Tropical Health Matters

This morning two key advocacy groups organized a teleconference with Christoph Benn, the Director for the External Relations and Partnership Cluster at the Global Fund to Fight AIDS, TB and Malaria, so that we could learn more about the recent GFATM Board Decision to cancel Round 11 proposals/funding. The main take away message is that the GFATM is NOT in an immediate financial crisis, but that longer term projections could be at risk.

Christoph Benn was reassuring about the ability to carry on and scale up commitments made for funding rounds 8, 9, and 10. Organizers of the teleconference, the Foundation for AIDS Research (amfAR) and Friends of the Global Fight (Friends), encouraged participants to strengthen advocacy efforts with the US Congress where the longer term challenges lie in getting pledges for future funding.

There was talk of the GFATM 2012-16 Strategy that calls for funding based on national policies, national need (gap analysis) and dialogue with partners.  Christoph Benn indicated that Round 11 would have been the last of the formal funding rounds as we have known them, and its cancellation simply pushes us faster towards the new funding strategy. It was also made clear that there would be a weaning of G20 countries off of GFATM money, though commitments to high risk target groups in existing projects would be honored until those grants closed.

Again the short term effect is that countries that would have needed Round 11 funding will be encouraged to apply for transitional funds that will hold them over until the 2012-16 Strategy is fully implemented.  The Roll Back malaria Harmonization Working Group, for example, will be helping countries who intended to apply for malaria grants in R11 to undertake their gap analysis and planning in order to obtain transition funding.  This can only happen after the GFATM revises the application guidelines. As Christoph Benn explained, the ramifications of last months’ Board meeting in Accra are still being worked out.

Back to the longer term concerns or what was termed the uncertainties  of funding forecasts based on donor conditions.  Many donor countries have pledged to continue their funding levels to GFATM, and the United Kingdom has even pledged an increase. But all eyes are on the U.S. Congress, who initially pledged to maintain level funding this past summer, but now is uncertain whether global health and foreign assistance will receive support. It was basically this change of heart that put the brakes on R11 funding.

Our advocacy partners had heard from members of the Congress that they were worried about the financial health of the GFATM, but now have been told that the GFATM is still very much viable.  It is the longer term expansion beyond current commitments that is in question.  Rephrasing Jeffrey Sachs’ concern, “Will Washington leave millions to die?”

This morning’s Washington Post featured a story concerning another setback in HIV/AIDS prevention research. The article stated that, “The abrupt closure last week of one part of a complicated study called VOICE marked the third time in eight months that anti­retroviral drugs did not prevent infection in those assigned to use them.” Ironically, the interventions had proven effective in smaller scale trials.  What happened during scale up?

The two research interventions focused on either having women insert a vaginal gel daily or people taking pills. One explanation offered for the failure the second time around was as follows:

The answers may lie in subtle differences between the groups being studied and the designs of the experiments. For example, the volunteers in Partners PrEP (pre-exposure prophylaxis study) were long-term couples in which one person was infected and the other not. It’s possible they may have been more motivated to take the pills every day. In CAPRISA (the South African PrEP study), the women inserted the vaginal gel before and after sexual intercourse rather than every day — a targeted approach that may have helped them stick to the program.

Such differences in the social and behavioral context of research make all the difference – basic research on drug effectiveness cannot be divorced from the people who receive the medications. The Post contacted experts who offered the following opinions about why there were problems.

• The daily regimen just probably was not acceptable; if the gel were being used according to instructions some differences between groups should have emerged.
• Other studies of vaginal microb­icides and pre-exposure prophylaxis have shown that few people use prevention tools as regularly as they say they do, but the more “adherent” people are, the more protection they get.
• What we have to face up to is that everything in HIV prevention is based in human behavior.

The article concluded by saying, “What seems clear is that this strategy, once viewed as the easiest and most certain, is going to require a lot of fine-tuning even if it works.”

With malaria interventions, similar lessons apply. ACTs do not protect is people do not adhere to the 3-day regimen. LLINs do not protect if people use them to cover their vegetable gardens. IPTp is not effective unless pregnant women attend antenatal care regularly. Rapid diagnostic tests are wasted if health workers do not believe in their efficacy.

Often we wait until problems of non- or inappropriate utilization of health interventions occur before we start looking at social and behavioral factors. The Post quoted one epidemiologist who said, “People are upset. It’s a big head-scratcher as to why it didn’t work.” Researchers should be embarrassed to admit such, as this means they did not do adequate formative research in advance to understand the social and cultural context into which they were introducing their innovations.

Certainly similar mistakes have been made in malaria research and intervention, but now with international donor funding severely threatened, we cannot waste resources pushing interventions that are not socially and culturally acceptable.