by Carolynn B. Race and Catherine Gordon

Since 1981, more than 20 million people have died of AIDS. It is estimated that 38 million people are now living with HIV/AIDS (50 percent women). In 2003, nearly five million people became newly infected with HIV, the greatest number in any one year since the epidemic began.

In its 2004 report, the Joint United Nations Programme on HIV/AIDS (UNAIDS) noted:1

"AIDS is an extraordinary kind of crisis; it is both an emergency and a long-term development issue. Despite increased funding, political commitment and progress in expanding access to treatment, the AIDS epidemic continues to outpace the global response. No region of the world has been spared. The epidemic remains very dynamic, growing and changing character as the virus exploits new opportunities for transmission."

The number of people living with HIV/AIDS in the developing world is huge: 25 million in sub-Saharan Africa. Botswana and Swaziland have the highest HIV prevalence rates, 37-38 percent. In Asia, 7.4 million people are living with HIV/AIDS, and in 2003, 1.1 million people became infected in Asia, the highest one-year rate ever. In Eastern Europe and Central Asia, about 1.3 million people are living with HIV — more than 80 percent under 30. In the Caribbean, about 430,000 people have HIV.

In the U.S., more than 460,000 have died of AIDS since 1981, and it is estimated that 950,000 people are now living with HIV/AIDS. Half of new infections in recent years have been among African Americans. As noted by Gwen Ifill of PBS during the Vice Presidential debate, in the United States, black women ages 25-44 are 14 times more likely to die of the disease than their white counterparts.

How can we, as Presbyterians, respond to HIV/AIDS? What policy and funding changes are necessary to curb this epidemic? An update on federal policy and calls to action are below.

International Issues

In mid-October the United Nations warned that Africa must brace itself for an AIDS time bomb. As 8,000 people are infected each day, the region hardest hit by the AIDS pandemic is heading for a doomsday scenario if preventive measures are not scaled up.

Per capita growth in half of the countries in sub-Saharan Africa is falling by .5 percent — 1.2 percent each year because of AIDS. And, per capita gross domestic product in some of the countries hardest hit by the disease may drop by as much as eight percent by 2010.

As we have seen with Afghanistan, devastated, unstable states can become breeding grounds for terrorists. AIDS is not only a moral issue but also an economic and security issue. While Africa is the most severely threatened by the disease, it is also increasing in other regions. Officials in the USAID HIV/AIDS Research Project in Russia and Ukraine warn that Ukraine, which has a high infection rate, faces a crisis and needs help from the international community to protect the country and the social, economic and political development and security of the entire region.

The United States has taken some steps to address this international emergency, but much more needs to be done.

In January 2003 the President announced his Emergency Plan for AIDS Relief (PEPFAR) — a five-year, $15 billion plan with three goals; prevent 7 million new infections, treat 2 million HIV-infected people, and care for 10 million HIV-infected individuals and AIDS orphans.

Many health professionals have been disappointed with PEPFAR. The Bush Administration says it is providing treatment to 25,000 people through its own programs, as well as from its contributions to other AIDS programs. This figure represents 1.25  percent of the goal of treating 2 million by 2008. In addition, Congress set a goal of providing treatment for 500,000 people by September 2004 in last year's AIDS authorization. The current numbers are only 5 percent of what Congress had called for by this point.

The Ecumenical Pharmaceutical Network (EPN), comprised of Christian Health Associations and hospitals, non-profit drug supply organizations, and church-related development agencies from 22 countries, expressed the following major concerns:

1. PEPFAR's insistence on FDA approval for all medicines purchased, and the 'buy American' requirement for medicines other than anti-retrovirals (ARVs), causes needless delay in making life-saving drugs available and may be inconsistent with national treatment protocols.
2. PEPFAR's overwhelming preference for brand-name drugs, and the barriers to using more affordable generic ARVs and drugs for opportunistic infections raise four concerns:
   • It introduces a situation where patients are given different brands of the same drug, thus creating a multi-cadre patient system in an institution, leading not only to misunderstandings but also a lot of additional work for the health staff.
   •  It will be difficult for the institutions to continue providing the same treatment at the end of the PEPFAR programme.
   • Using drugs approved only by the FDA may kill the local industries and threaten the sustainability of the already existing drug supply chains. This is particularly true of drugs against opportunistic infections, which are produced locally at affordable prices.
   • Use of expensive branded products, where equally good but cheaper alternatives are available, is not a cost-effective use of resources.
3. In some cases, PEPFAR disregards national drug regulations and local supply chain management systems, which could damage national health systems, especially the pharmaceutical sector.
4. Treatment requires a lifetime commitment, yet there is no long-term strategy to provide a continuance of care at the end. The high level of donor control — and little or no country or local ownership — further undermines the sustainability of health care and other services.
5. The implementation of PEPFAR promotes extensive use of U.S. skills and capacities (personnel and institutions) to the detriment of available local expertise with greater understanding of the issues in their local contexts.

There is excessive delay caused by bureaucracy and conflicting operational rules and regulations. Cumbersome and time consuming documentation requirements; complicated procurement procedures for drugs and other needed items and restrictive expenditure regulations, under- mine the efforts of institutions trying to implement PEPFAR.

The implementation of PEPFAR is mostly unilateral, undermining other international efforts such as the '3 ones' (one co-ordination, one strategy and one monitoring/evaluation) and the UN Prequalification Project managed by WHO.

