MSF Teleconference: 'No Time to Quit?AIDS Treatment Gap Widening in Africa'

Emi MacLean, U.S. Director of the Access to Essential Medicines Campaign at Doctors Without Borders/Medecins Sans Frontieres (MSF), Mit Philips, health and policy analyst at MSF, Dr. Eric Goemaere, medical coordinator for MSF in South Africa and Jimmy Gideyi, a person living with HIV in Nairobi, Kenya, take part in a teleconference on the international community’s retreat from funding HIV/AIDS treatment worldwide.

Sandra Murillo: Good morning everyone. My name is Sandra Murillo and welcome to the Doctors Without Borders/Médecins Sans Frontières (MSF) press teleconference on the global retreat from HIV/AIDS treatment funding.  Today we are launching a report titled "No Time to Quit: AIDS Treatment Gap Widening in Africa," an analysis of external support for a scale-up of ART (anti-retroviral therapy) in Malawi, Mozambique, Zimbabwe, South Africa, Lesotho, Kenya, Uganda and Democratic Republic of Congo. On the call today are Emi MacLean, U.S. Director of the Access to Essential Medicines Campaign, at Doctors Without Borders, Dr. Eric Goemaere, Medical Coordinator of the MSF program in South Africa and Jimmy Gideyi, a person living with HIV receiving care and currently on antiretrovirals in Kenya. Emi MacLean will begin the teleconference and provide an overview and some of the key findings of the report. Dr. Goemaere will then speak about his ten years of experience with MSF HIV/AIDS care and treatment in Southern Africa. Jimmy Gideyi will talk about this issue from a patient perspective. Dr. Mit Philips, health policy analyst at Doctors Without Borders, and one of the authors of the report, is also here to answer your questions. Thank you. Emi?

Emi MacLean: Good morning everyone, and thank you for joining us. MSF has been involved with providing care and treatment for HIV/AIDS for a decade now. We now provide treatment to over 140,000 people in thirty countries. We've been able to scale up treatment, in some contexts treating large numbers of patients, in other contexts, providing treatment for smaller and particularly vulnerable populations. We've re-committed to the HIV care and treatment of the populations that we work with because we recognize that HIV/AIDS continues to be an emergency, and we see the provision of life-saving anti-retroviral treatment as particularly at risk at this juncture. The last years have shown unprecedented success. There are 4 million people alive on treatment today in developing countries. This simply would not have happened without the support of international donors.

And these people, hit by this disease in the prime of their lives, would not be alive without treatment. The scale-up of prevention of mother-to-child transmission programs has also made significant strides in reducing pediatric HIV. Quite simply, we're beginning to see a meaningful response to a devastating pandemic that continues to ravage many of the poorest countries of the world. For the past year, we at MSF have become increasingly alarmed by how the HIV/AIDS treatment landscape is shifting. The global fund, and the countries that fund it, the U.S. bilateral PEPFAR program, UNITAID and the World Bank are all beginning to retreat from their commitments to the global HIV response. We have seen the trajectory over the last decade, and we are afraid of going back to the time of more rationed care and treatment. Patients have come forward to get tested, we've rightly given them the expectation that treatment will be available for them when they need it, and we cannot go back.

So what is the changed funding environment? The Global Fund is facing a severe shortfall in funds to meet the demand with various countries, including the U.S., announcing a reduction of contributions to the Fund. The funding limitation threatens a core principle of the Global Fund: that demand of countries and quality of proposals will drive funding choices. After years of PEPFAR's expansion, the White House has a flatlined budget in 2011, which would be the third year in a row. Some EU countries are also scaling back their contributions. And UNITAID and its grantee, the Clinton Health Access Initiative, are phasing out funding of key HIV drugs and commodities. UNITAID and CHAI, the Clinton initiative, have been critical in ensuring that pediatric and second-line AIDS medicines reach populations in need. The report that we released today details new information from the ground in the countries where we work.

