Health GAP Policy Analysis: Making a Mistake on Treatment – PEPFAR’s New Five-Year AIDS Strategy

by Brook K. Baker, Feb. 5, 2010

Abstract: Just when testing trends are so positive, just when the costs of medicines have plummeted to new lows, and just as scientific modeling and research shows that treatment reduces the risk of HIV transmission, funding – the lifeblood of AIDS programming – is being capped both by donor countries and their partners in the developing world that are suffering the worst of the global recession. As a result, people are beginning to stand in line and to die in that line while waiting for treatment.

Solemn promises to achieve universal access have been made repeatedly over the past 5 years, including by President Obama and other U.S. leaders, but the world is currently treating only 30% of those in need of treatment under new WHO treatment guidelines. The Global Fund to Fight AIDS, Tuberculosis and Malaria is rationing funding to meritorious applications and is running out of funds for new proposals. U.S. commitments to Global AIDS have been essentially flat-lined in FY 2009 and 2010 budgets and now in the proposed FY 2011 budget. That flat funding has a cost, and the cost is that twice as many PWAs will die under the PEPFAR Five Year strategy than would die under a universal access scenario.

AIDS treatment has had dramatic success in extending and improving lives in both rich countries and poor. It has also created positive synergies for other health services, it has rewarded people for knowing their status, and it has spawned the most powerful movement for global health justice the world has ever known. Given evidence of the impact of early treatment and lower viral loads on reducing the risks of horizontal and vertical transmission, treatment can also be a key component to comprehensive prevention – to actually reversing the tide of infection.

People are playing the blame game in a concerted backlash against HIV/AIDS programming and treatment in particular. And they are complaining about inadequate resources even as we spend trillions on financial sector bailouts and military adventures. There is more than enough to increase FY 2011 appropriations to $7.25 billion and to increase U.S. spending on its Global Health Initiative from $63 billion to $95 billion as demanded by a coalition of health activists in the U.S. Untreated, our brothers and sisters will die – with modest and pragmatic increases in funding and programming, the delayed goal of universal access to comprehensive HIV/AIDS prevention, treatment, and care can be reached.

Full analysis below, or click here to download as a PDF.

Programming for HIV/AIDS prevention, treatment, and care is leveling off as PEPFAR is flat-funded in the U.S. and as the Global Fund to Fight AIDS, Tuberculosis and Malaria begins to ration resources as its coffers go to half empty.  At the same time that people living with HIV/AIDS are celebrating recent WHO and UNAIDS reports estimating that there were 4 million people on treatment at the end of 2008, a ten-fold increase in just six years, health care workers in Africa are being told that they can no longer continue to start people on antiretroviral therapy – in essence, that treatment is capped at the current figure.

 
People in Africa and elsewhere are learning about their HIV status at an unprecedented rate. Overcoming self-condemnation, ignorance about the disease, and the risk of discrimination and buoyed by the prospects of life-saving antiretroviral therapy and a return to work and parenting responsibility, millions of people are learning whether they are HIV-positive or not.  Just when testing trends are so positive, just when the costs of medicines have plummeted to new lows, and just as scientific modeling and research shows that treatment reduces the risk of HIV transmission, funding – the lifeblood of AIDS programming – is being capped both by donor countries and their partners in the developing world that are suffering the worst of the global recession.

 
So people are beginning to stand in line in South Africa, in Zambia and Uganda, and in other countries as well.  They are being asked to stand in line until a person currently on treatment dies or is otherwise lost to care.  Those who arrive in wheelbarrows, on the brink of death, will die first unless they are rushed to the front thereby postponing treatment for others whose prospects on treatment are greatly enhanced if they start treatment while their immune systems are still functioning.   Mothers in line will wonder:  should I begin treatment in order to dramatically reduce the risk of transmission to my newborn from 30% to 2%, or should I grant my place in the line to an already infected baby who has a 50% chance of dying before the age of two unless promptly treated?  Will husbands and wives or brothers and sisters flip coins – when one gets treatment, will they split their pills creating resistance in both patient?  Or will the czars of rationing choose to provide new treatment slots for health workers, many of whom are HIV infected and all of whom are needed to provide desperately needed health care within the tattered and brain-drained health care systems of Africa?

