Q and A with Mitchell Warren

How will the re-election of US President Barack Obama impact domestic and international AIDS spending and policies? Long before the bitter contest was settled on Nov. 6, the focus had already shifted to Jan. 1, when US $7 trillion worth of tax increases and automatic spending cuts over 10 years will begin to take effect unless Congress acts. Most economists agree that doing nothing will push the US economy over a so-called “fiscal cliff” and drive the country into another recession. But what specifically would that mean for AIDS spending, both on the ground and in the lab? With negotiations now underway in Washington and gridlocked US lawmakers trying to forge a compromise that has eluded them for two years, VAX science writer Regina McEnery asked the executive director of AVAC—a global HIV prevention group advocating for a vaccine—what he thinks a second Obama term likely means for the global AIDS agenda. The interview was conducted Nov. 9.

Has the outcome of the US election changed the dynamics of these budgetary talks? 

It’s a great question. I hope it changes something. It really comes down to—will the US government find a solution to the fiscal cliff by January. It is an incredibly important issue, one with huge importance for global health. If the US government goes into sequestration [across-the-board automatic spending cuts] it would have a staggeringly bad effect on both global health, and science and technology research and development. It could cut potentially 8% from the US National Institutes of Health’s budget, which has been flat-lined the last couple of years. In the case of PEPFAR [the US President’s Emergency Program for AIDS Relief], many countries have already gone through caps on treatment slots because resources are thinner. If we saw significant cuts to foreign aid, there would be even fewer people in treatment. It will become harder to help people adhere to treatment and suppress viral load.

Do you think this crisis can be averted? 

My hope, and I tend to be an optimist given the re-election of Obama and the Democratic-controlled Senate, is that they all seem to get it. Obviously the current business-as-usual has to change. We have to get the US deficit under control. But while hard cuts have to be made, sequestration is the worst way to do it. Jobs would be lost, progress would be rolled back.

What role are AIDS advocates playing during these budget talks?

A lot of advocacy has to be around making sure people see what the impact of sequestration will be. And I think we also need to make sure we keep in view the long arc of what we are trying to accomplish, to show the hard-fought investments that have been made. Despite some setbacks, we have seen advances over the last several years in R&D and global health. It took a long time to create these programs. Once you turn the tap off, and have to lay people off and close down programs, to restart [those programs] even a year later is far more complicated.

What should be the goals and objectives of the blueprint to get us to an AIDS-free generation, which US Secretary of State Hillary Clinton called for at the International AIDS Conference this summer? 

The office of the Global AIDS Coordinator is working on the blueprint and we expect it by World AIDS Day [Dec. 1]. Our eyes are on that blueprint. Will it be just a lot of flowery language or will it provide us with a clear, feasible and ambitious program with achievable targets that enable us to make very hard decisions that are aligned with the [scientific] evidence? More importantly will it lay out a management system that quantifies quarterly and annually what we need to do? If we need to, say, perform four million circumcisions in certain countries, by 2014, we can’t wait until 2015 to make sure if we hit that number. In 2003, Jim Kim, then director of the World Health Organization’s AIDS Program launched the 3 by 5 initiative [3 million on ARVs by 2005]. People said he was crazy and the target would not be met, and while those people were right about the target, setting those targets and using them to measure against progress was pivotal.

Should a goal of this blueprint be a vaccine? 

Absolutely. Along with short-term goals, the blueprint has got to include a long-term, end-game strategy for today and for the next 20 years that emphasizes the need for a vaccine and I would argue investment in cure research. There has to be an R&D agenda for new technologies and interventions while scaling up existing interventions.

It looks like the Affordable Care Act [ACA] is here to stay. How will the law impact HIV services?
We have been a treating society, not a preventing society. One of the best things [in the law] is that prevention is now part of the health care system and that means more access to things like HIV testing and preventive services. And more people will also have access to care. The challenge right now is: How do you implement [the ACA]? Many states are in a waiting situation. We all need to be keeping our eye on that.

The fiscal cliff aside, PEPFAR is also up for reauthorization next year. Where does it stand? 

We need to make sure [PEPFAR] is funded robustly. Advocates are pushing for reauthorization and for it to be included in the blueprint to make sure PEPFAR gets implemented. There is also a concept you are hearing more and more called country ownership. Countries will need to step up and own their [AIDS] programs.

And what about the $63 billion Global Health Initiative?

PEPFAR was supposed to be the foundation of the Global Health Initiative. Since its rollout questions have been raised about how much money should be spent on AIDS, should we not be focusing on other diseases. Yet if one looks at the last decade, the AIDS treatment response fundamentally changed the way health systems were funded and implemented around the world in a great way. We have to be sure, even as we look to the more comprehensive approaches, that we don’t let things slip back to the pre-PEPFAR days. To me, whether you are talking about PEPFAR, the Global Health Initiative, the Global Fund [to fight AIDS, Tuberculosis and Malaria], the single biggest issue in 2013 is global leadership. We know Sec. Clinton has had a huge role to play, but she has said she will not serve in Obama’s second term. Who will be her replacement? Her successor has very large shoes to fill.