As a medical organization with a combined 120,000 patients on anti-retroviral treatments in the eight countries identified in the report, we began this analysis out of a concern for the patients under our care. Because of a growing barrage of stories of more limited treatment availability, and because we recognize an increase in incidents where MSF was asked to come in to provide emergency ARV supplies, in Malawi, Zimbabwe, the Democratic Republic of Congo and Uganda, we are reaching deeper and more often into our emergency buffer stock of medicine in various countries than we have had to in the past. This is based on developments witnessed by MSF teams in the field. This report should not be read as an authoritative account of various global initiatives, nor is it a description or critique of global AIDS architecture. Rather, it's a description of anecdotal evidence that we have at this juncture, that for us serves as a warning of the potential for systemwide problems that may be deeper and broader if there is not a change in direction.

So what are we witnessing on the ground? Our teams in South Africa and Uganda report patients are being shuffled around from one clinic to another because of limited treatment slots. There are now new waiting lists and doctors and nurses facing the agonizing choice of which patients they should treat: the patient who arrives very sick, with late-stage AIDS, or the patient not yet sick but who needs AIDS treatment and will get sick quickly without it. Patients are not starting treatment when they need to, from reports from our teams in Zimbabwe, South Africa and Uganda. A letter from the U.S. Centers for Disease Control in Uganda to PEPFAR implementing partners suggests that rationing be to, "the sickest patients, eligible pregnant women, children, TB/HIV patients and family members of persons on ART." This rationing of treatment moves programs backwards rather than forwards, with patients targeted for treatment later, even though the science and the medical advice is unanimous that treatment should start earlier.

Funding for recurrent costs associated with AIDS/HIV care is in jeopardy, such as drugs for opportunistic infections, laboratory tests and ARVs. MSF staff in Mozambique, for instance, were told by the U.S. embassy that PEPFAR intended to reduce the purchase of commodities by 10 to 15% over each of the next four years. The anticipated withdrawal of UNITAID and CHAI, the Clinton initiative, from the purchase of pediatric and second-line AIDS medicines places those particularly vulnerable populations at ever greater risk. And the World Bank is re-focusing on capacity-building and health-system strengthening, but stepping back from funding drugs and medical supplies. Countries are not implementing the World Health Organization guidelines calling for earlier treatment with better medicines and the best chance to reduce mother-to-child transmission. And there are some reports of early signs of a negative impact on prevention and testing as well.

A major PEPFAR implementer in Uganda reported reducing HIV testing efforts, in keeping with the reduced provision of ART. They simply cannot guarantee that those who test positive and are in need of treatment will be able to get it, so they cut or limit the opportunity to test each week. At this point, I will open up to Dr. Goemaere, who can discuss how South Africa's national program is struggling to meet the needs of the world's largest population of people on ARVs and people in need of treatment, and the reality on the ground in Southern Africa. Thank you.

Eric Goemaere: Thank you, Emi. Good morning everyone. My name is Eric, and I'm talking to you from Johannesburg. I think that, from a clinical perspective, it raises some major questions. The first question would be will we be forced to go back in time and fight an ongoing uphill battle like Sisyphus, forever. And it reminds me of, we started ten years ago, in a program we started here in Khayelitscha where 50% of our patients were at less than 50 CD4 count, they had no immune system any more. They were brought in to the clinic in a stretcher. We recorded in that time about 20% mortality after starting on ARV. And it took us a hell of a long time to stabilize them before we could even start treatment.

This meant high burden on doctors, mostly hospital bed care, and difficult patient management. With time we've seen the reality, new MSF programs in the region. We've seen slowly the baseline CD4 count going up. It means we are catching up on this backlog of very severe patients. Nowadays. it's as an average, all over the place, certainly above 100 CD4 count. As a result, we see that the mortality went down to around 5% after initiation, mostly it allowed for an increased enrollment. Certainly, things started to go at scale. To give you an example, we recruited 400 new patients in Khayelitscha in 2003, and last year in 2009, we recruited 4,000 new patients. Where the difference comes from, it comes from the fact that, as I said, it was much easier, but also that the patient could be now initiated in every single clinic and initiated by nurses, which multiplies your capacity multiple-fold.

