This week, the WHO upheld its current guidelines in relation to use of hormonal contraception and women living with HIV. President Obama released his administration’s budget request for 2013, with some surprising news for US global heath policy. Finally, polio eradication efforts in Pakistan have been hamstrung by government health care and regulatory incompetency and the CIA’s fake vaccination program.
WHO Upholds Hormonal Contraceptive Use Recommendations for HIV
Last year, I wrote about a new medical study that found that the use of hormonal contraceptives could double the risk of HIV infection and transmission. This month, the WHO convened a technical consulting group to discuss the findings from this study and others that examined the relationship between hormonal contraceptive use and HIV acquisition by HIV-negative women, the transmission of HIV from women to HIV-negative men, and disease progression in HIV-positive women. In a technical statement (PDF), the WHO concluded that the current studies did not provide strong enough evidence and that it would not alter its current guidelines. The UN body did add a “strong clarification” to its guidelines, however, emphasizing the importance of condom use (the only contraceptive method that provides high protection against unintended pregnancy, HIV, and most STIs).
According to UNAIDS’ corresponding press release, 11% of women of childbearing age (15-49) worldwide have unmet family planning needs. In sub-Saharan Africa, that unmet need jumps to 25%. In many low- and middle-income countries, there is a deadly convergence of high HIV prevalence, low uptake of contraception and other family planning methods, and high maternal and infant mortality. Even if hormonal contraceptives carried such a risk, they have a very positive effect on to lowered maternal mortality rates, poverty, and other factors. In global health, decisions about treatment and prevention measures must be carefully weighed. For example, mothers living with HIV in high income settings are recommended, if not required, to use replacement feeding options (formula) because of the risk of HIV transmission during breastfeeding. In low- and middle-income settings where lack of access to water and convenient kitchens, stigma and discrimination, and the cost of formula are barriers to safe replacement feeding options, the WHO recommends that women living with HIV exclusively breastfeed their infants, while adhering to ARVs (as AVERT outlines here). Although the WHO cites inconclusive evidence as the reason for upholding its current guidelines, I’d wager that they would not amend them unless the evidence were incontrovertible that the use of hormonal contraceptives carried an extremely high risk of HIV acquisition or transmission. The other health and development considerations are as vast and as dire.
Obama Administration’s 2013 Budget Request and Global Health
President Obama released his administration’s budget request for 2013 (for the US government, the fiscal year begins in the previous October, and barring any more nasty Congressional fights, a version of this proposal would take effect on October 1, 2012). Reactions to the request, which must pass Congressional approval, are mixed. According to a US Department of State fact sheet, President Obama has requested $7.9 billion for his Global Health Initiative, of which $5.4 billion would be allocated to the President’s Emergency Plan for AIDS Relief (PEPFAR), as part of the administration’s commitment to put 6 million people on antiretroviral treatment by the end of 2013.
What the fact sheet does not mention (and is the highlight for many in the global health sector), is that the request also asks for $1.65 billion for the Global Fund, as Ambassador Eric Goosby, the US Global AIDS Coordinator, writes in a post for the State Department’s DipNote blog. He notes that this request puts Obama on track to fulfill his pledge of seeking $4 billion in US funding for the Global Fund over the next three years and argues that support for the Global Fund will increase the effectiveness of PEPFAR and inspire other donor countries to support the beleaguered multilateral organization. The Kaiser Family Foundation has a good break down of the requests for global-health related funding and their relative increase or decrease from 2012–it’s worth noting that PEPFAR’s overall budget would decrease slightly from the deep cut made in 2012 (following negotiations with Congress). Amanda Glassman and Denizhan Duran of the Center for Global Development are optimistic about the shift towards multilateral funding, using facts and figures to argue that multilateral organizations like the Global Fund are more efficient. Christine Lubinski of Science Speaks is less pleased with the 2013 budget proposal, writing: “Slashing the PEPFAR program to increase funding for the Global Fund would seem to undermine the promise of treatment scale up.” Lubinski also quotes Matt Kavanaugh of Health GAP, who called this aspect of the budget request “a bait and switch worthy of Wall Street.”
Of course, hand wringing now is putting the cart before the horse: given that this is an election year, I anticipate a floor fight or another near-government-shutdown crisis. With politics in the US as acrimonious as they have been, it can only get worse when political power is on the line. I’m happy to see that President Obama is focusing on the Global Fund (and domestic HIV/AIDS programs as well!), and I hope that the draw down in Iraq will give him a little more wiggle room on spending while decreasing the deficit. Of course, the Obama administration could always do more, but I am less worried about his goals and intentions for global health than I am about those of Congress. This appears to be a shrewd political move that could have positive effects on the global health and development fronts. We’ll just have to wait for the Congressional response.
Pakistan’s Polio Problem
In the past, I’ve written about the massive gains the global community has made against polio, with a 99% reduction in cases reported in 2011. It’s not all been successful, however, and one of the main backsliders is Pakistan. The BBC reported this week that Indian health officials are vaccinating all Pakistani children who cross the border. According to the BBC, India has remained polio-free for at least a year and wishes to remain so, while Pakistan has reported 175 cases–hence the vaccination efforts. According to IPS (who writes that India has had one case and Pakistan 197 in the last year), Pakistanis are rejecting polio vaccines due to distrust of the Pakistani public health system. In Lahore this year, 125 cardiac patients at a government-run hospital died after being administered a cardiac drug contaminated with high doses of an anti-malarial. Fears over government healthcare and regulatory incompetencies are driving parents away from polio vaccinations. Clearly, more must be done to improve the current health system and shore up weak regulatory safeguards. When governments do not or cannot commit to their health programs, this is the kind of result that we will see, as I discussed with the possible outbreak of totally-drug-resistant tuberculosis in India.
Furthermore, Pakistanis are refusing to vaccinate their children following the revelation that the US Central Intelligence Agency launched a fake polio vaccine program as part of efforts to find Osama Bin Laden, which I covered last July. As I wrote then, the CIA’s program was reprehensible because it damaged the trust that ordinary people must place in their health care providers. Very unfortunately, this seems to have had an adverse effect on not only polio eradication efforts within Pakistan’s borders, but potentially in Afghanistan and India as well. Disease outbreaks do not exist in a vacuum, especially in a world where one has the ability to cross the world in a day. Shame on the CIA and the US and Pakistani governments.