An Interview with Dr. Richard Feachem—Impact of Global Fund Begins to Be Felt

Dr. Richard Feachem

TREAT Asia Report: How do you see the HIV/AIDS epidemic unfolding in Asia?

Dr. Richard Feachem: I have no doubt that the epicenter of the pandemic is moving to Asia within the next few years. The two most populous countries, India and China, are a cause of great concern. Other Asian countries are set to have very large epidemics if there is not massive scale-up of the appropriate interventions very quickly.

TA Report:  Is it really preordained that the epicenter of the epidemic has to move to Asia?

Feachem: No, it is preventable. But if we continue to do as little as we are doing—and overall in Asia, we are doing very little—then I think it’s preordained. If we were to massively scale up both preventive and treatment interventions very quickly, then I think that outcome can be avoided.

TA Report:  Could you tell us a little about the Global Fund’s progress in the region?

Feachem: The Global Fund encourages ambitious, large-scale applications from both public and private organizations across Asia to do those things that will prevent large epidemics from unfolding. We’ve had two rounds of funding so far and we’re coming to closure on a third round. If we look at the first two rounds, there is a substantial list of Asian countries which the Fund is supporting in relation to HIV/AIDS programs. (See special section at the bottom of this interview: “Funds Start to Flow in Asia Pacific Region”) 

TA Report:  Do you have any sense of the number of people who may be infected in China, India, and across Asia? There’s a pretty broad spectrum of estimates.

Feachem: There has been this strange collusion between Western experts, international organizations, and the Chinese and Indians to first say that the HIV epidemic is not seriously going to affect China and India at all, then to say, well, maybe they’re going to have a small epidemic, and then to say, well, maybe they’re going to have a rather larger epidemic.

But only very recently has there been anything approaching a consensus that China and India are set for very large epidemics. Because of this history of minimizing the epidemics in China, India, and in Asia more generally, I would go with the higher-end estimates now being produced. If we’re going to be proved wrong, let’s be proved wrong for being too pessimistic rather than overly optimistic

TA Report:  What are those higher-end estimates?

Feachem: Basically, they’re the estimates coming out of the American intelligence community from the end of last year. I think those estimates represent the more gloomy end of the spectrum, but it seems to me that they are the ones to give credence to if we continue to do as little as we’re doing.

Take India, for example. India recently revised its official estimate to over 4 million infected. But many Indian experts believe the true number is several million higher than that. If you look at how the estimates are derived, a lot depends on the ratio between urban prevalence rates and rural prevalence rates. Recent data from Maharashtra and Tamil Nadu show that the difference between urban and rural prevalence rates has been greatly underestimated, that rural rates are now approaching urban rates, at least in these two states. And if you begin to apply that to the national estimate, you come up with much higher numbers.

My general guidance would be to treat the Chinese epidemics with great alarm and concern. If you have a choice between apparently well-founded upper-boundary estimates and lower-boundary estimates, go with the upper-boundary estimates. History has told us they are more likely to be true.

TA Report:  The Global Fund’s objectives have been boiled down to three things: raise it, spend it, and prove it. How are you progressing on those three fronts?

Feachem: That is the total business of the Global Fund—“Raise it, spend it, prove it”— and it’s our mantra. It keeps us focused. On the “Raise it” side, we have confirmed assets of $4.7 billion. We have about $1.5 billion in the bank.

TA Report:  Is that money on hand and pledges?

Feachem: Actual cash in the bank as of today is about $1.5 billion. That’s been a remarkably rapid rise in a wholly new financing mechanism and it represents substantial new money in the fight against AIDS, tuberculosis and malaria. That’s the good news.

On the other hand, the promise of the Global Fund is to rise to the ‘cruising altitude’ of about $7 or 8 billion of income and actual expenditures per year by 2008. To keep on that upward trajectory, we need to raise very substantial additional funds quickly.

In the short term, we need $3 billion before the end of 2004 to permit us to fully fund Rounds Three, Four, and Five. Now that’s a challenge. We have various individuals, notably French President Chirac, fighting on our behalf and calling for Europe to put up $1 billion and to encourage the United States to put up $1 billion. The third $1 billion would come from all other sources including Japan, Canada, the oil-rich states, and private-sector sources.

On the “Spend it” side, we had set a target of $100 million in disbursements by mid-October. We passed that target in August. By the end of the year we will have disbursed $200 million. We have current commitments of $1.5 billion to support 155 programs in 93 countries.

TA Report:  So every dollar in the bank is committed?

Feachem: Exactly. The work is beginning to scale up, faster in some places than in others. The recipients are public and private, and some of the programs are completely innovative. So I think on the “Spend it” side, the news is extremely good and encouraging.

In October, our Board will approve Round Three, which will substantially increase the financial commitment. We will be approaching a scale where global impact is possible when you look at the totality of the programs in all of those countries. The system is in place for the money to flow in a way that is accountable and open to scrutiny by everyone with a legitimate interest.