Going to primary care brings another advantage. As we all know, primary care clinics are the pillar of most public health services in Africa. And it makes, then, the whole debate about supporting vertically HIV rather than supporting the health service completelyirrelevant because inevitably when you support the clinic, you support it in all its aspects. It brought an enormous advantage to the patient because bringing the treatment process to the patient's home of course increases their confidence, increases the enrollment, lowers lost to follow up and allows us to give them treatment for much longer. At population level, we measure nowadays in those project where we have a high impact. We measure not only an HIV-related mortality, that's the first impact that we can see there, but the entire area, and this is typically the case in Thyolo in Malawi, or in Khayelitscha we see the entire HIV-related mortality going down, which includes of course the maternal mortality and the pediatric mortality.

So, there again, in the whole region, there is substantial evidence to say that more than 50% of the prenatal maternal mortality is due to HIV. Everybody knows that the best way to reduce that mortality is actually to treat pregnant women with anti-retrovirals. And this dichotomic debate, either/or, does not make sense in our perspective. Furthermore, we see reduction at population level of the TB incidence very interesting, and even though this [is] in a high-coverage area, we see a reduction of the HIV incidence because probably we have reduced the population threshold of HIV. This brings us to a substantial success story.

This brings us to a second question which is, I would phrase it as, is it rational to ration care as it is proposed by different countries nowadays because of the reduction in funding? The message that is sent around is for government to look back at the targets and probably reduce the ambition because, of course, when they decide what they will afford by all means, this is top failure which it is the worst-case scenario. We enter into yet again a discrepancy between the WHO's latest recommendations, which very clearly are speaking about initiating patients not only at 200 CD4 count but at 350, and it is already since two years now, and switching from a relatively toxic drug like D4T to a tenofovir containing regimen, well, actually, it's presented as a rational choice.

We have evidence that just came up from a study we did in Lesotho, and will be presented [at the] Vienna International AIDS [Society] conference that [compares] patients started below 200 CD4 and patients started between 200 and 350 [i.e., those who initiated treatment earlier]. We measured actually a difference of 60% in mortality, [with those initiating treatment below 200] 60% [more likely to] need hospitalization, and [with those initiating treatment earlier] 40% [less likely to be] lost to follow up. 

So this is all a standard of care, backed by wide evidence, and what's happening today, is that we are walking back into double standards, because there is no money. Something we promised the whole world not to do when we started anti-retroviral treatment.

The third question it raised for me is will we one day have to look back in time and see that the 2001 decade was the golden age for the fight against HIV? Why so? Because as presented by Emi, actually, in the beginning of the 2000s, the whole public discourse was to say those drugs are not affordable. We did, with lots of organizations, a huge battle to reduce the price of anti-retroviral treatment thanks to generic competition and bring it down so that in South Africa it was, when we started here, $6000 US per person per year. And nowadays, a D4T containing regimen is around $100 US per person per year.

Literally, we managed to melt the price down. So the question was not any more about affordability and it brought us to this [which] we hope [was] not illusion in 2005, with the G8 committed to universal treatment if countries can provide service. It was clearly set and promised. And actually, today 2010, already since 2009, this discourse has changed into ‘is universal treatment really affordable?’ So the question then is, are we going back into the discussion that we faced at the beginning of this decade?  Back into this nonsense discussion like, [asking] ‘is it not better to do prevention than treatment?’, opposing both, while it's obvious, it has been shown, that the two go together.

