The jury is back!
The jury is back with a verdict: PEPFAR has been a great success. Yes, there may be problems, headaches, struggles, and frustrations, but, at the end of the day, nearly two million people are receiving antiretroviral treatment that otherwise wouldn’t, palliative care in Africa has been given a big boost in resources, and a new standard for international health assistance has been set. The American people, often quite sceptical about the real value of ‘development assistance’, have been happy enough about their initial investment in PEPFAR to agree to nearly triple its size (even at its original $15 billion it was the largest public health initiative in history directed against a single disease) in the recent reauthorisation.
PEPFAR’s impact on palliative care in Africa has been significant. It has provided many millions of dollars in funding to organisations that directly provide and support palliative and hospice care across the continent. Additionally, because the original PEPFAR legislation specifically recognised the importance of palliative care, thousands of policy makers, government ministers, and health professionals around the world have had to ask, ‘What is palliative care?’ The African Palliative Care Association (APCA), as a key PEPFAR partner, has been front and centre to answer this question and has led the way in developing national palliative care associations, providing technical support, education, and establishing relationships that will carry palliative care in Africa on into the future.
This a good start. It is remarkable, even historic, that so many care, treatment, and prevention resources have been mobilized in the few years since PEPFAR’s original authorisation in 2003. But we are far from done. The next years of PEPFAR will be critical for long-term health outcomes in Africa and will require close attention to the quality, as well as the quantity, of care and services being provided.
Quality is a key issue for those interested in palliative care because the strongest argument in favour of including palliative care in the package of health services supported by PEPFAR has always been that any treatment strategy that does not include palliative care cannot be considered a quality effort. There was some loss of this vision evident over the past years as, in one way or another, emphasis on palliative care diminished in importance in PEPFAR implementation. In fact, palliative care-specific language in the recently reauthorised PEPFAR has been weakened from the original legislation.
Palliative care is not the only arena of quality that could erode without constant vigilance on the ground. Pharmaceuticals and treatment regimens are another. PEPFAR has always insisted that the U.S. Food and Drug Administration or other stringent regulatory authority review any pharmaceutical purchased with U.S. funds. In effect, this has meant that any African taking antiretroviral drugs supplied by PEPFAR receives the same level of consumer protection as a U.S. citizen. Other donors have allowed looser standards in their efforts, effectively creating a two-tiered system with a lower standard (no stringent regulatory review) for Africa. This should be questioned. Similarly, if we see that treatment regimens are being used in Africa that have generally been relegated to second or third line options in the developed world, we should ask ‘Why?’
Acquiescence in the assumption that quality HIV care cannot be given in Africa, that inferior care is the best that can be done, should not be accepted. Strong consumer protections, first tier treatment regimens and palliative care are not optional for Africa. If the 25-year struggle to find and make accessible treatments for HIV/AIDS has taught us anything, it is that what seems impossible is often merely difficult and that progress requires constant vigilance from those most affected by the virus. Today, in the second PEPFAR era, that effort from the front line in Africa must focus on quality. St. Francis of Assisi got it right those many years ago when he said, ‘Start by doing what is necessary, then what is possible and suddenly you are doing the impossible.’
Author
Dr Joe O’Neill, MD, MS, MPH, is the former director of the White House Office of National AIDS Policy and is currently working in the biotechnology and drug discovery area.
Contact: Dr Joe O’Neill
Email: joseph.f.oneill@gmail.com