Ten years ago, a shipping container was converted into Ethiopia’s first HIV treatment centre, in Addis Ababa, the capital. Created in response to a dramatic rise in new HIV infections and AIDS -related deaths, the centre offered the only hope for HIV-positive Ethiopians, who had to pay to access the life-prolonging antiretroviral therapy (ART).
When US Global AIDS Coordinator Ambassador Eric Goosby joined other US and Ethiopian officials at the centre on a recent trip, they found a state-of-the-art facility, where thousands of clients receive free, comprehensive HIV treatment. The centre, a wing at the Empress Zewditu Memorial Hospital, has just added an outpatient annex.
“At least 350 clients will be seen daily in this new facility, some of whom have not been able to receive the services they need and deserve elsewhere. I particularly applaud Zewditu for its tremendous effort to build the first site in Ethiopia that offers counselling and testing services for the deaf and blind,” Goosby said at the inauguration ceremony.
The centre is now one of 900 sites across the country where over 290,000 people are receiving ART. The new centre, like thousands across Africa, was funded by the US government-run President’s Emergency Plan for AIDS Relief (PEPFAR).
Established in 2003, PEPFAR was the product of a rare bipartisan deal between former US president George W. Bush and lawmakers spearheaded by the Congressional Black Caucus. It was first a commitment of US$15 billion in funding to fight the global HIV/AIDS pandemic; at the launch of the plan, only 50,000 Africans were accessing ART, according to Eric Goosby who heads PEPFAR.
In 2012, an estimated 8 million people were receiving treatment in low- and middle-income countries - of which PEPFAR directly supported 5.1 million. This was a 20-fold increase in treatment coverage since PEPFAR was created in 2003. In 2012 alone, the emergency plan helped carry out 46 million HIV tests, preventing 230,000 babies from being born HIV-positive, Goosby said in an interview with IRIN.
Funding cuts versus AIDS-free generation
But experts are concerned that consistent budget cuts in PEPFAR funding could make reaching the goal of an HIV-free generation difficult, if not impossible.
Chris Collins, a vice president and director of public policy at the Foundation for AIDS Research (amfAR), argues that despite impressive gains made in the AIDS response now is not the time for funding cuts.
"Funding for PEPFAR has fallen 12 percent since 2010 in the State Department HIV bilateral budget line. Last week, the White House proposed an additional $50 million cut for 2014. When the mandated sequestration cut is taken into account, the programme is now at its lowest funding level since 2007," Collins noted in an April editorial.
“The honest truth is that the world won't end AIDS without PEPFAR. Some will say: judge PEPFAR on its outcomes, not its funding. But when PEPFAR's own Blueprint calls for rapid scale-up of effective services in order to show tangible gains, it's hard to understand why now is the time to cut back,” Collins argued.
But Goosby explained the cuts are being made for three reasons. The first is because they are “getting better and smarter” in service delivery, such as procuring and shipping commodities like condoms and test kits at cheaper costs and favouring less expensive generic drugs over pricey brands.
“We also started a dialogue (this… was an attempt to try to make these services sustainable, not just dependent on one funder) with governments around what their contribution was now to these services and what they could be. And governments all heard this and [began] to pour… their own money into the service pot,” he told IRIN. “So, again, it would be additives, so we can build on what we have already started... with a donor-start but it is a government finish.”
The US is also looking to more cooperation with the Global Fund to Fight AIDS, Tuberculosis and Malaria to raise funds to pay for the HIV prevention and treatment programmes, according to Goosby, who says the US donates a third of the money that goes to the Global Fund.
“So we think of it as a shared responsibility... We see our ethical obligation to the patients that are using these services... We will not renege on that. But we also feel that in order to make sure these services continue, we need to diversify the fund portfolio so others are contributing.”
But whether poorer countries in the region will be able to take over the ongoing programmes is a concern for many.
According to the African Union commission, a number of countries have begun to implement innovative AIDS financing measures intended to reduce dependence on external funders such as PEPFAR.
“Zimbabwe and Kenya now earmark a portion of domestic tax revenues for an AIDS Trust Fund, while countries such as Benin, Congo, Madagascar, Mali, Mauritius, Niger, Rwanda and Uganda have established special HIV levies on mobile phone usage or airfares,” said the commission in a statement issued on May 26. “Taking a different approach, South Africa reduced its spending on antiretroviral medications by 53 percent by reforming its tender process to increase competition among suppliers.”
“Our continent is demonstrating strong political commitment and action by embracing transformative reforms to address AIDS, TB [tuberculosis] and malaria,” said the commission’s chairperson, Nkosazana Dlamini Zuma.
PEPFAR's Goosby agrees it is not yet time to scale back the fight against HIV/AIDS. “If we pull back on what we are doing for HIV, it will come right back, without any doubt. We see that in just about every infectious disease, but HIV is notorious for this. So keeping this going becomes the challenge. That's why we want to emphasize the shared responsibility."