Despite Recession, New Funding Stimulates Research

New research dollars will energize scientific projects, including many focused on HIV prevention strategies, but uncertainty remains about the sustainability of long-term HIV/AIDS funding

By Regina McEnery

In recent years, budgets of the major US government research engines, including the US National Institutes of Health (NIH), have not increased. Tighter budgets have meant more competition for research dollars, much to the chagrin of scientists who rely on government funding to get their projects off the ground. During difficult economic times, all types of discretionary spending, including scientific research budgets, can get squeezed even further. Yet, even in this time of great economic uncertainty, science funding in the US is now actually on the rise. Ironically, the current recession has spurred dramatic levels of new funding for research projects as part of the US economic stimulus package. Some of the projects that will be funded involve HIV prevention strategies, though not related to AIDS vaccine research. This new money, along with a strong commitment to science from US President Barack Obama, has many researchers excited.

Apart from the stimulus money, there are also some much smaller increases being doled out to HIV/AIDS research. Obama’s 2010 budget, which is yet to be approved by lawmakers, seeks a US$45 million, or 1.5%, overall increase in HIV/AIDS research, for a total of $3 billion. This includes less than a $1 million, or 1%, increase for AIDS vaccine research and a 3.2% increase for research on microbicides—topical gels applied prior to sex with the aim of preventing HIV transmission. As the HIV pandemic approaches its third decade, the Obama administration maintains that HIV/AIDS prevention and treatment is a priority and will remain so despite the recession. “In a time of tightening budgets and economic constraints, the 2010 budget request demonstrates commitment to the global fight against HIV/AIDS,” Acting Deputy US Global AIDS Coordinator Thomas Walsh said when he appeared before Congress.  

Stimulating science

Since promising to return science to its rightful place in government policies, Obama has unveiled several plans to increase research budgets. During an address in April at the National Academy of Sciences, he pledged to devote 3% of the US gross domestic product (GDP) to strengthen science and technology—the current level of spending is 2.6% of GDP. This amount of money exceeds the nation’s peak level of spending on science, which occurred in 1961 when President Kennedy pledged 2.9% of GDP to scientific research, vowing to put a man on the moon by the end of the decade. If Obama’s budget pledge pans out, the money will double funding for the National Science Foundation within 10 years and provide more money for the NIH, including notably nearly $6 billion for cancer research.

This isn’t the only money being funneled into the NIH. After many years of flat funding, the NIH received a 3% annual budget increase already this year, based on the budget of the previous administration, and in February 2009, under a one-time economic stimulus package known as the American Recovery and Reinvestment Act, the NIH received $10.4 billion more in new funding. The National Institute of Allergy and Infectious Diseases (NIAID) at the NIH, the largest funder of HIV/AIDS research in the world, will receive $1.2 billion of the economic stimulus money. About a third of it will likely go toward funding two-year research grants focused on HIV prevention, says NIAID Director Anthony Fauci. NIAID will use the stimulus money to fund already submitted grant applications, which were previously unfunded because of tight budgets and increased competition for research funding over recent years.

Two categories of prevention research being considered by NIAID for the stimulus dollars involve broader applications of antiretrovirals (ARVs). One is studying the delivery of ARVs prior to HIV exposure to prevent infection—a strategy known as pre-exposure prophylaxis (PrEP). The other is looking at the feasibility of providing ARVs to every HIV-infected individual who meets the World Health Organization’s treatment guidelines, a concept known as treatment as prevention, which aims to reduce the spread of HIV. Individuals on ARVs have much lower levels of virus circulating in their bodies and it is therefore thought that they will be less likely to transmit the virus to others.

The third category involves the tantalizing prospect of eradicating HIV from infected individuals. Although complete eradication of HIV—essentially curing an infected individual—is considered a long shot, some scientists think it may be possible to achieve a “functional cure” with strategies that could help eliminate HIV from some of its hiding spots in the body. This probably wouldn’t clear the virus entirely, but it might make it possible for a person’s immune system to keep the residual HIV in check without the aid of ARVs.