Reneging on Universal Access – the cost of broken promises

 
Throughout the past decade, politicians from rich countries have made solemn promises to achieve Universal Access to AIDS prevention, treatment and care.  They did so first, incrementally, in 2000 via Goal 6 of the Millennium Development Goals, thereafter ratified in 2001 via a United Nations General Assembly Declaration of Commitment.  Subsequently, at the United Nations General Assembly High-Level Meeting on AIDS in 2006, countries promised to work towards what we now call Universal Access by a specific date, 2010.  In successive G-8 meetings since 2005, big-power countries, including the U.S., have committed to Universal Access, promising to provide needed resources through bilateral and multilateral channels including the Global Fund to Fight AIDS, Tuberculosis and Malaria.  These global commitments have been mirrored in the U.S. where, during the 2008 Presidential campaign, Senators Obama, Biden, and Clinton all promised to spend $50 billion on global AIDS programming 2009-2013, a promise that was codified in the $48 billion PEPFAR reauthorization that they signed that same summer.

These promises are coming due – 2010 has arrived – but the myriad promises of adequate funding and comprehensive programming have not been met.  Admittedly treatment now reaches over 4 million people, but 10 million additional patients who need treatment under new WHO treatment guidelines are still without medicines.  So, in reality, the world is only 30% of the way towards Universal Access with respect to treatment and likewise has achieved only partial success in prevention, reducing new infections by comparable 30% over the past 12 years.

Rather than fully funding the Global Fund so that it can meet growing, country-led demand for AIDS programming and health system strengthening, donors have underfunded the Fund over the past two year resulting in rationing of resources for technically sound plans.  There were 10% reductions in the first two years, and 25% in the last three years, of approved Round 8 grants.  There were even deeper reductions in Round 9 grants; for 2010, the Global Fund has been forced to discontinue rolling continuation grants and Round 10 and other funding streams are at risk as there is a 50% shortfall of needed resources.   By undermining the Global Fund, donors are signaling that recipients must scale-back their ambitions and resist investing in activities with recurrent costs, such as hiring desperately needed health workers or enrolling new patients on treatment.

 
Likewise, in the U.S., PEPFAR is being flat-funded rather than expanded as promised in the $48 billion reauthorization.  In FY 2008, the last year of PEPFAR I, bilateral AIDS received $4.6 billion and the Global Fund $850 (not including NIH research).  This represented more than a doubling of PEPFAR spending over five years. In the FY 2009 budget prepared by the lame duck Bush administration, bilateral AIDS received $ 5 billion and the Global Fund $1 billion, a modest 10% hike.  In President Obama’s first budget, FY 2010, bilateral AIDS is projected to receive only $5.1 billion and the Global Fund $1.05 billion, an increase of only 2%, not even matching inflation. The proposed FY 2011 budget is equally dire – a $50 million cut to the Global Fund and only $141 million in additional funding for bilateral AIDS, $100 million of which is diverted to a new undefined Global Health Initiative Plus Fund.

 
Although it is clear that President Obama and Global AIDS Ambassador Eric Goosby will continue to give verbal support to the US commitment to fight AIDS, they are signaling a retreat from Universal Access to treatment in the new PEPFAR Five-Year Strategy and their FY-2011 budget, all under the guise of the new Global Health Initiative [GHI].   The GHI and the Five-Year Strategy have many important features that portend significant improvements in PEPFAR and a more vigorous effort with respect to other compelling global health needs.  In particular, they promise more programmatic integration and attention to child and maternal health, increased country-ownership and partnership, the training, hiring, and retention of at least 140,000 new professional health workers, and a new emphasis on health system strengthening in the public sector with less reliance on international NGOs.   

However, by flat-funding PEPFAR and the Global Fund and touting sustainability and a take-over of fiscal responsibility by its “partners,” the Five-Year Strategy is subtly reneging on the U.S.’s promise of long-term financial assistance to countries that simply cannot shoulder the financial burden of comprehensive AIDS programmes on their own.  In doing so, Obama administration not only risks undermining treatment scale-up that it has promised, it also threatens PEPFAR’s future success and the survival of existing programs.

Flat-funding AIDS means twice as many die

 
Broken promises and flat-funding AIDS will have consequences.  Unfortunately, those consequences will be measured by the increased number of AIDS-related funeral processions that we will witness under the Administration’s Five-Year Strategy versus what we would achieve by fulfilling the promise of Universal Access.

