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Shift tactics in AIDS battle

The Baltimore Sun

Saturday is World AIDS Day, and we Americans should be proud of what our country has achieved in the fight against AIDS. But we also should be improving our efforts.

The President's Emergency Plan for AIDS Relief (PEPFAR), a $15 billion program, has supported the care of 2.4 million people with AIDS, saving them from certain death. President Bush's initiative and the American people's generosity should be commended. Having met South Africans and Ugandans who are alive because of the program, I have seen firsthand the difference PEPFAR is making.

Almost five years into its lifesaving mission in sub-Saharan Africa, PEPFAR is due for reauthorization by Congress. This presents a great opportunity to increase PEPFAR's strengths and move the program beyond its initial triage approach and into a second phase that builds for the future.

Where does PEPFAR fall short? First, it is not creating a public health or clinical care infrastructure. If the program ends, its staff will pack up and go home. The United States needs to do a better job of leveraging PEPFAR to create health care systems that will improve the health of Africans, regardless of their HIV status. Upon its demise, PEPFAR should leave countries better equipped than when it started.

Second, PEPFAR is not spending taxpayer dollars wisely. About 7 percent of PEPFAR funding goes to abstinence-based programs. According to the Institute of Medicine, there is no evidence that abstinence-based interventions prevent transmission of HIV. If the American people are going to donate billions of dollars to save lives in Africa, they - and the Africans whom PEPFAR is charged to help - deserve a program that is as efficient and effective as possible.

Third, it does not support research. PEPFAR is the equivalent of an emergency relief airdrop. That's important when you have an immediate crisis, when people are dying. But HIV/AIDS is not a short-term challenge. We must start thinking about the long term. We need to know that the drugs are getting to the right places, that the treatment protocols are not leading to drug resistance, that optimal drug distribution methods are being employed, and so on.

The HIV crisis in sub-Saharan Africa exists because of social, economic and political issues - one symptom of which is a lack of functioning and equitable health care systems. Most countries there have dismal health problems besides HIV. Additionally, because PEPFAR pays its staff well, it has created an internal "brain drain," drawing skilled workers away from primary care and other sectors of the health system. Also, as countries develop economically, they have to prepare for the "epidemiologic transition" - the shift from infectious diseases such as cholera to chronic diseases such as hypertension that are common in developed countries.

To help them survive this double-whammy of disease, we need to assist in the creation of a health care infrastructure. Since health care systems must be led by local people, we need to train pharmacists, nurses, physicians and epidemiologists in order to secure population-wide health.

President Bush has proposed doubling the PEPFAR budget to $30 billion. A modest reallocation of funds can achieve drastic results in African health. Here's what I propose:

Two percent of the budget should fund research to investigate the effect of PEPFAR's HIV therapy on the spread of HIV and on drug resistance, and to test new drug regimens.

Two percent should fund health services research to explore new and effective ways of building health systems in the developing world. Such systems should lay the foundation for confronting other serious health issues, such as neonatal and maternal mortality and the coming epidemic of chronic disease.

Two percent should fund the education and training of Africans in public health, medical and allied health fields because, ultimately, Africa's problems can only be solved by Africans.

In all, this 6 percent of the $30 billion proposed by the president for the next phase of PEPFAR would be $1.8 billion. Taking this small percentage from the abstinence portion of PEPFAR monies would not reduce drug delivery. The National Institutes of Health's Fogarty International Center can administer these initiatives because it has the mechanisms to peer-review proposals, monitor programs and evaluate results.

With PEPFAR, our country and our president have decided to do something very generous. Now, let's do it right.

Dr. Michael J. Klag is dean of the Johns Hopkins Bloomberg School of Public Health. His e-mail is mklag@jhsph.edu.

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