The Future of U.S. Global Health Policy

Mike Saccone writes from Denver, Colorado: "Knowing that antiretrovirals and other HIV/AIDS treatment drugs are most effective when someone is well-fed, to what extent should HIV/AIIDS prevention dollars be paired with food aid and other forms of relief?" Christine Lubinski?

CHRISTINE LUBINSKI: Well, in fact, the PEPFAR program, as it was reauthorized last summer, does provide for resources and better coordination with food and nutrition programs for precisely the reason that writer suggested; that to take these drugs without adequate nutrition is to undermine their effectiveness.

So I think what's little appreciated in this talk about vertical and silo programming is that the global AIDS initiative, in fact, has many integrated components - from taking care of children who are not themselves HIV-infected, to providing food and nutrition, to hiring and retaining healthcare workers that will be available not just to provide AID prevention and care, but a whole range of urgently needed services in resource-poor settings.

RAY SUAREZ: When I was in South Africa looking at a PEPFAR-assisted program recently, I was talking to one of the clients, he was an HIV-positive guy; he had had terrible lesions covering his body; he had lost fully half his body weight; and he looked great. He was on antiretrovirals and I asked him, what were the difficulties, if there were any, now that he was on these drugs and feeling better. And he said that the chronic unemployment and underemployment left him afraid some weeks that he couldn't get enough to eat, and that it was really hard to keep on taking the drugs when he wasn't getting enough to eat. They made him really sick, but he was so afraid of backsliding that even during those weeks when he was very short on food, he kept on taking his medicine. Michele Moloney-Kitts, is that a widespread problem in parts of the world where antiretrovirals are now a common therapy?

MICHELE MOLONEY-KITTS: I think it is. Well, I mean, I think there are two widespread problems. One is unemployment, or lack of a way of earning money or earning food, and that includes urban versus rural areas. And then there's the quite specific issue of the difficulty of taking these drugs when you don't have enough food. Certainly in the PEPFAR program, as was noted, we do support food, particularly for people who are just starting their drugs.

But indeed, it's very hard for us to provide not only a lifetime of antiretrovirals but also a lifetime of food. And the one thing that we have to be very, very conscious of in all AIDS programs is that we definitely don't want to create what we call "AIDS exceptionalism." In other words, many people live in communities where people go hungry every day, but if you have AIDS you get food. But if you don't have AIDS, you don't. So this is another reason why the Obama administration is looking really comprehensively at development, as well.

And, certainly, through PEPFAR programs, we also are working on income generating schemes and trying to help people get back to work or improve their agricultural methods or things like that,  very small-scale, just to kind of keep them going. And I would say that those two elements of jobs and work and income generation are extremely important, in particular, with two populations. One is women, because, as you know, HIV/AIDS really disproportionately affects women. And the second is with orphans and vulnerable children because so many children in many parts of the world have been orphaned as a result of HIV.

CHRISTINE LUBINSKI: Well, we believe that more resources for global tuberculosis are urgently needed. And, in fact, when PEPFAR was re-authorized, it included $4 billion over five years for tuberculosis, which would include resources both to intervene with drug-resistant TB as well as resources to develop desperately needed new tools to diagnose and treat drug-resistant tuberculosis. So it's important to note that the re-authorized PEPFAR program includes a huge mandate for tuberculosis.

Moreover, the Global Fund is the Global Fund to Fight AIDS, TB and tuberculosis in a critical multilateral program that provides tuberculosis treatment to more than 4 million people over the last five years. So in our mind, it's not a sort of tradeoff between HIV and TB. Tuberculosis kills more people with HIV in the developing world than any other cause. But fighting AIDS equals fighting TB, which is such an endemic problem in HIV-infected people.

RAY SUAREZ: Now, XDR-TB is kind of an interesting case because it has a very tiny two-year survivability even if you get treatment. So if dollars are scarce, if medical professionals in the developing world are scarce, if hospital beds are scarce, how do you apportion your time and your treasure to a disease that nobody's going to survive, or virtually nobody's going to survive? How do you do the cost-benefit analysis when you're trying to fight a half a dozen other fires at the same time? Michele Moloney-Kitts?

MICHELE MOLONEY-KITTS: Yes. I guess what I'd like to just say here is that we would like to invest our resources very effectively now in treating TB effectively and appropriately at the right time so that, in fact, you don't have widespread emergence of XDR-TB. And I think that that's one of the approaches that we're trying to take.

The other piece is that, I mean, there are two other critical components. One is, as you noted, I mean, I'm not a TB expert, but I think that there's somewhere - and maybe Christine knows - a 100 percent overlap between people who have XDR-TB and those that are HIV positive - at least it's very, very close - there's huge co-infection rate. So certainly, in Southern Africa, one of the things that we're looking at is investments and the relationship between AIDS and TB and making sure that anybody who has AIDS is screened for TB and vice versa, so that we can hopefully treat people effectively and stop the spread of this.

