This article was first published on 24 July 2012 in theAtlantic.com.
Four years ago, President Obama's election generated hope for new American leadership in the fight against AIDS here at home and around the world. On that day, South Africa's Treatment Action Campaign -- the movement which combined massive demonstrations with sophisticated insider legal cases and science-based activism to force South Africa to create the world's largest HIV treatment program -- recalled his visit to their offices in the township of Khayelitsha, Western Cape, in August of 2006, and how it had urged him to run for president to have a chance to fulfill his commitment to addressing AIDS.
"Obama took a strong position on preventing and treating HIV/AIDS," the group recalled in 2008, "and was critical of President Mbeki and the South African government's response to the epidemic," then expressed through a deadly form of HIV denialism.
Since becoming president, Obama has continued to talk the talk, promising last December on World AIDS Day to lead the way towards an AIDS-free generation, and to increase U.S. support for global HIV treatment to cover antiretroviral therapy (ART) for six million people around the world by the end of 2013. That makes his silence this week, during the first International AIDS Conference to be held on American soil since the 1990 gathering during the George H.W. Bush administration, all the more striking.
Obama simply hasn't walked the walk when it comes to funding for AIDS. In fact, earlier this year, he proposed a shocking cut of $550 million to the President's Emergency Plan for AIDS Relief (PEPFAR), the most successful U.S.-funded global health program in history.
At first, the administration failed to provide any explanation for such drastic cuts, which could put the lives of thousands who depend on the United States to pay for treatment at risk. Later, in response to pressure from the Treatment Action Group and its activist colleagues, administration officials claimed that they had been so successful in reducing costs that they could reach the target of getting medicines to 6 million during 2013 even with dramatically reduced funding.
It's true that costs have gone down. Earlier this week, the Clinton Health Access Initiative released data showing that the cost of providing HIV care and treatment has dramatically fallen in the past two years due to increased use of generic medications and overall program efficiencies. The annual cost of HIV care in Ethiopia, Malawi, Rwanda, and Zambia -- including drugs, lab costs, and health worker salaries -- is now just $200, while in more developed South Africa it is $682. In her speech to the International AIDS Conference on Monday, Secretary of State Hillary Clinton indicated that these economies of scale enabled PEPFAR-supported programs to enroll 600,000 people in the last six months, compared with 700,000 in the past fiscal year.
With these successes in hand, the Obama administration could easily have proposed a more rapid scale-up towards unmet HIV prevention and treatment needs, rather than slashing PEPFAR. There are plenty of global health needs to which the funds saved on "efficiencies" could have been applied -- expanding TB testing in mothers and children, purchasing GeneXpert TB test kits, which can diagnose the disease and its most common drug-resistance patterns in two hours rather than the two weeks or more traditional TB culture takes -- as well as expanding ART treatment slots and growing maternal and child health programs. All these would have been steps forward towards the making administration's AIDS-free generation promise a reality.
Instead, the administration decided to pocket the savings, leaving millions of people out in the cold.
Some people even wonder if the president's lack of enthusiasm for PEPFAR heralds the program's demise next year, when it is due to be reauthorized by Congress. PEPFAR was launched in 2003 by President George W. Bush and, along with the Global Fund to Fight AIDS, Tuberculosis and Malaria, has channeled $39 billion in U.S. aid towards HIV treatment and prevention efforts (as well as the fights against TB and malaria) around the world, making the United States the single largest source of dollars addressing the global HIV pandemic. Four-and-a-half million people today are receiving life-saving HIV treatment through PEPFAR in low and middle-income countries in Africa, Asia, the Caribbean, and South America.
Had Obama attended the International AIDS Conference (Secretary of State Hillary Clinton, HHS Secretary Kathleen Sebelius, PEPFAR chief Eric Goosby, and NIH AIDS supremo Anthony Fauci and other members of the administration have been speaking or attending in his stead), he would have heard deep gratitude for the U.S. role in responding to the HIV epidemic around the globe. He would have heard optimism that the world is on the cusp of being able to do something long thought unthinkable -- actually bring about an end to the AIDS pandemic.
But since he won't be there, here's a to do list the president should consider if he wants to walk the walk to truly begin to make that happen:
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