While PEPFAR needs improvement, Congress has passed additional funding for combating the epidemic, which is good news. In September the Senate passed the Foreign Ops Appropriations bill (including 2.4 billion for the President's AIDS initiative, and $400 million for the Global Fund for HIV/AIDS, Tuberculosis, and Malaria.) The Senate appointed conferees after the bill passed, but it is likely to be passed in an end-of-session omnibus spending package. On July 15th, the full House of Representatives approved their version of the FY 2004 Foreign Operations Appropriations bill. During debate, several Members spoke eloquently about the global health programs but no amendments were approved that would have increased funding for them. The House bill provides a total of $2.2 billion global assistance to combat HIV/AIDS, tuberculosis and malaria. Within the $2.2 billion, $885 million is provided for bilateral assistance through the Child Survival and Health Programs Fund, and $1.26 billion is provided to the Global AIDS initiative.  

Domestic Issues

Congress is in recess until November 16, when Members will return for a 'lame-duck' session. At that time, Members are expected to finish work on FY05 spending bills, as only four of 13 appropriations bills (military construction, homeland security, defense, and District of Columbia) have passed both chambers. In November, Congress may take up the remaining spending bills in one omnibus measure.

Spending bills that deal with FY 2005 domestic HIV/AIDS funding, including Labor, Health and Human Services, and Education (Labor-HHS) and Veterans Affairs, Housing and Urban Development, and Independent Agencies (VA-HUD), have not been completed. Now is a perfect time to contact your Members to ask them to strengthen HIV/AIDS-related programs, especially for care, treatment, research, support services, and prevention services for people impacted by HIV/AIDS.

Labor-HHS Appropriations

The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act provides services to 533,000 people living with or affected by HIV throughout the U.S. and its territories. It is the single largest source of federal funding focused solely on the delivery of HIV/AIDS services. The CARE Act exists because so many people with HIV lack the insurance and financial resources to pay for care.

Though both chambers included an increase for the AIDS Drug Assistance Program in their FY05 Appropriations bills, the House and Senate flat-funded the remaining programs in the Ryan White CARE Act. Contact your Members and urge them to increase funding for the Ryan White CARE Act in the Labor-HHS Appropriations bill. National Organizations Responding to AIDS (NORA), whose diverse membership includes the Presbyterian Washington Office, recommends an increase of $425 million to come closer to meeting the needs of people living with HIV/AIDS. 2

AIDS Drug Assistance Program (ADAP)

Within the CARE Act, House and Senate appropriators recommended increased funding for ADAP, the federal- and state-funded programs that provide HIV/AIDS-related medications to low-income, uninsured and underinsured HIV-positive individuals. Costs for medications are increasing, and as AIDS Action noted, "A single drug in the multiple-drug regimen of highly active antiretroviral therapy (HAART) — the standard of care for HIV disease — may cost as much as $15,000 annually. Drugs to treat other infections may bring the annual cost for a single HIV patient to $40,000 a year." 

Both chambers are supporting a $35 million increase in funding for ADAP, which is welcomed, though not enough to meet increased need. The House included $20 million for ADAP. Advocates, including NORA, call for an additional $217 million for ADAP to maintain fiscal solvency and to meet the needs of the growing demand of new clients seeking to enroll in the program.

Thank your Members for increasing ADAP funding. Though it is not enough to meet current need, urge them to include, at a minimum, the following in the final bill; the $20 million ADAP earmark (House version) and the $35 million increase in FY05 in both the House and Senate funding bills. 

VA-HUD Appropriations

Housing Opportunities for People with AIDS (HOPWA)

HOPWA is the only federal housing program that funds comprehensive community-based HIV-specific housing programs. Without stable housing, people with HIV cannot access care services or promising new treatment protocols that can improve and prolong their lives.

In this year's VA-HUD Appropriations bill, the House Appropriations Committee recommended cutting the program approximately $13 million — to $282 million. This would be the first cut in HOPWA in its 10-year history. The Senate Appropriations Committee approved $294.8 million for HOPWA, which flat-funds the program. Contact your Members of Congress, and tell them to oppose any funding cuts to HOPWA and other critical, low-income housing programs. Urge them to restore HOPWA funding- at least to the level the Senate has proposed-in order to meet the needs of people living with HIV/AIDS.

What You Can Do 

Pray

Pray for people living with or at risk of HIV/AIDS. Host a special service or Christian Education class on HIV/AIDS on World AIDS Day, Wednesday, December 1st. (A prayer is below.)

From Maryknoll AIDS Task Force: 

"...I shall light a candle of 
understanding in thy heart, 
which shall not be put out..."

(2 Esdras 14:25)

God of all compassion,
comfort Your sons and daughters
who live with AIDS.
Spread over us all Your quilt of mercy,
love and peace.

Open our eyes to Your presence
reflected in their faces.
Open our ears to Your truth
echoing in their hearts.

Give us the strength
to weep with the grieving,
to walk with the lonely,
to stand with the depressed.

May our love mirror Your love
for those who live in fear,
who live under stress and
who suffer rejection.

Mother, Fathering God,
grant rest to those who have died
and hope to all who live with HIV.

God of life, help us find the cure now
and help us build a world in which
no one dies alone and where
everyone lives accepted,
wanted and loved.

Contact your Members of Congress

Insist that they provide more money to combat HIV/AIDS in fiscal year 2005 Appropriations.  

General Assembly Policy 

In 1994, the 206th General Assembly passed a resolution that encouraged and challenged all congregations, presbyteries, and synods of the General Assembly to live out Jesus' ministry of healing love, compassion, and justice for all God's children living with HIV/AIDS through ministries and education efforts.

In 2001, the 213th General Assembly approved a report, "Women and AIDS:  A Global Crisis."  That Assembly encouraged congregations and national and local HIV/AIDS networks to 1) educate their constituencies about the global pandemic by holding educational events or writing articles about the issue and 2) engage in advocacy efforts —  to increase funding for prevention strategies and to make affordable medications available throughout the developing world.