So my last question would be, that comes to mind, how can we guarantee a long-term political commitment and funding for this kind of program because usually [these programs] are lifelong . Some years ago, messages to governments in the region were unambiguous. They were told, and they were at that time reluctant to engage… they were told we want to see ambitious targets because we want to see a population-level impact on the HIV epidemic. We want you to show that you can have an impact to stop this epidemic. And today the message switched to, ‘let's see what you and [we] can afford together.’

If this trend is confirmed, I would call it a moral betrayal. A moral betrayal because we will have failed first our patients, who were told to get tested and all the ones who tested positive. We promised them we'd provide them treatment. We will fail our health staff, who managed to start 4 million people on treatment, an unprecedented effort for the health services in developing countries in such a short time, and who are today told that they cannot initiate patients. And finally we would fail regional governments, with some of them already contributing a substantial amount of their own resources. The economic crisis is happening here as well as in the United States and Europe, and we would fail them if we would tell them that we cannot any more support this effort.

So it brings us to the question, why punish success and condemn those regional countries, to live permanently in the dark age of epidemic control? Thank you.

Sandra Murillo: At this point, Jimmy will join the conversation. Jimmy, whenever you're ready.

Jimmy Gideyi: Good morning. My name is Jimmy Gideyi, from Kibera, Nairobi, Kenya. I was diagnosed to be HIV-positive in 2004. I'm fortunate enough to be living a healthy and active life thanks to funded anti-retroviral treatment for six years now.  When I was initiated on ARV, I was very weak. But my life changed for the better, I became healthier, stronger, and I was able to fend for my family once more. Now, if the international donors pull out of the commitment to fund HIV care, it means the level of treatment will diminish, and less people in Kenya and other parts of Africa will benefit less from life-prolongings benefit of ARV. This makes me, as an HIV patient, feel very worried and vulnerable. I get even more worried when I think of the millions of other people living with HIV in Africa who do not have the opportunity to have their voices heard like I am being today.

In Kenya, and by extension, Africa in general, governments have the responsibility to look after the health of their people, but it is true that the international donors fund up to about 95% of HIV programs and ARVs in Kenya. The government should be able to catch up for the treatment of AIDS people. That is the bottom line. But Kenya depends much on external funding to sustain its ARV program. We, as activists in Kenya, have been fighting really hard for the government to increase the level of spending on HIV tests since 2001.

Back then, the government paid about 1% of the national budget on HIV programs. Today, it has risen to about 5% of the national budget. To us, people living with HIV, this is a very big problem because if the international donors decide to withdraw their funding, the HIV programs will not be sustainable according to the present funding levels by the government. We already have so many problems to take on, such as stigma, beliefs,  misconceptions, cultural practices, which contribute to the spread of HIV in the community, without having to worry [about] where more money will be coming from to catch up on our treatment.

When donors withdraw funding and commitment for treatment, no matter how slowly, in the end, life for a lot of people in Africa will be either miserable or nonexistent. Thanks to ARV, I can now look after my three sons. They are all HIV negative, but I fear to think that supposing that one of them becomes infected with HIV. I would be happy to know that if this thing happens, he should be able to accept quality ARV treatment on a family basis. But if things get worse, we know that they will die without having the opportunity to live their lives to their fullest.

These are the worries a lot of parents like me have to go through on a day-to-day basis. If donors withdraw funding, therefore, this will mean a less productive population, and ultimately lead to more deaths, and we cannot guarantee that people who will test positive in the future will have access to life-saving ARV care. Granted, we know that donors have the prerogative of where to take their money. But it is our belief and our request as people living with HIV that it is our wish to continue living.

I don't think donors really understand what is at stake. If they saw the problem from HIV-positive people's perspective, maybe then they would think of a way to sustain HIV and AIDS funding, and to keep giving additional resources for pressing health-care needs. Thank you.

Emi MacLean: So we're increasingly, this is Emi again, we're increasingly seeing that anti-retroviral treatment is being delayed, deferred and denied in the communities where we work. This last decade we proved that treating HIV/AIDS in Africa was both feasible and effective. Let's not leave the next decade to demonstrate that the international community cannot sustain its commitment to meaningly respond to this public health emergency. Thank you.