One drawback to using economic stimulus money on these projects is that researchers lucky enough to receive the extra cash, which must be spent by 2011, may find it difficult to receive funding to continue their projects once these stimulus grants expire. Unless more money is added to NIAID’s annual budget in 2011 to support these additional grants, “it will be a very difficult year for [these] people to secure funding,” says Fauci.  

Global programs

While the new research money is a boon for scientists, another battle is being waged over US spending on international HIV/AIDS programs. US funding to fight AIDS internationally has grown significantly in recent years due to the President’s Emergency Plan for AIDS Relief (PEPFAR), a program started in 2003 under then-President George W. Bush. PEPFAR started as a $15 billion, five-year program, and was reauthorized last year by the US Congress for $48 billion over five years (or $9.6 billion a year) to fund HIV/AIDS prevention, treatment, and care, as well as tuberculosis and malaria programs.

Obama’s budget proposal includes a $6.6 billion allocation for PEPFAR in 2010, an increase of $165 million over the amount being spent this year. This is significantly less than the $1 billion increase per year that Obama promised during his campaign. He also promised to spend $50 billion over five years on PEPFAR, and though he says he still intends to spend that amount, he says it will be over six years rather than five.

This drew criticism from AIDS advocates who argue that failing to fund PEPFAR at the originally promised level will compromise the program’s ability to provide life-saving ARVs to more HIV-infected people in need. According to the Global AIDS Alliance, about 2.9 million people in developing countries are currently receiving therapy—only a third of the 9.7 million who need it. Others say that delaying the expansion of PEPFAR will also hamper HIV prevention efforts. “People now are coming in for testing in huge numbers because there is the hope of getting treated if they are infected. If that hope is no longer there, people will not seek testing,” says Peter Mugyenyi, director of the HIV/AIDS Joint Clinical Research Centre in Uganda and a PEPFAR recipient. “Without testing, you can’t have effective prevention.”

PEPFAR has brought ARVs to more than two million people in 15 target countries—most of them in Africa—but has not reduced the rate of new HIV infections, according to a recent study published in the Annals of Internal Medicine. In testimony before US lawmakers, Walsh said, “PEPFAR will redouble the focus on prevention.” He called this one of the highest priorities for the program, adding that, “While treatment is incredibly important, we cannot beat this epidemic with treatment alone.”

Obama has praised PEPFAR’s goals but is also interested in a more integrated approach to tackling global health problems. In May, he introduced plans to meld PEPFAR into a $63 billion Global Health Initiative, which will support global health more broadly, including programs related to maternal and infant health and immunization.  

Forecasting the future

In addition to the less-than-expected allotment in Obama’s budget for PEPFAR, AIDS activists and public health experts have raised concerns that the sour economy could pose a threat to the sustainability of global AIDS funding in the future for many programs, including The Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund depends on annual contributions from many wealthy countries to fund its treatment and prevention programs. “Despite lack of resources being a major challenge, failure to continue a scale-up [of] investments in health will betray the trust of millions of people who have been given hope of survival from deadly diseases by the promises of the international community,” says Michel Kazatchkine, director of The Global Fund. Obama’s budget calls for $900 million for The Global Fund in 2010, the same amount that was authorized by the US Congress for 2009.

Although lower prices have been negotiated for many ARVs, overall treatment costs continue escalating as more and more HIV-infected people require treatment and more people become newly infected. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that by 2015 it will cost approximately $54 billion a year to provide ARVs to all people in need living in low- and middle-income countries. The world is currently spending $5.5 billion on HIV treatment, according to the latest UNAIDS estimates. Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations, says there is already fatigue among some international donors and that two decades from now the money to sustain these AIDS treatment programs may not be there. “Either you have a fantasy in which somehow a series of drug [regimens] are available for pennies, or you have to start really focusing on prevention.”