PEPFAR Opens the Door: Integrating HIV/AIDS with an NCD

One criticism of the UN High Level Meeting on Non Communicable Diseases (NCDs), held in New York over September 19-20, is that donor nations came to the table, but made no real financial commitments to deal with the rising tide of NCDs. In part because of the global financial crisis that is squeezing all major sources of development assistance for health, but also because of the enormity of the problem, few nations stepped forward with significant new resources to combat illnesses like cancer, heart disease, lung disease, diabetes and mental illness that were the focus of the meeting. Some commentators singled out the US Government for special criticism, noting that the United States typically leads the planet in providing funding for global health. In some quarters, unfavorable comparisons were drawn between the commitments made by the Bush Administration following the first UN High Level Meeting on a global health topic (AIDS in 2001).

But the Obama Administration announced two important new commitments with potential significant impact on NCDs just prior to the New York meeting, oddly enough by a US Government agency known mainly in the health sphere for its work on an infectious disease. On September 13, the State Department and the George W. Bush Institute announced a significant expansion of the President’s Emergency Plan for AIDS Relief (PEPFAR)’s existing work to combat cervical cancer. Because of that cancer’s connection to reproductive health -- many cervical cancers are caused by infection from human papilloma virus (HPV) transmitted sexually – and the fact that HIV-positive women also infected with HPV are at increased risk for cervical cancer, PEPFAR announced it would be increasing the US Government commitment to screen and treat for this type of cancer from $20 million over five years to $30 million, a 50 percent increase. The goal of this activity will be to reduce deaths from cervical cancer by an estimated 25 percent among women screened and treated through the initiative. Adding to this effort, the announcement also included significant in-kind donations from companies including GlaxoSmithKline, Merck, Becton Dickenson, and QUIAGEN. Together, this initiative known as Pink Ribbon Red Ribbon (PRRR), amounts to new commitments of $75 million.

But the significance of PRRR only becomes clear in its second element – breast cancer education. Through PRRR’s highly innovative public-private partnership, Susan G. Komen for the Cure is also adding funding to expand breast cancer awareness and prevention among the same target population of women receiving care at PEPFAR-funded HIV service sites. Of course this sort of integrated prevention program makes good public health sense; one would always provide as much health-related information to women in a clinic setting as possible, dealing with cervical and breast cancer awareness together. However, even though PEPFAR has been one of the most successful global health programs in history, its success has been limited to work only on HIV/AIDS and closely-related conditions, in part because its Congressional authorization limits PEPFAR funds to HIV/AIDS prevention, treatment and care. For example, contraceptives provided to women in PEPFAR-supported clinics must be purchased by other programs of the host government, the U.S. government, or another donor, where available, rather than by PEPFAR. Through PRRR, the wonderfully robust PEPFAR prevention and treatment platform, considered one of the great global health achievements in recent times, has been made available to a whole new type of prevention – in this case for an NCD.

This intriguing and creative model has potentially far-reaching consequences. Imagine if other private funders decided to provide resources for diabetes or cardiovascular care, and were able to utilize PEPFAR clinics to make these services available. In the end, the opening up and integrating of the PEPFAR platform could turn out to be one of the most revolutionary “outcomes” of the UN High Level Meeting. Today, because of PRRR, women in Africa will receive HIV/AIDS prevention and care and integrated breast cancer education. Will tomorrow see the integration of an entire spectrum of NCD prevention?

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Comment by Jeff Meer on November 29, 2011 at 9:05am

Thanks for the comment, Johanna.  You are right: a whole person approach to prevention would avoid a lot of the issues that result from even well-intentioned but narrowly-focused programs. The key to broadening the PEPFAR platform though will be finding the resources outside the existing HIV/AIDS funding stream.  There are very real limits placed by the US Congress on what PEPFAR can do beyond HIV/AIDS prevention, and there is no other logical place to look within the US Foreign Assistance funding structure right now to support a general non communicable disease prevention strategy.  Other potential large-scale funders, like the Global Fund for HIV/AIDS, Malaria and TB, have their own fiscal constraints right now and are certainly not looking to expand their mandates into NCDs. The only real option may be to build upon existing platforms using strategic investments from private funders until the main international donors for health assistance (USAID, DFID, JAICA, the Nordics and others) are prepared to come to the table. 

Comment by Johanna Ralston on November 28, 2011 at 11:42am

I want to start by thanking Dialogue4Health for taking up this discussion. In the lead up to the UN High Level Meeting (HLM) on NCDs, the NCD community turned to the HIV/AIDS community for guidance on how to best approach an HLM on health given their success on HIV/AIDs in 2001.  Going forward, we may very well turn once more to the HIV/AIDS community for guidance, this time on implementation and integration of services. As you have mentioned, some initial joint NCD-HIV/AIDS projects have already begun.  In addition to high level initiatives such as Pink Ribbon Red Ribbon, promising results have been seen in country level programs as demonstrated by an FHI pilot program in Kenya integrating cardiovascular disease (CVD) screening and prevention counseling into HIV clinics, meanwhile collecting vital data that could reveal more about the biological links between CVD and HIV.  However I would agree, it would be ideal if we could see integration not only of CVD or breast and cervical cancer prevention and screening with HIV services but rather the development of a whole-of-body approach to the clinical encounter.  

In some cases, the success of modern medicine has allowed HIV/AIDS to itself become a chronic condition that requires ongoing care, much the same as NCDs.  If care centers are currently equipped to manage the chronic care of HIV/AIDS patients, why not expand the services provided to cover other conditions as well?  Additionally, HIV is a contributor to cardiovascular disease.  HIV positive patients, especially those on antiretroviral treatments, are at a higher risk of developing CVD.  Given that the greatest increase in NCD deaths is predicted to occur in Africa, a region which also experiences the highest rates of HIV/AIDS, it seems most appropriate that NCD prevention be integrated into the HIV/AIDS care setting. Let one of the revolutionary outcomes of the UN High Level Meeting indeed be integration of services and partnership across disease groups.

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