Sandra Murillo: Thank you to the panelists, and to you all for listening. We will now take your questions.

First question comes from Rebecca Voelker from JAMA.

Rebecca Voelker: Yes, good morning. You mentioned treatment during your, prevention, during some of your comments, and I've heard the comment that no matter what is devoted to treatment, that you just cannot out-treat the epidemic, the pandemic. And so I'm wondering if anyone could comment on, during the past decade, has there not been the appropriate balance between prevention and treatment?

Emi MacLean: Eric, would you like to take that question?

Eric Goemaere: Yes, I could take that question. I think there's a little bit of a bias perspective because the fight and all the focus of the fight was about treatment. Treatment was not existing, while prevention was already existing. What we managed to work out is a false dichotomy between treatment and prevention, either/or. And this was sorted out, I believe, already several years ago because it was shown that if you don't provide treatment, people are not interested, are not feeling concerned,

they will not go for a test. This makes sense when the chances of a sexually-active adult, the chances to come out of that test are 30% positive. People are not interested to take a test and they are not interested actively to pay attention to the disease because they prefer to go for other explanations. So we typically, to give you an example, in Khayelitscha, we distribute, thanks to different partner organizations that we are using, one million condoms, male condoms, per month.

We, this substantially reduced the number of STI and probably HIV incidence as well. We have reduced mother-to-child transmission from 28%, as it was initially without the intervention, to 3.5%. So there has been an enormous amount of preventive efforts also done. We are looking now at further intervention like, male circumcision, but there is no magic bullet. But what we definitely do not want to [do is] enter into a dichotomic opposing the two, because we believe that they go together.

Rebecca Voelker: Thank you. Yes, I'll ask another [question]. The situation that you're in now, do you get a sense of whether this is due to the international economic recession, or just donor fatigue that may have happened anyway, without the recession?

Emi MacLean: Well, the recession certainly comes as the most prominent excuse to why this is actually happening, but it's clear from us that the intellectual groundwork was laid for this, and the political groundwork was laid for this, before the economic recession. I think the primary arguments that we see for why this is happening are arguments about putting women and children first at this juncture, putting prevention first, which Eric just responded to, and putting the economy first, and the fact that the economy can't withstand a continued scale-up and the sustainability of AIDS treatment. I think Eric earlier and myself a little bit responded to some of those questions, but I’d like to respond to them a little bit more directly here.

I would just reiterate that we work in many other areas, have worked in maternal and child health for decades, and will continue to for decades into the future. And we recognize that a strong and well-funded response to child and maternal mortality must not be neglected. But we strongly reject the notion that to treat diarrhea or maternal mortality, we must forget about patients with HIV. It's a false choice. Eric talked about that quite clearly in the context in which he's working in South and southern Africa, and it's an unfortunate and unnecessary debate that's become increasingly present in the conversation around HIV/AIDS and the retreat. A couple important figures to put out there, which you probably are familiar with at JAMA, but HIV/AIDS is the greatest cause of death of women of reproductive age around the world, and over 40% of deaths of children under 5 in Swaziland, Botswana, Lesotho, Zimbabwe, Namibia and South Africa are due to AIDS.

So, really, very clearly, in Africa's most AIDS-devastated countries, child and maternal mortality are inextricably linked to HIV. For all the reasons that Eric just mentioned, it's not acceptable from our perspective, and from the scientific perspective, to create a debate between treatment and prevention. Both are obviously needed and also linked, and lastly, on the economic conversation which, as I say, is used as an excuse, I think, more often than it is used as the reality, financial choices are choices. The groundwork, as I mentioned, for the backtracking from international HIV/AIDS commitments was laid prior to the economic nosedive, and, importantly, the economic nosedive is also hitting AIDS-affected countries, too, both at a governmental level and at a family/household level. So both poor governments and poor households can even less withstand the burden.