When treatment is started with improved, first-line therapies that are more durable, tolerable, and efficacious and when that treatment is started when the immune system is still robust, people can live a nearly normal life span.   The converse is also true – when treatment is delayed, people die prematurely, many in the first year of treatment; and when treatment is denied, people will certainly die.  The people who are dying of AIDS today, are the people who became infected eight to ten years ago and have not received treatment.  As shown in the chart below, the number of new HIV infections peaked in 1995 when 3.5 million people became infected. There has been a gradual and steady decline of about 70,000 cases a year over the last 12 years so that in 2008 there were approximately 2.7 million new infections.  Correspondingly, the annual number of deaths peaked in 2004 – roughly nine years after the peak in incidence and just as AIDS treatment started to accelerate.

Within the constraints of existing health care capacity, treatment has been expanding by nearly 1 million people a year over the last three years, as shown in the chart below.

Scaling up to Universal Access, defined as 80% of people eligible for treatment receiving it, by 2015 would certainly require expanded investments in increasing the number of health workers and strengthening health systems.  Simultaneously, it would require increasing the number of new people on treatment from 1 million per year to 3 million per year over the next five years and then leveling off to something closer to 2 million a year thereafter.   Under the Universal Access scenario, deaths would quickly fall from over 2 million a year to under 1 million a year.

The Five-Year Strategy pales in comparison.  Admittedly, the Strategy does commit the U.S. to expand its treatment target from the current number of patients supported on antiretroviral therapy as of September 30, 2009, 2.4 million, to at least 4 million by the end of 2013.   However, this 1.6 million total translates into an extremely modest goal of adding only 400,000 patients on treatment during each of the next four years.  (Note:  even this modest number includes nearly a 1/3 overlap with Global Fund treatment figures and also significant overlaps with treatment efforts by partner countries. )  Accordingly, it is highly likely that the Five-Year Strategy’s treatment goal, when combined with other slowing global efforts, will only succeed in maintaining the current global pace of roughly 1 million new treatments each year achieving only half the treatment coverage attained under a Universal Access by 2015 scenario.

If the current treatment goal of only 4 million by 2013 is maintained and continued at the same pace thereafter, the AIDS death rate under the Obama Five-Year strategy will remain at nearly 2 million a year falling only slightly because of the slight decline in new infections over the past decade.  This contrasts with only 1 million deaths per year under Universal Access.  Accordingly, six years from now, there would be roughly twice as many deaths under the Obama Strategy as under the Universal Access scenario.   

Turning our back on treatment success

 
Turning our back on AIDS treatment makes no sense given its success on many fronts.  Of course, the first and most important measure of success is lives saved and years of productivity gained.  In Western Europe and North America, where HAART started more than decade before significant scale-up in Africa, 7.2 million life-years have already been saved, but there is also growing evidence of lives saved in Africa as well.  Moreover, the lives saved are not only those of the people-living-with-HIV/AIDS.  Saving mothers’ lives has also been shown to have dramatic impacts on child survival as well.

 
Treatment scale-up has also led to health system strengthening as health care workers were retrained to deal with a chronic disease and as health information, laboratory, and procurement and supply systems were strengthened. Treating patient with AIDS has freed up bed spaces in hospitals, which before treatment were inundated with PWAs dying from opportunistic infections.  Treating health care workers has had a greater positive impact on number of health care workers in high prevalence countries than any other intervention to date.  In some countries the number of health worker lives saved more than offsets the number of health care workers needed for providing expanded treatment access.

 
A focus on AIDS has also permitted renewed focus on co-morbid conditions and health systems linkages with respect to tuberculosis, malaria, sexually transmitted diseases, and other conditions.  Although the imprint of vertical AIDS programming has created some negative externalities, much of the available evidence suggests that AIDS programming has created positive synergies for other health care services, especially as it is more broadly integrated into primary health care systems and as global health initiatives become more intentional about enabling positive, system-wide effects.

 Treatment has been the reward for people getting tested.  The incentive to know one’s status greatly increases when a person will receive something other than knowledge of a death sentence.  The provision of testing and associated counseling has been shown to strengthened prevention.  There is evidence in both rich and poor countries that people who know their status engage in safer sex than those who don’t.

 
Perhaps the greatest virtue of treatment is that it has sustained a movement of activists and empowered communities that are demanding sea changes in global health, not only for AIDS programming but for other compelling health needs as well. Treatment activism, born of optimism about equitable access to life-saving medicines, has been the leading edge of a broader movement that has coalesced to demand greater attention to child and maternal health, to sexual and reproductive health, and to comprehensive primary health care.

