Simon Mphuka, the Executive Director of the Churches Health Association of Zambia (CHAZ) and a good friend of the Center for Global Development (CGD), passed away on Monday, August 4th. The world, and particularly Zambia, has lost a skilled physician and public health professional, and above all, a man of faith and passion who worked tirelessly to battle AIDS in Zambia. My thoughts are with his wife and three daughters, who so generously shared Simon with many of us in the global health and development world. The world is poorer without Simon, but his dedication and commitment to saving lives will endure and will continue to enrich our efforts in the fight against AIDS.

I was expecting to see Simon in Mexico City at the International AIDS Conference, where he had kindly agreed to participate in an HIV/AIDS Monitor event on AIDS funding and health systems, so I was shocked and deeply saddened by this news. I had the great pleasure of getting to know Simon over the last few years as we developed the HIV/AIDS Monitor research initiative at CGD. Simon was an important member of the Global Fund Working Group and a key member of the advisory group for the HIV/AIDS Monitor. I will miss his sharp and real, on-the-ground insight about the Global Fund and PEPFAR donor programs, as the head of an important recipient of funding from both. Forever congenial, but never concessional, Simon spoke knowledgeably about what was working and not working in the fight against AIDS in Zambia and ways in which donors could improve their policies and practices.

I knew Simon only as a professional colleague/friend, but Pastor Conrad Mbewe of the church that Simon belonged to has written a very personal and moving account of Simon's life as an active member of his church and about the last few weeks off his life before his sudden demise and another about the funeral proceedings.

The author, Yazeed Kamaldien, seems to find solace in the fact that "these drugs are used only to treat primary TB, however, and not other cases, such as multi-resistant TB." He appears to completely misunderstand a primary cause of MDR-TB (multi-drug resistant TB) and drug resistance in general. While he is correct to breathe a sigh of relief that this discovery will, hopefully, not cause any MDR-TB cases to become the virtually untreatable XDR-TB (extremely-drug resistant TB), episodes such as this undoubtedly increase the risk of resistance among uncomplicated, primary TB patients. As MDR-TB can cost up to 300 times as much (in time, money and human resources) to treat as primary TB, these errors can put incredible strain on an already weak health system.

In sharp contrast to the biomedical and pharmacological advances, though, the science of implementation of large-scale programs is far less developed. We have relatively little solid evidence to go on to ensure that the billions of donor dollars on offer are going to bring about the greatest individual and social benefit, with the fewest costs to nations' ability to deal with other health priorities. Instead of findings from systematic study, for the most part we are left with common sense, instinct and belief, shaped by the occasional compelling anecdote or observational study.

The early "emergency"-oriented nature of PEPFAR, which eschewed "the R word" (research), did little to fill the knowledge gaps. As the Institute of Medicine noted in its 2007 assessment of PEPFAR's performance, "There are still more questions than answers about how to best provide ART" in low-income, high-burden countries. And the paucity of knowledge about the effects of PEPFAR's HIV prevention efforts has been even more profound – and more lethal.

Since the Stockholm conference in 1988, which was the fourth ever held, I have attended almost all of these international conferences and a substantial number of the regional conferences in between. During the early conferences, most attention was on HIV prevention with only the most specialized medical researchers and activists from the rich countries talking about treatment. Then as triple-drug therapy was developed and improved, attention turned towards extending access to poor countries. In 1997, when Martha Ainsworth and I launched our book on the economics of AIDS at the African AIDS conference in Abidjan, effective treatment still cost $20,000 or more per patient-year with only about a 50% price reduction in Thailand and Brazil. So our book's major message was that efficiency, equity and public health arguments all compellingly converged to support government action to prevent HIV infection, especially among those most likely to contract and transmit the epidemic. Our message on treatment was one of horizontal equity. Countries should subsidize AIDS treatment to the same degree they subsidized the treatment of equally expensive chronic adult illness. These two messages were and have been very unpopular. Indeed, ACTUP and other activist groups sometimes marched through the auditorium chanting hostile slogans when I was on the list of speakers. Even the World Bank turned its back on the first of our messages.

Now, 20 years after I attended my first AIDS conference and 11 years after the launch of Confronting AIDS, I think I detect a movement towards both of our 1997 messages. On treatment, after worldwide efforts have substantially lowered treatment costs and expanded access, there are now calls (including here at the Mexico conference) for horizontal equity between AIDS and other diseases within developing country health sectors, but the more dramatic change is on prevention.

The PEPFAR reauthorization bill, now signed by President Bush, is historic for several reasons. In our last blog we addressed the implicit entitlements to treatment confirmed by this bill. Today we discuss the role that unit cost measurement is mandated to play in determining the targets set for future administration performance.

This may be the first time in history that any government has mandated performance targets based on estimates of the unit costs of meeting those targets. The language of the bill says: "the treatment goal...shall be increased...by the same percentage that the average US Government cost per patient...has decreased ..." [Sec 403(3)(d)(3)].