So efficiencies can and must be found, and MSF has, for the last decade, advocated quite strongly for policies that could contribute to the downward pressure on the price of drugs. Our contribution was part of what led to a 99% decrease in costs of drugs and in health service delivery. In Kyolo, Malawi, where we've been able to achieve universal coverage, we've brought the average annual cost of AIDS treatment per patient down to $237 per year, and we've reached that low cost by treating and using more of existing capacity, simplifying treatment, bringing the cost of drugs down, and really also keeping patients healthy. The questions of sustainability are also used in this context and have been used back from 1999, when there was not even a U.S. federal penny that was used for ARVs globally. That's obviously changed, so this financial choice at this juncture, and like it was in 2001-2002 when the international community initially became more engaged in this, is actually an imperative that has been agreed to with eyes wide open and by the international community, and those commitments need to be kept.

Rebecca Voelker: If I could just follow up on that, I'm wondering in the area, in the countries that you assessed, have you been able to actually calculate a reduction in dollar amount coming in for treatment?

Emi Maclean: In some of the countries, there is actually a CDC analysis in South Africa that shows decrease in number of dollars that are spent on treatment, and a decrease in dollars that are spent nationally. Right now, we're pulling together information from different sources, and in Uganda, as there's this very powerful CDC letter that was sent to all PEPFAR implementers that talked about a flat funding in the years to come, and the need to make sure that more patients are not put on than can be sustained, expecting flat funding, and within a context in which patients who are currently on treatment need to be kept on treatment, flat funding will necessarily lead to fewer patients being put on treatment. But a lot of the figures about decreased costs coming into the future are going to be figures that come out in the months to come.

Sandra Murillo: Are there any other questions?

Next question is David Baron from The World. Your line is open.

David Baron: Yes, thank you. I'm going to follow up on something that Jimmy Gideyi mentioned, which is the role of governments, such as the Kenyan government but other African countries, and whether they're doing enough to take on the responsibility of paying for ARVs. Obviously, they are feeling the effects of the economic crunch, but it's my understanding that there really is a desire on the part of PEPFAR and the Global Fund for African countries to make a greater commitment to paying for at least some of the treatment on their own. Do you think that the recipient countries are doing enough, making it a high enough priority?

Emi Maclean: Just to start off the question, then I think it would be helpful to have Eric give a little bit of a perspective about some of what's happening in South and southern Africa. It's important to note that, despite what Jimmy said in the Kenyan context, African governments do contribute to 25% of the global AIDS response. African governments did commit, with the Abuja declaration to funding 15% of their national budgets on health, and few governments, few African governments have actually reached that commitment. That's something that obviously needs to be changed. African governments need to keep their commitments, but the international community also needs to keep their commitment. So, Eric, I think it would be helpful if you intervened here and provided a little bit of insight into what's happening in the South African context and elsewhere in southern Africa.

Eric Goemaere: I'll leave it to Jimmy, if you don't mind, to give the activist perspective I think it’s very important and also to Mit who is going to give more figures about what's happening here.

Jimmy Gideyi: You can say, we in Africa are trying to better to push our governments to take care of the health of their people. But this is not going to be able to happen overnight. It will require planning, it will require arrangement in the way the budgetary systems are going to be done, and, while this is taking place, it will be counterproductive for donors who have been supporting HIV programs currently to simply pull out because it is not their responsibility to do so.

We appeal to them to continue supporting us so that we can live as we continue fighting for increased funding from our government. I will hand over to Dr. Mit to continue from there. Thank you.

David Baron: Thank you.

