PEPFAR Editorial Packet: Time Running Out to Pass Major Global Health Act

Lantos-Hyde AIDS, TB and Malaria Act stalled in Senate

June 2008 — When President Bush traveled to Africa, he noted the progress made against AIDS, thanks in no small part to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). Widely acknowledged as one of the greatest achievements of the Bush administration, the resources provided by PEPFAR have undoubtedly saved millions of lives around the world. Since its implementation, PEPFAR has provided nearly 1.5 million people with life-saving antiretroviral (ARV) medication, over 60 percent of whom are women and girls, and supported prevention of mother-to-child transmission of HIV in 10 million pregnancies.[1]

But now that PEPFAR is being considered for reauthorization, the greatest bipartisan effort in recent years has run into an unfortunate Congressional roadblock.

Initially, the reauthorization of PEPFAR appeared to be going smoothly. The House of Representatives took the bold step of passing a reauthorization of PEPFAR that calls for $50 billion over the next five years[2], adding important investments such as training new health professionals and at least a doubling of funding for the Global Fund to Fight AIDS, TB and Malaria. In addition, the legislation — titled the Tom Lantos and Henry J. Hyde United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008 — comprehensively addresses TB (based on a well-developed Global Plan to Stop TB — see below), authorizing $4 billion over the next five years in critical resources for TB treatment and prevention worldwide, as well as key provisions for scaling up life-saving TB/HIV efforts.

However, passage of the bill is currently being stalled in the Senate by seven senators — Tom Coburn (R-OK), Jim DeMint (R-SC), Jeff Sessions (R-AL), Saxby Chambliss (R-GA), David Vitter (R-LA), Jim Bunning (R-KY) and Richard Burr (R-NC) — who have voiced concerns about the size of the bill. Members of the global health community — as well as voices from across the political spectrum — have acknowledged that the scale-up is in fact necessary to transform PEPFAR from an emergency response program into one that produces sustainable, long-term results. This is accomplished by funding not only treatment programs, but prevention efforts and programs to address TB/HIV co-infection, AIDS orphans, maternal health, nutrition and other broader aspects of keeping those living with HIV/AIDS healthy and thriving.

The emergence of drug-resistant tuberculosis threatens to undermine all of the progress made so far in the AIDS pandemic. People living with HIV/AIDS are much more susceptible to TB, and without effective diagnosis and treatment of drug-resistant strains, TB becomes a rapid death sentence. With TB already the biggest killer among people with HIV/AIDS, these drug-resistant cases — far more difficult and costly to treat — must be detected and cured, so the deadly cycle of transmission can be stopped before death rates skyrocket. This is all the more reason for the increase in PEPFAR funding to be passed as soon as possible.

In a May 14 op-ed, Washington Post columnist Michael Gerson wrote of the stalled bill, “It is the nature of the Senate that the smallest of minorities can impede the work of the majority. But it takes a conscious choice — an act of tremendous will and pride — for members to employ these powers against an AIDS bill with overwhelming bipartisan support.”

Activists across the country are not only urging their members of Congress to apply pressure to the seven senators holding the bill, but also to the Democratic Senate leadership to schedule the bill for a vote before the July 4 recess, which so far has not been done. Passing the bill before the recess would give the U.S. enhanced credibility on global development heading into the G8 Summit, held in Japan next month. If the U.S. fails to pass this major global health legislation, then other wealthy countries would be less inclined to support global health and development goals in turn. Were the bill to be scheduled for a vote, it is almost certain that it would garner enough support to override the objections of the few who are stalling it.

The U.S. has long been a leader in the fight against HIV/AIDS and infectious diseases like TB around the world. The passage of the Lantos-Hyde Act marks a major opportunity to demonstrate our true commitment to this issue. Failure to pass this legislation quickly will undermine the gains made in reducing AIDS deaths and could push us to an almost pre-antibiotic era in the TB battle. The consequences would be dire for poor countries, but would present a dangerous threat to developed countries as well. As Archbishop Desmond Tutu — himself a TB survivor — has written, “XDR-TB sounds a clamorous warning: without the political will to control TB, we will not only fail to defeat HIV but may enable the rise of an incurable, airborne disease.”

The deadly connection between TB and HIV

When PEPFAR was first authorized, little attention was given to TB and its impact on people living with HIV/AIDS, and XDR-TB had not even been officially identified. While U.S. global AIDS funding made major gains, TB funding has languished — and this neglect has left both efforts terribly vulnerable. Armed with the knowledge we now have — and the latest data on the growing crisis of drug-resistant TB — Congress must connect the dots to see that the fight against AIDS will not ultimately succeed without an equally aggressive effort against TB. The emergence of XDR-TB is a consequence of our collective failure to adequately address the TB epidemic. For decades, TB programs and health systems have been shortchanged, leaving them ill-equipped to control a disease that kills about 1.7 million people a year — 4,700 people per day — despite a low-cost cure. XDR-TB occurs nowhere in nature. It’s a human-made problem arising from inadequate or incomplete TB treatment provided in the context of under-funded TB control and weak health systems.

The WHO identifies 49 countries with confirmed cases of XDR-TB — including the U.S., Canada, Mexico and the entire roster of G8 member states. Although XDR-TB represents a relatively small percentage of overall TB cases, its high mortality rate and difficult treatment make it a global threat to public health. Knowledge about the full extent of XDR-TB is incomplete, because of major gaps in lab capacity to test for drug-resistance — let alone to track the epidemic and respond.

Some facts about XDR-TB:

• XDR-TB is resistant to not only the most effective first-line drugs, but also to critical second-line drugs. An outbreak of XDR-TB in KwaZulu Natal (KZN), South Africa, in 2006 killed 52 of 53 patients. A result of improper treatment and management of regular TB, XDR-TB is entirely human-made.

• In the first group of 53 XDR-TB patients reported in KZN, 70 percent died within one month of being diagnosed with TB (untreated or ineffectively treated TB is rapidly fatal in people living with HIV/AIDS). Current methods of testing for drug-resistance can take between 6 to 16 weeks, so many HIV-positive patients with drug-resistant TB die before the disease can even be accurately diagnosed.
• According to the U.S. Department of Homeland Security (DHS), in some sampled populations, XDR-TB has had fatality rates approaching 100 percent. DHS has identified XDR-TB as an “emerging threat to the homeland.”

The Global Plan to Stop TB

Launched in 2006, this comprehensive 10-year business plan to fight TB, if fully implemented, will save an estimated 14 million lives and put humanity on track to wipe out one of our oldest and deadliest killers by:

• Expanding access to high-quality TB testing and treatment for all
• Treating 50 million people for TB
• Developing more effective tools to diagnose and treat TB and creating a new vaccine

In June 2007, the WHO released the MDR/XDR Global Response Plan to complement the existing Global Plan, with strategies and resources necessary to address the MDR/XDR-TB emergency, including lab strengthening, infection control, more aggressive treatment, and prevention efforts. If fully implemented, the plan will increase by ten-fold the number of MDR- and XDR-TB patients being treated and cured under WHO guidelines.

[1] http://www.pepfar.gov/about/c19785.htm

[2] President Bush has asked for $30 billion for the reauthorization of PEPFAR over the next five years — but this funding level equates to a near flatlining of the current funding levels, and would slow the rate of progress.