Does the new AIDS bill constitute recognition that AIDS treatment has become a de facto "entitlement"? If so, will AIDS continue to be exceptional in this respect -- or will Americans and the citizens of other relatively rich countries increasingly be willing to accept that the recipients of their assistance are "entitled" to its continuation.

The US congress passed last week and has sent to President Bush for signature the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act (H.R. 5501). This bill extends the US commitment to treat foreign AIDS patients by doubling the time period (from 5 years since 2003 to 10 years) and increases the target number of patients to be enrolled in treatment from 1.73 now to 2 or more million in five years.

After months of wrangling, the U.S. Senate last night finally passed legislation to reauthorize the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. global AIDS program that has been allocated nearly $19 billion over its first 5 years. The bill authorizes spending $48 billion for the next 5 years, including approximately $5 billion for malaria and $4 billion for tuberculosis. Contributions to the Global Fund will amount to about $2 billion per year. With Senate passage, it appears likely that the bill could be signed into law by President Bush within days.

While the increase in funding is welcome, Congress has missed a prime opportunity to improve PEPFAR by responding to the growing body of evidence from the last few years on what's working and what's not. Instead, several policies that research has shown to limit the program's effectiveness remain in place. There are even some new provisions that could further confuse the way PEPFAR does business. One bright spot is the bill's commitment to increase PEPFAR's role in addressing the African health worker crisis and the requirement for an impact evaluation of PEPFAR this time around. Some of the most salient issues arising from the new bill include: failure to completely remove restrictive funding earmarks; failure to improve prevention efforts; a muddled treatment target; a mixed bag on gender; but a step forward on health workers and evaluating the impact of PEPFAR.

Stay tuned for a series of blog posts from CGD's health team elaborating on the issues raised above.

We begin the series today with a short analysis on the issue of earmarks:

Is the surge of AIDS money strengthening national health systems? Or is it weakening them by pouring disproportionate funds into systems that target one disease - while neglecting others?

Some of the effort of responders is devoted to demonstrating that the effects of AIDS are worse than its burden of disease would indicate. This effort to justify donor spending on AIDS seems futile, since the same is true of many other diseases, including tuberculosis, motor vehicle deaths, smoking caused disease, etc. (In any case, the cost-effectiveness of public spending should play a larger role than the total burden of disease in guiding the allocation of public health spending). Much of the rest of this prodigious rhetorical effort asserts that AIDS spending is really helping, not harming, the rest of the health sector.

If Roger England's assertion that AIDS spending harms the health sector could have been refuted by data, one of those posting would have cited such data and the others would not have felt the need to post. The problem is that we really don't know, in any general way, what the extraordinary scale-up of AIDS spending has done to other parts of the health sector.

[For previous discussion of this issue on our blog, look here, here, and here]

An interview I had last November with the nurse who was responsible for managing a health center in Western Kenya is perhaps revealing. His district health center had tripled in size due to the addition of a clinic, lab, waiting and storage space for treating AIDS patients and for warehousing the fresh produce, cooking oil, flour and other groceries given to supplement the diets of many AIDS patients. The staff nominally reporting to him had increased by several young physicians, who had received special training in AIDS case management.

The authors sum up their results with this:

So I urge the Senate to work to resolve the impasse and quickly reauthorize PEPFAR.

That said, I believe that the pause engendered by this hold can be used to improve the PEPFAR reauthorization bill. I suggest that the Senate consider the following three improvements:

One person characterizes the paper as saying that donors should "improve our efforts in prevention, and avoid ART financing." Another person feels that the title of the paper places treatment and prevention too much in competition and might lead to slower increases, if not reductions, in AIDS treatment funding. Both seem to feel that the paper exaggerates the trade-off between treatment and prevention - to the disadvantage of treatment.

In fact, I do not argue for the avoidance of ART financing, only for a clear recognition that it entails a permanent, lifetime commitment to the individual patients who receive treatment. I hope that my article helps to assure that donors who start patients on AIDS treatment in 2008 and 2009 never subsequently drop their patients for lack of budget or political will. I also urge that an increasing share of US funding for these patients be routed through multilateral institutions like the Global Fund or the development banks, in order to dilute what is otherwise an extreme form of dependency of patients and their home countries on a single donor country, namely the U.S.

Since I am a member of the research team, it's not surprising that I think this is a good idea. Although no one knows whether the idea can be shown to work in the proposed Tanzanian location or elsewhere, there are reasons to be optimistic.

First, so-called "conditional cash transfers" have previously been shown to be successful in changing health-related behaviors and improving health. For example, in Mexico's Progresa program (See the CGD evaluation in Millions Saved) cash grants conditional on a poor family's preventive health visits are associated with improved health of the family, adults and children alike.