On the “Prove it” side, we have very urgent challenges. The Global Fund cannot sustain this pace of growth unless it is able to demonstrate very convincingly that the money is buying the right progress on the ground in the fight against the three pandemics. Evidence of that is beginning to come in, but I think we still have quite a long way to go to have in place the mechanisms that really would prove it on a month-by-month basis.

TA Report:  Several countries in Asia are producing, or gearing up to produce, their own antiretroviral drugs. What do you say to those who suggest that there isn’t sufficient infrastructure to deliver these drugs?

Feachem:  If you look at the fight against HIV/AIDS, it’s prevention, it’s treatment, it’s working with orphans, it’s voluntary counseling and testing, it’s all the things we know make a difference. And for all of those things, there are questions about “absorptive capacity” and how quickly you can scale up in the real world. The Global Fund is the first huge empirical test of absorptive capacity. We will know pretty soon whether the absorptive capacity skeptics are right or wrong. I’m optimistic and I think that, generally speaking, they’re wrong.

We already have evidence that some of our recipients can run faster and scale up faster than the skeptics would have told us. When the skeptics speak about absorptive capacity, they’re typically talking about government absorptive capacity and the capacity of the public health care infrastructure. The Global Fund is investing in everybody’s absorptive capacity and is therefore making good use of NGO, faith-based, and private capacity to mount good programs if provided with the finance.

Now, antiretroviral therapy is a particular challenge. You’re speaking about one of the most ambitious clinical enterprises being scaled up in the context of some of the weakest and most underfunded health care systems in the world. How fast can it move? I think the answer will be very different in different countries.

Again, the question of private scale-up versus public scale-up becomes very important, particularly in Asia, where the huge majority of health care services are delivered privately, not publicly. In India, it’s 80 percent private, in Cambodia it’s 92 percent private. So the challenge really is not only to strengthen the governments’ systems, but also to pay a lot of attention to the quality and volume of services offered through the private sector, which is where more people go when they get ill.

The kinds of things that TREAT Asia is doing are absolutely critical to the scale-up. My understanding of the TREAT Asia collaborative network is that it’s exactly the kind of thing we need to have a prospect of scaling up both quickly and safely, because there are dangers inherent in doing this too rapidly.

TA Report: How is the Global Fund faring vis-à-vis the Bush administration’s $15 billion authorization for international AIDS treatment and prevention programs?

Feachem: The support that the Global Fund has received from the Bush administration has been enormous. The U.S. has been constantly in the lead on the resource-mobilization side.

When the President’s initiative was first announced in the State of the Union address, it was proposed that, of the $10 billion in new money, $1 billion would be for the Global Fund over the five-year period. That would be $200 million a year. That number’s been moving steadily upwards since then. I think the indications are that the ’04 appropriation will be considerably larger than $200 million.

This very positive shift in thinking about support for the Global Fund is primarily the realization that U.S. leadership is necessary both in the bilateral initiative in the 14 countries [in Africa and the Caribbean], and in the Global Fund multilateral initiative in the 93 countries. There’s a clear recognition in Washington that you can do good work in 14 countries, but you can’t turn around the pandemic in 14 countries, none of which happen to be in Asia. For that you need a much larger mechanism working in many, many more places—and that is the Global Fund.

TA Report:  Looking back, is there anything that has really surprised you during your tenure to date at the Global Fund?

Feachem: Scaling up the global response to HIV/AIDS truly is the biggest challenge facing humankind. The Global Fund is at the center of this challenge and because of that, we have this fantastic tidal wave of support from around the world. I think my big sense of wonderment arises from the tens of thousands of people in government, in the private sector, activists, communities living with the diseases, who are working for the vision of the Global Fund to become a reality. It’s an endeavor that everyone wants to succeed and everyone is cheering for. And that’s really special and unusual in this divided world.

TA Report: Dr. Feachem, thank you very much.

Funds Start to Flow in Asia Pacific Region

The Global Fund to Fight AIDS, Tuberculosis and Malaria is supporting several HIV/AIDS programs in Asia and the Pacific, including the following:

• Cambodia – A program that aims, in part, to slow the spread of HIV/AIDS among at-risk groups, including garment factory workers and youth; to improve sexually transmitted infection services; and to expand care and treatment programs, including limited antiretroviral therapy.

• Indonesia – A program to expand peer education, voluntary counseling and testing, laboratory examination, and referral treatment care in 13 districts within four provinces, and to prevent a further increase in the prevalence of HIV among vulnerable populations.

• Laos – A prevention and education program that targets female sex workers and their clients. Although Laos currently has a low prevalence of HIV infection, high sexually transmitted disease rates among female sex workers indicate the possibility of increasing HIV infection rates.

• Thailand – A program that aims, in part, to prevent sexual transmission of HIV/AIDS through education and public awareness programs in schools, juvenile programs, prisons, and other high-risk environments. The program also aims to foster a sustainable system of care and support programs, including antiretroviral treatment.

• Western Pacific islands – A five-year regional program that plans to reduce sexually transmitted infections to a general prevalence rate of under 10 percent and maintain HIV prevalence among high-risk populations at under two percent.