Newsday - April 5, 2001
Laurie Garret, Staff Writer

It calls for rich countries to create an HIV/AIDS Prevention and Treatment Trust Fund, which would purchase discounted anti-HIV drugs to be distributed in poor countries via a closely monitored system similar to that now used for anti-tuberculosis drugs.

The plan, which was conceived by economist Jeffrey Sachs and AIDS physician Bruce Walker, envisions transplanting the essence of the U.S. HIV treatment paradigm to Africa, India and other hard-hit areas at a cost that would gradually increase over five years as the treated population grows from an initial target of 1 million to 3 million people.

Currently, an estimated 36 million people worldwide are living with HIV, more than 80 percent of whom reside in poor countries that lack the means to treat the disease. The Harvard group estimates that about 4 million Africans currently have AIDS and another 25 million are HIV-positive.

"Only 10,000 Africans-mostly members of the elite-are on anti- retrovirals [AIDS drugs] now," Sachs said in a telephone news conference yesterday. "This is a plan to bring drug treatment to Africa and to finally break the back of the HIV pandemic. Many issues have been raised-and they're serious issues-about whether these drug therapies really could be provided in poor countries...We analyzed these alleged obstacles in detail, and the 128 signatories have concurred that these obstacles either don't exist or can be overcome."

Because most anti-HIV drug manufacturers recently have announced price discounts of more than 60 percent for sale of their products to poor countries, and further reductions are "very close at hand," Sachs said, "what is missing right now is the international donor funding."

Here is how the Harvard scheme would work: For the first two years the goal would be to treat, test and conduct field research on 1 million people at a cost of $1.1 billion, or $1,123 per patient. By 2006, it envisions treating 3 million people at a cost of $3.3 billion. The United States is asked to foot one-third of the tab, with the remainder donated by Europe, Japan and Canada.

Besides the Harvard plan, the UNAIDS Programme in Geneva has requested funds for campaigns aimed at preventing further spread of the virus. Without large-scale prevention campaigns and behavior change, UNAIDS argues, such a treatment campaign is unlikely to slow the epidemic. Further, the drugs are not curative: Several recent studies in the United States and Europe indicate the anti-retroviral drugs, when properly used, add an average of three to five years of life expectancy to HIV patients.

Sachs said the Harvard group endorses the basic UNAIDS prevention effort, which would increase the need for donations from rich countries to $4.1 billion for the first two years, and "something like $7 billion to $8 billion from all sources" by year five.

That would boil down to $1.37 billion from the United States for the first year, scaling up to between $2.3 billion and $3 billion by 2006.

The plan may face a rough reception in Washington, where the Bush administration aims to reduce U.S. government spending.

"We are a $10 trillion economy," Sachs said. "So $1 billion is about one cent of every 100 dollars in our economy. That, to save five million lives a year...to offer a chance for children to grow up with parents ...a chance for a continent that is dying. It's an incredibly modest effort."

White House spokesman Ken Lisaius told Newsday that "the president is concerned about the global implications of AIDS. That's why we're in the process of putting together an Office of AIDS here in the White House. And that's why we're continuing to work for a cure for the disease."

Next week the White House will issue a U.S. health sector budget proposal, much of which was leaked this week to the media. Among other things, it would cut by 48 percent the Centers for Disease Control and Prevention's funds for fighting outbreaks and epidemics; reduce by 86 percent medical-care funds for uninsured Americans; put a cap on AIDS treatment funds; and slash budgets for substance abuse treatments of intravenous drug users.

Across the board, AIDS-related programs would take a $775 million hit under the administration plan. Further, a report from the administration's newly appointed Mission to the United Nations calls for shifting international AIDS prevention and control efforts away from treatment and condom use to programs that emphasize sexual abstinence and personal responsibility.

A spokesman for Health and Human Services Secretary Tommy Thompson said the agency had not yet seen the Harvard proposal and declined to comment on it.

Though he made no direct statements regarding the Bush administration's AIDS efforts, Sachs noted that "the highest priority right now is the knock on the door at the White House. That's where the sticking point is, bar none, right now."

No longer a sticking point, Sachs insisted, are pharmaceutical companies. Under tremendous pressure from activists, the World Health Organization, UNAIDS and the leaders of several countries most hard- hit in this epidemic, drug manufacturers have brought their anti-HIV drug prices down. Exact discounts vary from company to company and are based on which government negotiated a given deal. Overall, it now seems possible to purchase a cocktail of three anti-HIV drugs for use in Africa for less than $1,000 a year from the manufacturers, and for as little as $350 a year from CIPLA, a generic drug maker in India.

At a news conference yesterday in Geneva, Harvey Bale, head of the International Federation of Pharmaceutical Manufacturers' Associations, said drug prices simply weren't the problem. Infrastructure -or the lack thereof-for health-care delivery is the problem, Bale insisted.

That message was echoed this week in the World Bank's annual report, which emphasized the need for poor countries to take greater responsibility for their own problems. Last year the U.S. Congress gave the bank $200 million to fight AIDS; the money is part of a $500 million HIV/AIDS fund run by the World Bank. This week the World Bank said that it would disburse those funds only to countries that have in the past proven capable of properly using health-related donations.

The Harvard Group rejects such criticisms, arguing that AIDS drugs can be disbursed in the same manner as are drugs for tuberculosis. Under a program called Directly Observed Therapy, or DOTs, TB patients take a combination of antibiotics every day for several months, always under the watchful eye of an assigned monitor. Such a program was successful in stopping New York City's TB epidemic of 1991-1993.

Harvard's Bruce Walker calls their AIDS scheme "DOTs-HAART," a reference to highly active anti-retroviral therapy. Even in desperately poor areas entirely lacking in medical facilities, Walker argues, a family member or village elder can be designated responsible for directly observing AIDS patients' drugs use.

Last week, however, the World Health Organization announced that despite DOTs, the global burden of active TB cases and deaths reached the highest level in history. And multi-drug resistant strains of tuberculosis bacteria have now been identified in 112 countries.

The failure of DOTs globally for control of TB, Sachs said, is primarily due to "inadequate donor support" for purchase and distribution of curative antibiotics.

Craig Gordon in Newsday's Washington Bureau contributed to this story.

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