Treating our way out of the AIDS pandemic

 
Treatment is fully defensible in its own right, but there is growing evidence that it has an even stronger significance for AIDS prevention than was previously understood.  It has been well known that the risk of HIV transmission is directly related to the viral load (the quantity of HIV) in an infected person’s blood and sexual fluids.  People newly infected and those in last-stage disease are most infectious, but even during the long period of latency people can still transmit the disease.

 
However, a growing body of observational evidence from discordant couples and informed scientific modeling has reinforced the idea that treating HIV so-as to reduce the viral load to undetectable levels could have a dramatic impact in reducing the risk of transmission.  This evidence is so compelling that WHO has undertaken to explore the benefits of treatment-as-prevention more rigorously, and there is already a consensus that treatment could be the next major prevention tool, though efforts at positive prevention will need to continue as patients live much longer lives with at least some residual degree of infectivity.

Attacking AIDS Treatment:  Playing the Blame Game

 
Despite the multiple benefits of expanded AIDS programming and treatment described above and the costs of inaction and flat-funding, academic, global health, and political analysts, including Zeke Emmanuel, have been lining up to argue that treatment is not cost effective, that HIV prevention has been neglected because of AIDS treatment, that AIDS exceptionalism has caused underfunding and inattention to other more compelling and more affordable health needs, and that the response to AIDS has distorted and undermined health systems in developing countries.

To the contrary, treating AIDS has been shown on multiple occasions to be cost effective even under the parsimonious metric used by mainstream health economists.  It’s not the cheapest investment in health, but it preserves the life of young adults, an absolutely critical demographic in any society.  This is the age group that is most economically productive.  It is the age group that ordinarily raises children and cares for elders. Remove it from Africa and you leave hollowed families and communities in the wake.

 
Pitting treatment versus prevention has been an old canard since the beginning of treatment access. Least we forget, under World Bank policy advice prioritizing prevention and cost-effectiveness, treatment was excluded as an even remote possibility for developing countries throughout the 1990s, the time period when the pandemic escalated at its fastest pace. However, many AIDS-proactive countries like Brazil, Thailand, Australia and Senegal invested heavily and broadly in prevention even as they simultaneously and later introduced treatment, and there is no reason other countries and funders can’t do the same. Likewise, there is nothing in promoting AIDS treatment that undermines or is contradictory to expanded investments in comprehensive prevention targeting the local dynamics of the disease.  Indeed, prevention has not been undermined by treatment – it has been undermined by a myopic moralism that disregards human rights and eschews targeting prevention measures to young people and key populations including men who have sex with men, sex workers, and injecting drug users.  This warped, pseudo-prevention ideology rejects comprehensive sex education, widespread availability of male and female condoms, effective birth control, needle-exchange and methadone substitution.

 
Contrary to the pundits’ blame game, compelling health needs in developing countries have been neglected for decades.  For example, despite the Alma Ata Declaration and the commitment to Primary Care for All by 2000, donor countries refused in invest in comprehensive health programming in developing countries in the 1980’s and 90’s. Instead, they promoted and adopted the selective primary care interventions advocated by the World Bank and then did many of those interventions in a half-hearted way.  At the same time, they allowed the Bank’s partner, the International Monetary Fund, to impose structural adjustments that resulted in disinvestments in health infrastructure, health systems, and health personnel and that resulted in privatization of health care delivery and the imposition of user-fees and other cost-recovery measures.  All of this neglect to child and maternal health, to sexual and reproductive health, and to primary care more broadly occurred long before the intensification of the AIDS pandemic and long before the expansion of its funding.

Creating competition between maternal and child health, sexual and reproductive health, and AIDS is particularly disingenuous considering how closely linked they all truly are. AIDS is the number 1 killer of women of child-bearing age worldwide and a leading killer of children in Africa.  AIDS activists, along with other SHR activists, have been at the forefront of promoting sexual and reproductive health and addressing the gender dynamics of the pandemic. They have demanded treatment for sexually transmitted diseases, have advocated for access to reproductive technologies, and have promoted circumcision as a viable prevention measure.  AIDS activists are not against funding for deworming children, for reconstitutive fluids, or for inoculations.  These simple and cost effective interventions are not undermined or countermanded by AIDS; they are neglected because of donor stinginess and inadequate investments in health by countries themselves.

