In a widely hailed move, President Obama announced an end to the two-decades-old ban on travel and immigration to the U.S. by HIV-positive individuals Friday.

Obama said the ban was rooted in “fear rather than fact,” and disease experts agreed, saying the prohibition had no basis in public health or science and only served to deepen the stigma and discrimination suffered by HIV-positive individuals.

“Good riddance to this discriminatory rule that had no basis in public health or sound science,” said HIVMA Outgoing Chair Arlene Bardeguez, MD, MPH, in a news release issued by HIVMA and the Center for Global Health Policy. “This long-overdue move brings the U.S. in line with current scientific and international standards of public health and will lessen the painful stigma and discrimination suffered by HIV-positive people.”

The travel ban served to undermine public health by discouraging people from determining or disclosing their HIV status. It also highlighted a troubling paradox in US policy. Even as Washington took a leading role in combating the AIDS epidemic globally, the US kept in place a policy that prevented international HIV/AIDS activists and researchers from coming to here. Indeed, no major international AIDS conference has been held in the US in nearly two decades because of the ban.

“If we want to be the global leader in combating H.I.V./AIDS, we need to act like it,” Mr. Obama said at the White House on Friday, during a signing ceremony for the Ryan White H.I.V./AIDS Treatment Extension Act.

Overturning the ban puts HIV-positive people on a level playing field with any other foreigner wanting to visit or immigrate to the U.S.

“This move brings common sense to US policy and means that people from developing countries who  receive US funded-HIV treatment will finally be welcome here,” said Kenneth Mayer, Co-Chair of the Global Center’s Scientific Advisory Committee and professor at Brown University, where he directs the AIDS Program.

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A diverse coalition of more than two dozen organizations outlined a bold, comprehensive approach to global health at a Capitol Hill briefing today. The briefing comes as White House officials work behind closed doors to flesh out the details of a much-anticipated new US strategy on fighting disease and improving health across the globe.

Today’s event brought together, for the first time, experts and advocates who work on HIV/AIDS, malaria, tuberculosis, child and maternal health, and other health issues, with a unified message: President Obama’s proposal for a new Global Health Initiative  (GHI) offers a significant opportunity for the US to take a transformative role in global health, but the new plan will fall far short if the US does not provide the leadership and resources to back up its promises of more comprehensive, integrated care. If given short-shrift, advocates warned, the GHI could force false choices between diseases and threaten key gains made in combating global AIDS and other epidemics.

“We are massively excited about the possibilities, but we are massively worried” that the funding will not match the rhetoric, said Matthew Kavanagh, director of US advocacy for Health GAP, who moderated today’s Congressional briefing.

Kavanagh said the President’s proposed price tag for the GHI—$63 billion over six years—is simply not sufficient to achieve the goals his plan has identified. The GHI, which the White House first sketched out in May and is expected to detail more fully later this year, listed six target health areas: HIV/AIDS; malaria; tuberculosis; reproductive, maternal, newborn and child health; health systems and health workforce; and neglected tropical diseases.

To truly address those global health issues, the White House and Congress will need to spend about $95 billion over that time period, according to a new report, “The Future of Global Health: Ingredients for a Bold & Effective U.S. Initiative,” released in conjunction with today’s briefing.

In addition to robust funding, the report says the White House needs to set bold targets for prevention and treatment in its focus areas. Targets can help “drive success” by creating accountability, building political momentum, and galvanizing the world community, Kavanagh noted. In short, they can help translate promises into action. Click here to read the full report and see the suggested targets and funding levels for each health area. Click here to see the coalition’s website, where you will also find audio of a media conference the group held before today’s Congressional briefing.

“The world desperately needs the President and the Congress to get this right, not just in words but in execution,” said Ann Stars, president of Family Care International, a nonprofit dedicated to making pregnancy and childbirth safer in the developing world.

Stars said everyone has heard stories of “shiny new AIDS clinics” that are well staffed and resourced to deal with the HIV epidemic, while down the road sit “shabby” clinics overwhelmed and unable to cope with other health needs. “But people get the wrong moral from this story,” she said. When one family is well fed and another is hungry, the solution is not to take food from the first family and give it to the second, she said.

Similarly, when it comes to global health, the way to providing better care for more people “is not to cut the pie into smaller and smaller pieces until everyone goes hungry. We need to make a bigger pie.”

Another presenter, Patrick Almazor, a Haitian doctor with Partners in Health, spoke eloquently about how HIV/AIDS funding has helped PIH clinics in his country scale up much more than HIV treatment. Hospitals and clinics where people used to come to die because they offered few or no services, he said, are now offering prenatal care, family planning services, immunizations, and other care.