Mit Philips: Yes. I just wanted to highlight some of the countries that are doing really their best to take leadership also in the fight against HIV/AIDS. I think it's important to make a difference between the resources that are mobilized and the financial resources that have to come in to achieve HIV treatment, for example. What we see from the countries that we studied, we know that Malawi, for example, is moving closer to the Abuja target, 15% of the public budget concentrated to health, and also you have, even Zimbabwe, they have put in a tax specifically to raise funding for HIV/AIDS treatment. So for example, it has, last year, raised about $5 million. And Lesotho is already paying for about 60 or 65% of the ARVs they are providing to their population.

But the point is, of course, that because the majority of the funding in Africa for HIV/AIDS is coming from international sources, you cannot replace that in the short term by domestic funding, and especially with the economic crisis now, it becomes more difficult. There are some figures about how much domestic public funding goes into HIV/AIDS but most of the figures, they are a bit scattered, and sometimes not so recent, but we know for example from the UN AID figures from 2007, Malawi paid more or less 33% of the funding for HIV. South Africa 77%, so it's a very diverse picture, also, that you can paint.

Eric Goemaere: Just a word, briefly, about South Africa, because South Africa is a particular example. As we all know, we worked out of ten years of so-called state denial South Africa actually has decided that it was an absolute priority to fight this aggressively, to more than double the budget for anti-retroviral treatment, an extremely ambitious target, raising the threshold to 350 for infected TB-HIV patients and pregnant women. But we already have more than a million people on treatment and they intend to recruit half a million within the next year, decentralizing every single primary care facility, so almost too much. What's striking there is that of course South Africa is the richest country in the region; they depend only by 20% on external aid, but they clearly say that they will need more international aid, so even the richest country cannot do it by itself.

The richest country in the region will require international aid. [Commitment from South African government to treating HIV] didn't come spontaneously . [It came from] strong pressure from the civic society. As Jimmy explained, for Kenya and of course something we are very well concerned, it will only happen if there is pressure from the local interested people, and mostly people living with HIV, to make sure that in their government's mind, it is an absolute priority. We are pretty  much aware of this, but…what is happening today is that people try to say, to shift the responsibility in a sterile debate over how much the other is doing.

We are pretty conscious that European countries are only doing the written, probably much less, actually, than the American government. We need to come to a decent definition of what will be the fair share of the financial burden, to tackle this epidemic. For each country, according to their means, for a rich country, according also to their GDP, and I think it will only then give us a benchmark about who is really not participating in the fight.

Sandra Murillo: Thank you, Eric. Are there any other questions?

Teleconference Operator: Our next question comes from Brenda Wilson, from NRP News, your line is open.

Brenda Wilson: Yes. It's NPR. I spoke with Mr. [Jerry] Coovadia and he says that, in fact, he didn't see any shortages. I've spoken with a number of people who say that the whole issue of shortages has been somewhat exaggerated, and that the situation in Uganda is a bit more complicated because a lot of funders have pulled out because of the issue surrounding that legislation regarding homosexuals, and so you're getting reactions from private donors as well to some of these initiatives in various countries, you know, about gays, the crackdown on gays. So that the picture I'm hearing is not as cut-and-dry as the funding is tightening up and I think the characterization that I heard one person give it is that people are having to wait for someone to die before they can get treatment.

Emi MacLean: We're giving, as we mentioned, we don't, we're not trying to give an authoritative account of what is happening everywhere. I haven't personally talked to Dr. Coovadia about this although maybe Eric has more insight, but certainly I was in Uganda before the uproar around the legislation that you refer to and there were widespread accounts from a number of different sources in the country where, PEPFAR is obviously the biggest funder in the country of HIV/AIDS care and treatment. Widespread accounts of waiting lists of starting enrolling people in treatment and then stopping, initiating people on treatment because they were unsure about what the financial stability would be. The CDC letter that we reference is very clear and it's a direct and official letter from the U.S. government that's now six months old, that has been distributed to all of the CDC-implementing partners in Uganda, which speaks about flat funding, the need to really ration care within a limited funding environment.