 
Finally, as discussed briefly above, evidence that the response to AIDS has undermined and distorted health systems is weak at best.  True, AIDS programming via multiple donor-controlled initiatives has produced undesirable transaction costs for countries.  Likewise, there is some evidence that the demand for AIDS-trained health workers has caused some internal brain drain in some countries.  In addition, there are clearly examples where public sector strengthening has been sacrificed on the altar of expediency through creation of parallel systems and use of international NGOs.  But all of these negative effects must be weighed against the benefits of AIDS programming and the prospects of even greater positive synergies as programs and funding evolve in the future.

 
There’s not enough money – the most implausible excuse

 
Underlying almost all of the attacks on AIDS are claims about limited resources. Expanded treatment is alleged to create an unaffordable international entitlement and a treatment mortgage that will be unsustainable for rich economies.  Because the U.S. is in the middle of financial crisis and because costs must be contained, the economic pragmatists urge a period of restraint or even scale-back in AIDS funding.

 
World AIDS day occurs on December 1, and that same evening President Obama announced a 30,000 troop surge in Afghanistan that will cost $30 billion in the short term and much more in the long term. This is, of course, on top of an already bloated military budget of nearly $515 billion in 2009.  Rich governments argue collectively argue that they cannot come up with $10 billion more for AIDS and another $25 billion for other global health needs, the bare minimums they have previously promised, yet they came up with trillions of dollars, euros, and pounds to bail out bankers and rich elites who speculated their way to a financial crisis that taxpayers have to pay for.   The idea that there is not enough money for global AIDS is laughable.  A simple .005% levy on major currency transactions would raise $33 billion a year and a similar but broader levy on all financial transactions could raise hundreds of billions a year ($690 billion at a .05% rate).

 
The issue isn’t the sufficiency of resources, but where existing resources go.  Certain political and economic elites feel comfortable turning their back on AIDS treatment, creating false debates, and hoarding their obscene wealth and privilege while others die for lack of medicines that cost only $80 a year. President Obama must act to fulfill the promise of a revitalized PEPFAR program that has planned many shrewd improvement for its second five years.   He should make sure that partners lead in planning, that the U.S. resources build broader and more durable health care capacity, that additional compelling health needs are addressed, that the health workforce is expanded, and that efficiencies are realized.  But, he cannot and should not turn his back on treatment nor should he imagine that insufficient resources can somehow magically be turned into the promise of Universal Access. 

Engaging in magical thinking about resources and wishing people well will not stop the crash of immune systems in untreated patients.  Untreated, our brothers and sisters will die, often in the prime of life, leaving vulnerable children, grieving parents, and depopulated communities behind.  The demand of AIDS activists is clear – if there is enough money for war and enough for bailing out bankers, there’s more than enough to save the 11 million lives that will otherwise be lost if the flat-funding continues and if PEPFAR’s treatment goals are kept artificially low at 4 million.  If instead, the U.S. signals its ongoing commitment to treat its fair share, 6 million by the end of 2013 and more millions thereafter, it will provide leadership for other countries to follow.   If FY-2011 appropriations reach $7.25 billion instead of zero growth, the U.S. would be on track to reach that target.  If it increases its financial commitment to its new Global Health Initiative from $63 to $95 billion over six years, as recommended by many health advocates, it can help achieve all of the health-related Millennium Development Goals.  With these modest and pragmatic changes, the delayed goal of Universal Access to comprehensive HIV/AIDS prevention, treatment, and care will be reached.

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Reuben M Granichet al., Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model, 373 Lancet 48-57 (Jan. 3, 2009) http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673608616979.pdf?id=9d3ded37aa4dcc76:-ced7b81:12338a96449:534e1250791687161. Derek Thaczuk & Michael Carter, Antiretroviral treatment lowers rates of HIV transmission in heterosexual couples in Africa, Aidsmap News (Feb. 10, 2009).  http://www.aidsmap.com/en/news/EE59A107-93DF-4B9B-AE5E-5E86DF018B41.asp?type=preview. Granich R., Crowley S., Vitoria M. et al.  2010.  Highly active antiretroviral treatment for the prevention of HIV transmission.  AIDS.  13:1 online.  Available at http://www.jiasociety.org/content/13/1/1 .

See, WHO, Antiretroviral Therapy for HIV Prevention (2009). Available at http://www.who.int/hiv/topics/artforprevention/en/.

