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Brook K. Baker and Donna J. Barry

An express line for AIDS treatment

By Brook K. Baker and Donna J. Barry
December 7, 2009

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HAVE YOU ever waited in line for a long time for something you didn’t just want but desperately needed? Have you ever faced the prospect of dying in line while you waited? Have you ever wondered which of the people near the front of the line will be chosen to start life-saving treatment?

Progress on HIV/AIDS prevention, treatment, and care is plateauing as the newly reauthorized President’s Emergency Plan for AIDS Relief is flat-funded and as the Global Fund to Fight AIDS, Tuberculosis, and Malaria begins to ration resources, with its coffers running low. While people living with HIV/AIDS are celebrating recent UNAIDS reports estimating that 4 million people were on treatment at the end of 2008, a 10-fold increase in five years, some health workers in Africa are being told that they can no longer start new patients on antiretroviral therapy because that treatment is capped at the current figure.

Africans 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 prospect of life-saving medicines and a return to work and parenting responsibilities, millions of people are learning their HIV status. Just when testing trends are so positive, when the costs of medicines have plummeted to historic lows, and when science shows that treatment reduces the risk of HIV transmission, funding is being capped both by donor countries and their developing country partners.

People have begun to stand in line in South Africa and in Uganda. They are being asked to wait until a person undergoing treatment dies or is lost to care. Those who arrive in wheelbarrows, on the brink of death, will die first unless they are rushed to the front of the line, thereby postponing treatment for others whose prospects are greatly enhanced if they start treatment while their immune systems still function.

Mothers in line will wonder: Should I begin treatment in order to reduce the risk of transmission to my newborn from 30 percent to 2 percent, or should I grant my place in the line to an already infected baby who has a 50 percent chance of dying before age 2 unless treated? Will husbands and wives or brothers and sisters flip coins? Or will the czars of rationing provide treatment slots for health workers, many of whom are HIV-infected and all of whom provide essential care within beleaguered health systems that have lost trained personnel to wealthier countries?

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 in 2000 via the Millennium Development Goals, thereafter ratified in 2001 via a UN General Assembly Declaration of Commitment. At the UN General Assembly in 2006, countries promised to work toward what we now call universal access by 2010. In successive Group of Eight meetings since 2005, countries, including the United States, have committed to universal access, promising to provide resources through bilateral and multilateral channels, including the Global Fund.

These commitments have been echoed in the United States where, during the 2008 presidential campaign, Barack Obama, Joe Biden, and Hillary Rodham Clinton, all promised to spend $50 billion on global AIDS programming from 2009 to 2013, a promise that was codified in the $48 billion reauthorization of the President’s Emergency Plan for AIDS Relief that they voted for in the Senate that summer.

These promises have not been met. The US budget proposal for fiscal 2010 flat-lines global AIDS and rumors are that fiscal 2011 will do the same. More than 10 million people needing treatment under new WHO guidelines are still without medicines and 3 million more join the queue each year. Although the United States has added 1.6 million patients to its revised five-year treatment target, the world is only 30 percent of the way toward universal access treatment and prevention goals.

What we need now is bold leadership and fulfilled promises from Washington to increase AIDS funding and continue saving lives, not longer lines filled with despair.

Brook K. Baker is cochairman of the Health GAP board and a professor at Northeastern University School of Law. Donna J. Barry is the advocacy and policy director at Partners In Health.

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