One Good Idea

Changing How AIDS Funding Is Used

Professor Emily Mendenhall proposes new plan to battle the diseases that can worsen AIDS.

National Journal
July 10, 2015, 1 a.m.

Emily Mend­en­hall, a pro­fess­or of glob­al health at Geor­getown Uni­versity’s Ed­mund A. Walsh School of For­eign Ser­vice, has de­veloped an idea that she hopes will help solve an on­go­ing health crisis in Sub-Saha­ran Africa. Mend­en­hall pro­poses that the Pres­id­ent’s Emer­gency Plan for AIDS Re­lief (PEP­FAR) fund treat­ment for non­com­mu­nic­able dis­eases—such as dia­betes and hy­per­ten­sion—in ad­di­tion to an­ti­ret­ro­vir­al treat­ment, which PEP­FAR has provided for more than 10 years. I re­cently spoke with Mend­en­hall, who has con­duc­ted re­search on poverty, de­pres­sion, and dia­betes in vul­ner­able pop­u­la­tions in Sub-Saha­ran Africa. Our ex­change has been ed­ited and con­densed. (Maria Fab­riz­io)

What spe­cif­ic prob­lem does your pro­pos­al try to solve? In 2004, George Bush cre­ated the Pres­id­ent’s Emer­gency Plan for AIDS Re­lief to ad­dress the glob­al HIV/AIDS epi­dem­ic, primar­ily in Africa. At that time, HIV/AIDS in Sub-Saha­ran Africa and in low- and middle-in­come coun­tries was a clear emer­gency. These funds de­livered an­ti­ret­ro­vir­al treat­ment and ab­so­lutely trans­formed the land­scape. Through this in­cred­ible amount of fund­ing for HIV treat­ment, many people walked away from their deathbed.

A dec­ade later, HIV has changed from an emer­gency to a chron­ic in­fec­tious dis­ease, largely be­cause people are now able to live longer and health­i­er lives on an­ti­ret­ro­vir­al treat­ment. But many are start­ing to suf­fer from in­fec­tious and non­com­mu­nic­able dis­eases, such as stroke, heart dis­ease, dia­betes, and men­tal-health is­sues, in ad­di­tion to HIV. There has been an in­crease in non­com­mu­nic­able dis­ease among the poor in low- and middle-in­come coun­tries, es­pe­cially among the HIV-in­fec­ted and HIV-af­fected, be­cause as these coun­tries be­come more eco­nom­ic­ally ad­vanced and people live longer and come out of poverty, people’s life­styles change sig­ni­fic­antly. For ex­ample, many people who trans­ition from work­ing in the field to the city may have to travel an hour across the city, and will of­ten find them­selves eat­ing on the go and con­sum­ing fried fatty foods along the streets. This is a com­mon nar­rat­ive that leads to wide­spread obesity, from which emerges hy­per­ten­sion and dia­betes, as well as men­tal-health is­sues. 

Hav­ing chron­ic ill­ness, es­pe­cially two severe chron­ic ill­nesses, can be really com­plic­ated. These dis­eases re­quire con­sist­ent man­age­ment. So if you have HIV, you are go­ing to have to go to the hos­pit­al quite of­ten for test­ing. But let’s say you have dia­betes as well. Dia­betes also re­quires go­ing to the hos­pit­al a lot. The prob­lem is that in a lot of health sys­tems, you don’t just go to one doc­tor to test all of your dis­eases; you go to dif­fer­ent clin­ics for every dis­ease. 

What are PEP­FAR’s cur­rent policies? The le­gis­la­tion and fund­ing have not kept pace with the epi­demi­ology. PEP­FAR says they’re try­ing to bring com­pre­hens­ive HIV treat­ment, but they’re not con­sid­er­ing co-mor­bid­it­ies or multi-mor­bid­it­ies. The in­ter­na­tion­al policy is cur­rently ex­clus­ively fo­cused on dis­ease-spe­cif­ic pro­grams. There is a lot of polit­ic­al re­cog­ni­tion of the im­pact of over­look­ing non­com­mu­nic­able dis­eases, but the glob­al health fund­ing doesn’t re­cog­nize this.

How Do you pro­pose that PEP­FAR change? The best thing that PEP­FAR could do for this chan­ging epi­demi­olo­gic­al land­scape would be to provide care for all the dis­eases that people who are HIV-pos­it­ive have. Al­though its le­gis­la­tion doesn’t cur­rently al­low for this, PEP­FAR needs to care for people as people, not simply as people with HIV dis­ease. If someone who’s HIV pos­it­ive also has dia­betes, hy­per­ten­sion, and de­pres­sion, they should get care for all of their prob­lems, not just their CD4 count. Over­look­ing those dis­eases is a death sen­tence in the long term. Their un­treated dia­betes is go­ing to af­fect their HIV dis­ease. 

We need to fund health sys­tems to provide com­pre­hens­ive health care to the poor. If every­one who com­mits to glob­al health could trans­form their fund­ing in­to build­ing health sys­tems, there would prob­ably be few­er short-term ad­vances and suc­cesses, but there would be many more long-term suc­cesses. You want to bring ex­traordin­ary suc­cess to the im­me­di­ate need as well as the long-term need.

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