Denny, C., and Emanuel, E.  US Health Aid beyond PEPFAR:  The Mother and Child Campaign.  300 JAMA 17: 2048-2051 (2008).  Available athttp://jama.ama-assn.org/cgi/reprint/300/17/2048. Brock, D., and Wikler, D.  Ethical Challenges in Long-Term Funding for HIV/AIDS.  28 Health Affairs (6):1666-1676 (2009). Available athttp://content.healthaffairs.org/cgi/reprint/28/6/1666. England, R.  Are we spending too much on HIV? – Yes. 334 BMJ 344 (2007). Available athttp://www.bmj.com/cgi/reprint/334/7589/344. Garrett, L.  The wrong way to fight AIDS.  New York Times (2008). Available athttp://www.nytimes.com/2008/07/30/opinion/30iht-edgarrett.1.14888763.html. Halperin, D. Putting a Plague in Perspective. New York Times (2008). Available athttp://www.nytimes.com/2008/01/01/opinion/01halperin.html?_r=1&scp=3&sq=%22a+plague+in+perspective%22&st=nyt. Lamptey, P.  Think Africa’s Disease Burden is HIV?  Think Again.  Global Health (2009). Available athttp://www.globalhealthmagazine.com/top_stories/think_hiv_is_africas_disease_burden_think_again. Marchal, B., Cavalli, A., and Kegels, G.  Global Health Actors Claims to Support Health System Strengthening – Is This Reality or Rhetoric?.  6 PLoS Medicine 4:31000059 (2009). Available athttp://www.plosmedicine.org/article/info:doi%2F10.1371%2Fjournal.pmed.1000059.

See e.g., Sue J. Goldie, et al., Cost-Effectiveness of HIV Treatment in Resource-Poor Settings — The Case of Côte d'Ivoire, 355 N.E.J. Med. 1141-1153 (2006).  Available at http://content.nejm.org/cgi/reprint/355/11/1141.pdf.

World Bank, Confronting AIDS: public priorities in a global epidemic (1997).

Italian Global Health Watch, From Alma Ata to the Global Fund:  The History of International Health Policy, 3 Social Medicine 36-48 (2008).  Available at http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/article/view/186/380.

Rick Rowden.  The Deadly Ideas of Neoliberalism:  How the IMF has Undermined Public Health and the Fight Against AIDS (Zed Books 2009).

WHO, Women and health: today's evidence tomorrow's agenda (2009).  Available at http://whqlibdoc.who.int/publications/2009/9789241563857_eng.pdf.

Robert Hecht et al.  Putting it all together:  AIDS and the Millennium Development Goals, 3 PLoS Medicine e455 (2006). Available at http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030455.

Biesma, R., et al. The effects of global health initiatives on country health systems:  a review of the evidence from HIV/AIDS control. 24 Health Policy and Planning 239-252 (2009).  Available at http://heapol.oxfordjournals.org/cgi/reprint/24/4/239

Mead Over, Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It.  Center for Global Development, Washington, DC, 2008.  Available athttp://www.cgdev.org/content/publications/detail/15973.

Carole Lochheed, Obama Adding 30,000 Troops to Afghanistan.  SF Chronicle (December 2, 2009).  Available at http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/12/01/MNPV1ATAMA.DTL.

Kathleen Pender, Government Bailout Reaches $8.5 Trillion, SF Chronicle (Nov. 26, 2008).  Available at http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/11/26/MNVN14C8QR.DTL.

Rodney Schmidt, The Currency Transaction Tax:  Rates and Revenue Estimates (United Nations University Press 2008).  Available at http://www.unu.edu/unupress/sample-chapters/currency_transaction_tax_web.pdf

Stephan Schulmeister, A General Financial Transaction Tax:  A Short Cut of the Pros, the Cons

and a Proposal, WFO Working Paper 344 (2009).  Available at http://www.wifo.ac.at/wwa/servlet/wwa.upload.DownloadServlet/bdoc/WP_2009_344$.PDF.

Letter to Ambassador Eric Goosby on Recommendations for US Treatment Target.  October 15, 2009.  Available at www.idsaglobalhealth.org/WorkArea//DownloadAsset.aspx?id=15447.

The Future of Global Health: Ingredients for a Bold and Effective Initiative. 2009.  Available at http://www.theglobalhealthinitiative.org/documents/report.pdf.   Institute of Medicine of the National Academies.  The U.S. Commitment to Global Health:  Recommendations for the Public and Private Sectors (2009).

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