About the Author: Ambassador Eric Goosby serves as U.S. Global AIDS Coordinator.
In June, I made my second visit to Uganda as the Global AIDS Coordinator. During the 1980s and 1990s, Uganda's successes in combating HIV/AIDS garnered global attention. But the disease remains a significant challenge for the nation, with the availability of antiretroviral treatment recently becoming a focal point of concern. My trip to Uganda was to engage in dialogue around this issue.
The dramatic expansion of access to health care services, including HIV treatment, in Uganda in recent years has been a remarkable accomplishment, one in which the United States has been able to play a key role. Over 200,000 Ugandans were receiving treatment at the end of September 2009, of whom 175,000 were directly supported by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). U.S. HIV/AIDS funding to Uganda is currently $280 million a year, and totals $1.4 billion since 2004. This is a historically high level of funding, particularly in a time of tightening budgets and economic constraints. In fact, the United States contributes approximately 70% of all funding for HIV/AIDS activities in Uganda.
Of course, the key metric is not the amount spent on a particular intervention, but the lives saved, a point made to us during our dialogue. The high point of my visit was a discussion with representatives of Uganda's extraordinary civil society sector, who have been leaders throughout the country's fight against AIDS. They eloquently presented their concerns regarding HIV needs in Uganda -- including treatment -- but also the need for effective prevention to prevent people from becoming infected in the first place. The key to ending this epidemic is to reduce the number over the long term of those who become HIV-positive, which is best accomplished as part of an overall effort to improve their health and the health systems that serve them.
That is why under President Obama's Global Health Initiative (GHI), we are working to save as many lives as possible by addressing the range of health needs people in countries like Uganda face, such as maternal and child health, health systems, neglected tropical diseases, and -- of course -- HIV/AIDS. By linking our activities, we will have a significant impact on the longevity and quality of life of millions of people now suffering from preventable and treatable diseases. PEPFAR is the cornerstone of this effort, which reflects lessons learned from the success of PEPFAR in Uganda and other countries.
In our discussions, we were candid about the issues and possible ideas for moving forward. I also spent considerable time with Ambassador Lanier and our PEPFAR country team to better understand the challenges and opportunities they see in Uganda.
Clearly, the challenges are significant. The country's unmet health need is large, with special challenges in HIV treatment. Despite the significant commitment by the United States, the Global Fund to Fight AIDS, Tuberculosis and Malaria disbursement for treatment in 2009 from a Round 7 grant awarded in 2007 was only $4.2 million, far below the amount allocated, due to continuing governance issues in Uganda. Although there has been recent progress in addressing these issues, unavailability of these funds over these years has led to a halt in enrollment of antiretroviral treatment patients in some clinics, which in turn severely increased the pressures on other service sites (including many supported by PEPFAR). In addition, the impending withdrawal of medicines donated by the UNITAID health fund has led to uncertainty regarding supplies among HIV treatment providers.
To meet the need, Uganda's national government must resume the central role in leading the national response on health in general, and HIV/AIDS in particular. Through GHI, our programs will be implemented not only to increase access for Ugandans in the near term, but also to catalyze a more candid dialogue with Uganda's political leadership. While all appreciate the extraordinary U.S. commitment, the U.S. cannot be the sole resource for reaching the shared global goal of universal access to AIDS treatment in any country. Resources from other external donors, and from each country's own resources to the extent of its ability, must be found and mobilized.
All of these issues are familiar ones. I have been involved in HIV care as a clinician and in government for over 28 years. From the beginning, AIDS has posed daunting and unique challenges -- but the history of this disease has been one of people coming together to overcome those challenges. From my consultations, I came away with renewed confidence that, working in partnership, we can come together to support Uganda in rising to meet the needs of its people.
In my discussions with the people of Uganda, I clearly reiterated PEPFAR's commitment to support continued expansion of treatment in Uganda, as the PEPFAR Uganda team did in a May 2010 communication to partners in-country. I also emphasized the need to find new ways, and commit more resources, to prevent people from becoming infected in the first place and eventually needing treatment.
As in every country, there are many pieces to the puzzle. Based on our intensive consultations, the key actions PEPFAR will take in Uganda include the following. This is not an exhaustive list, and we will certainly adapt it as we move ahead, but I believe it captures most of the elements of a way forward.
• Through the GHI, PEPFAR will strengthen linkages with other U.S.-supported health programs, to ensure that we are being effective and efficient in meeting needs holistically.
• PEPFAR will continue to support treatment scale-up in Uganda, as well as expansion of access to HIV prevention and care and other needed health services.
• To address immediate needs, PEPFAR will provide an immediate infusion of antiretroviral drugs to allow partners to refill buffer stocks, avoid stock-outs and continue expansion of treatment services.
• PEPFAR will provide increased short- and medium-term financial assistance to bridge this challenging period.
• PEPFAR will aggressively promote best practices and innovations in service delivery to enable both PEPFAR overall and individual partners to operate more efficiently in order to serve more people. Examples may include: partner rationalization to ensure no site is served by more than one partner in any one technical area; review of drug pricing and procurement; and portfolio review to ensure alignment of partner configurations, funding opportunities and programs with high-level strategic objectives for each program area.
• PEPFAR staff in the field and at headquarters will work with Ugandan counterparts to conduct a highly detailed analysis of treatment expenditures in order to develop a plan that results in more people accessing treatment. This analysis will include modeling costs, projecting costs for scale-up, and matching these with implementation realities (e.g., limited human resources for health, clinic space, and coverage, and growing waiting lists).
• To accelerate the full functioning of grants of the Global Fund in country, PEPFAR will actively work with the Government of Uganda and Global Fund leadership in Geneva to facilitate the partnership required to scale up treatment, including mobilizing the Fund to restart the infusion of funds from previously approved grants. PEPFAR will also continue to engage with UNITAID about its plans -- to date, UNITAID has agreed to delay its withdrawal date to 2011.
• Perhaps most importantly, PEPFAR will pursue a new approach to purposeful engagement with the Government of Uganda and civil society. We will seek meaningful collaboration and contribution to the HIV response from the Government of Uganda, engaging it to do more to address critical needs and achieve better health outcomes for the Ugandan population, including through heightened financial and strategic leadership commitment.
None of these steps are fundamentally different from our activities in all of the countries in which we work. The role of U.S. health programs under the President's GHI is never to lead another nation's response, but to work with it to identify opportunities where U.S. technical and financial support can make a needed contribution. This is an ongoing, iterative process, with our U.S. Ambassadors and outstanding teams in country providing the key interface in dialogue with government, civil society, and other donors.
I am fundamentally optimistic about Uganda's HIV/AIDS response, and indeed about the reinvigoration of the global response to this challenge. I am grateful to our friends in Uganda for once again reaffirming that optimism.