During a media teleconference, organized by the coalition partners before the event, Dr. Peter Mugyenyi, director of the Uganda’s HIV/AIDS Joint Clinical Research Centre, said that AIDS remains the most urgent health threat in Africa and that “no health initiative can succeed without treating the millions of AIDS patients in frantic need of lifesaving therapy,” because AIDS will “continue to incapacitate” other components of the health system. He noted, for example, that efforts to make gains in maternal, newborn and child health without combating HIV/AIDS would fail because AIDS afflicts so many mothers and children on the continent.

At the Congressional briefing, three lawmakers expressed support for the coalition’s goals and agenda; Reps. Diane Watson (D-Calif.), Jan Schakowsky (D-Ill.), and Betsy McCollum (D-Minn.) all made supportive remarks about the need to provide robust funding and take a more integrated approach to global health.

Rep. McCollum said a more comprehensive approach was “exactly” the right way forward. But she warned of challenges because of the global economic downturn. “New funding increases are going to be tough,” she said. “It means squeezing every penny out of every dollar” to get the most out of US investments. She also pointed to the continuing vacancy at USAID, which will hobble efforts to coordinate a winning strategy.

Advocates agreed and said the president’s new plan could have a “transformative effect,” as Kavanagh put it. But he and others emphasized that the initiative will fail if it takes funding from one disease to scale up another.

“It’s unacceptable to pit one sick patient against another,” said Dr. Matthew Spitzer, president of Doctors Without Borders/MSF-USA.

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The November issue of the Journal of Acquired Immune Deficiency Syndromes offers something of a roadmap for how best to move forward, more productively and less bitterly, in the decades-old debate that pits diseases-specific health initiatives against broader efforts to strengthen health systems. With nearly 20 articles exploring the relationship between HIV scale up and global health systems, JAIDS is weighing in on the hottest topic du jour in Washington and various academic circles.

But the opening piece, an introduction by Drs. Wafaa El-Sadr and Kevin De Cock, reminds us that this should not be an esoteric debate, disconnected from the health care realities on the ground in the developing world. “Health systems exist to provide services for real people to prevent and treat diseases that have names,” they write. Failure to recognize that could have devastating consequences.

“Perhaps most seriously, the debate fails to take account of the lives saved through PEPFAR and the Global Fund, and the implications for countries and systems if those advances are not sustained or extended,” Drs. El-Sadr and De Cock say. “We cannot forget that it was the unparalleled impact of untreated HIV/AIDS in Africa that launched these major initiatives and that the prevention of death remains a core public health function. At the same time, criticisms such as that HIV/AIDS programs steal health care workers or are sometimes ivory tower initiatives amidst a sea of misery need to be examined seriously.”

Instead of a polarizing and theoretical debate, these questions need to be addressed with strong “global health leadership, clarity of thought, pragmatism, and sound understanding of disease epidemiology.”

And that’s just the JAIDS opener on the topic. Click here to see the table of contents and read the rest.

In case lawmakers need an extra nudge as they consider lifting the ban on federal funding for needle exchange programs, here are two fresh facts on the effectiveness of this tool in reducing the spread of HIV:

*In India, needle exchange programs have contributed to a dramatic reduction in HIV seroprevalence among injection drug users—cutting the rate from 81% to 58% over a three-year period.

*In Brazil, syringe exchange policies have led to a 62% reduction in HIV infections among injection drug users.

This data comes from a new report, “Syringe exchange programs around the world: The global context,” out this week from the Gay Men’s Health Crisis. The report says that as of 2008, there were at least 77 countries worldwide that had introduced syringe exchange programs (SEPs) to curb the spread of HIV/AIDS.

The news of how effective SEPs can be in reducing HIV infection is no surprise to those who of us advocating for evidence-based global health policies. But it comes as Congress considers overturning its ban using federal money to support needle exchange programs. A House committee approved a measure lifting the ban, albeit with so many restrictions as to make it essentially useless. A Senate panel voted to leave the ban in place. That means a full-blown congressional fight on this hot topic is in the offing.

As we’ve written here before, the ban technically only applies to domestic programs, but PEPFAR officials have extended it to international programs, so this has major implications for global HIV prevention efforts. Dr. Eric Goosby, the US Global AIDS coordinator, has strongly signaled the administration’s desire to see the ban overturned and says a move to do so in the international context is in the works. But the White House seems to be waiting for Congress to make a more definitive move on this first. Given that, this report adds some important new points to the debate.

Here’s more from the GMHC’s news release and a link to the full report.

“The newly released report highlighted five policy lessons from the review of global SEPs: (1) the importance of government sponsorship and regulatory oversight of community-organized SEPs; (2) how legal regimes can inhibit the success of SEPs in reducing HIV infection rates; (3) the ways in which successful SEPs interact flexibly with IDUs, such as by providing mobile services, syringe vending machines, or even drug rehabilitation services; (4) how countries can use SEPs to promote rehabilitation and reduce the incidence of drug use; and (5) the ways in which SEPs have thrived even in countries with strong social and religious mores opposing drug use.”

http://www.gmhc.org/policy/2009/gmhc_intl_seps.pdf

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