is being stretched and that much more money will be needed to train, recruit, and retain the needed workforce, and that health and community-systems must be strengthened. Even the strategic investment framework estimates funding needs of $22- $24 billion by 2015, which is $7-9 billion more than is on the table today. And the strategic framework really didn't cost treatment as prevention.

So, here we are breathing a sigh of relief that we got an important victory, but one that took much more effort than it should. And we are beating our brains out just to try to get the Global Fund the money it was promised so that it could basically tread water. And we have stunning science that shows that the end of AIDS is possible and economic modeling that shows that early and expanded funding now will reap huge prevention and cost benefits in the future.

None of us has a magic wand about how to shake decision-makers out of their cynical, duplicitous lethargy to come up with the chump change that is necessary to save and extend lives and to beat back the flood of new infections. But, we know we won't simply praise the achievement of the obvious nor advocate for a Global Fund that is withering away. We have to keep beating the drum about the death march of the untreated. We have to talk about prioritizing what really works in prevention, which now headlines treatment. We have to talk about spending fractions more now to save vast sums in the future. We have to say that the no-money excuse won't fly and that parochialism is spending is immoral. We have to promote additionality between increased donor and domestic spending.

But our immediate challenge now is how to frame next steps forward at a time when budgets are be negotiated by Tea-Party flat-earthers, climate-denialists, and isolationists. Where's the next 6 million going to come from?

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