The other piece I'd like to note is this is also where investments in healthcare systems are so important. One of the big things that we've done in our work in HIV is support to laboratory capacity building. Many of the countries that we work in have had no labs. So by building laboratory capacity you are also not only improving their ability to respond to HIV but to many other diseases as well, including TB. But no doubt XDR is a very, very worrisome issue on the horizon.

RAY SUAREZ: Christine, I'm sorry I cut you off -

CHRISTINE LUBINSKI: So I think the sad reality is - I'm sorry.

RAY SUAREZ: Go ahead.

CHRISTINE LUBINSKI: I was just going to say the sad reality is that most people are not receiving treatment for MDR or XDR-TB so we're not really making those choices right now because the very costly drugs are not available in most parts of the world where MDR and XDR are endemic. And I couldn't agree with Michelle more about the urgent need - I mean, XDR and MDR are a failure of TB control programs and also an outcome of high prevalence of HIV.

So treating people with HIV makes them less vulnerable to getting TB which means less TB in the community and ultimately less drug resistance to TB.

Now, Michele Moloney-Kitts, you're a nurse midwife, you must have your fingers in this pie.

MICHELE MOLONEY-KITTS: Yes, and I'd like to thank the questioner, obviously a woman after my own heart. So not only does the Obama administration care passionately about this but it also again appeared in our reauthorizing legislation. There is actually a requirement there for us to train 140,000 new healthcare workers. We are currently working with a number of countries on a plan to do that.

The vast majority of those will be nurses or nurse midwives along with pharmacists, laboratorians, physicians and of course community healthcare workers because in the places that we work many places really don't have - they have very little infrastructure. So even a well-trained community healthcare worker who has access to professional staff can do a very good job.

We're also looking under this legislation at training some social workers, because as you know we have a crisis with the orphan population as well, and there is a complete dearth of social workers in many of these places. So indeed we share her concern and it is a high priority for us under the next phase of PEPFAR.

RAY SUAREZ: Michel writes from College Park, Maryland: "Perhaps the global health initiative should have more focus on funding grad students to work on projects related to bringing better health to the world at lower cost. Could the global health initiative be tied into funding for research labs that do work related to diseases with a global impact?" Are American universities and universities in the industrial world, Christine Lubinski, an incubator for this kind of work, as Michel is wondering?

CHRISTINE LUBINSKI: I think there's no doubt of that. There’s been a huge influx of interest and I think it's very exciting in schools of public health, social work, across the board in getting involved in international health. And many of our members, infectious disease doctors, are running global health programs at major universities.

And many of these programs provide opportunities for partnerships between developing countries and the university giving many students an opportunity to get some on-the-ground experience doing global health work in a developing country.

RAY SUAREZ: Genevieve de Messieres writes from Charlottesville, Virginia: "Should we be focusing more on increasing the availability of safe water in developing cities and rural areas as part of health?" Michele?

MICHELE MOLONEY-KITTS: Absolutely. We know that clean water saves lives and certainly we have a number of basically household-based water cleaning techniques and systems that we use in our programs and certainly for our HIV-positive clients who are either in a care program or in a treatment program, clean water at the household level is a key intervention. I think that we would all agree that there should be a broader approach to this, but I would say that's a bit beyond the kind of public health domain, even though it has huge public health benefits, and more into the domain of public works, something like that.

RAY SUAREZ: Well, isn't that, Christine, part of the problem? The way we tend to silo and fund by the disease and create assaults on specific health problems when some of the ongoing medical challenges, just daily health challenges in the part of the world, they're just so complicated and interconnected?

CHRISTINE LUBINSKI: Well, I think we have to remember that a looming catastrophe in HIV/AIDS is what provoked the major global response from the U.S. and other partners, and in fact that response has had a positive impact on other health problems. We have countries in sub-Saharan Africa where 10 to 30 percent of the young adult population is HIV infected, putting whole societies at risk, putting a whole generation of children at risk. And in fact the platform of HIV prevention and care has provided a vehicle to when pregnant women are being tested with HIV they are also being handed a Malaria bed net to take home. And that that kind of coordination increases, and one would expect it to get even better under the current administration.

In addition there is an activity underway in Congress to overhaul foreign assistance. And one of the goals of overhauling foreign assistance is to better integrate some of the development support, like clean water, with global health. So I think we all anticipate improvements in coordination of that area. But we cannot discount what a public health and human emergency the HIV/AIDS epidemic presented and continues to present in sub-Saharan Africa.