So I think that Uganda, every country context mentioned previously is different. There are different funders who are playing different roles in different countries. Different African governments play different roles, obviously, in different countries, and there's different prevalence and different populations that are affected in different countries, so we don't certainly say that the experiences of any individual country are representative and that's part of the reason why we try to do this analysis looking at a number of different countries and trying to get a sense of where there are early signs of retreat, but it is the experience that we have heard from our field teams on the ground and from doing an analysis in communicating not just with our doctors and our nurses and the patients that we treat, but also communicating with other implementing partners and government officials in these countries.

Eric Goemaere: A word about South Africa. It's true that it's a bit of a particular example and it's good to clarify what could be confusing. South Africa does not depend, as I said before, much from external aid, it's about 20%. They have just increased the target in the budget available for ARV treatment, so for doctors working in the public service, like myself, in the way I work, there is no shortage. To the contrary, there's an increase in the target nowadays. For South Africa, it touches particularly doctors, staff, working in privately-funded, mostly PEPFAR projects, as we have written in our report, who have been told to shift their patients towards the public service.

That's once again, South Africa is a bit of an exception. In the public service certainly, there no shortage. Not at this stage, with some exception like what happened in the Free State last year and not any more nowadays, but might happen again if there is no further support.

Brenda Wilson: I have a follow-up question, and that is, I guess listening to this, I couldn't help but wonder if more thought had not been given to, perhaps, different approaches. For example, I mean I think there are some people who question even whether PEPFAR is the best use of the money for getting HIV/AIDS treatment to people in developing countries, and if the money is going directly to the government, if we can rely on the government to handle the money responsibly to provide care and treatment. Perhaps that is a much more efficient way of doing it than sending it through these conduits, U.S. conduits, which require a huge amount of overhead as well. So, I guess, what's frustrating is not hearing some analysis beyond more money is needed because more people are needing treatment and budgets are being flat-funded at a time when the epidemic has not slowed down.

Emi MacLean: I'll take an initial response and then I imagine others will have a response as well. But just to make it clear, we're not defending a particular approach, we're defending the patients and the needs of the patients who are in our care. We've supported and implemented in the programs that we run integrated approaches working with the public sector where possible, and in most cases working within the public sector. A public health approach, decentralized care and treatment, as mentioned earlier, we have done everything in our power, and continue to, to push for decreased cost of commodities and decreased cost of the health services that we render. We've been supporting, for instance, the patent pool for AIDS medicines to try to bring the cost of second-line and fixed-dose combinations in pediatric drugs down, so certainly there are a variety of mechanisms that we are fighting for. It's not a defense of an individual approach.

We recognize multiple approaches are needed. But there, the issue now is that we are sounding the alarm given a really strong shift back, not necessarily from a particular initiative, but from a global response to HIV/AIDS when we're only really at the tip of the iceberg in terms of the responses needed.

Mit Philips: If I could add here also, I think what is clear from the experiences shown, is that we need a multitude of approaches, and preferably a multitude of actors also involved in HIV because the situation, the context, can differ from one part to the others, even in Africa. So one of the things that we have seen is that efficiency gains definitely can be obtained, and we mentioned some of them already, but that's not really rhyming very well with what we see now. What we see now is rather about cutting some of the costs, and shifting supplies of purchases of ARV for example, to technical assistance, or to more capacity building. Again, there we have a problem because if everybody is going to build the capacity and no one is really paying for the ARV drugs or for the other recurring costs, then these capacities will remain underused. So we need really to have this diversity also to review the vulnerability of the system.

What we've seen in the last month so far, is that if you have a single channel of funding, or a single channel of supply, the risk of the entire program being paralyzed by small problems. So that's why it's important to keep the level of the funding as according to the epidemic needs but also to have the number of donors involved sufficiently varied so that each can bring their part and their specificity.

Brenda Wilson: Thank you.

Sandra Murillo: Are there any other questions? Ok, we will close the call.