Young boy sitting on a wall outside 'Way Home', a UNICEF-assisted shelter providing food, accommodation, literacy trainings and HIV/AIDS-awareness lessons to street children in Odessa, Ukraine. Because of unsafe sex and injecting drug use, street adolescents are one of the groups most at risk of contracting HIV. Credit: UNICEF/G. Pirozzi

By Pavol Stracansky
KIEV, Dec 9 2014 (IPS)

Marginalised communities and civil society groups helping them are warning of a “tragedy” in Eastern Europe and Central Asia (EECA) as international funding for HIV/AIDS and tuberculosis (TB) programmes in the regions is cut back.

The EECA is home to the world’s only growing HIV/AIDS epidemic and is the single most-affected region by the spread of multi-drug resistant TB (MDR-TB). For years, HIV/AIDS and TB programmes in many of its countries have been heavily, or exclusively, reliant on funding from theGlobal Fund to Fight AIDS, TB and Malaria.

But this year has seen the Global Fund move to a new financing model based on national income statistics, under which funding in many EECA countries has already been – or will soon be – heavily cut.“This [reduction in Global Fund financing] could lead to tragedy because governments are not yet ready to take on the responsibility for addressing the HIV/AIDS epidemic. I would like decision-makers to understand that this is not just [about] epidemiological statistics but that our lives and health are at stake” – Viktoria Lintsova of the Eurasian Network of People Who Use Drugs (ENPUD)

Some of those likely to be most heavily affected by the cuts say that the reduction in Global Fund financing is putting essential HIV/AIDS and TB services, and with it lives, at risk.

Viktoria Lintsova of the Eurasian Network of People Who Use Drugs (ENPUD) told IPS: “This could lead to tragedy because governments are not yet ready to take on the responsibility for addressing the HIV/AIDS epidemic. I would like decision-makers to understand that this is not just [about] epidemiological statistics but that our lives and health are at stake.”

At the heart of their concerns are worries over funding for not just medical treatment for existing patients but prevention and other services for at risk and marginalised communities.

Injection drug use has been identified as the main driver of the HIV/AIDS epidemic in the EECA but HIV/AIDS is also being increasingly spread among men who have sex with men and sex workers – groups which are heavily marginalised because of political and societal attitudes to homosexuality and women.

TB, an equally severe health problem in the EECA, is closely linked to the HIV/AIDS epidemic because co-infection rates are often high.

Throughout the region, prevention and harm reduction services for marginalised groups are provided by civil society groups which rely almost exclusively on international funding.

Sveta McGill, health advocacy officer at international advocacy NGO Results UK, told IPS that the withdrawal of Global Fund funding could see many sick people slip under the health care radar.

She said: “It is affecting services provided by NGOs covering at-risk groups. These ‘low threshold entry’ services, while not necessarily medical interventions, are crucial to keep people from risk groups coming to centres where they get referred to medical institutions to get treatment and can access medical services as well.

“Often, they would not feel comfortable going straight to state health care institutions, and closing down these venues would mean that less people would be referred to state health care institutions.”

Critics point to rising HIV/AIDS infections in Romania in recent years as a sign of what could happen in other EECA countries when the Global Fund cuts back its financing.

The Global Fund ended financing for programmes in the country in 2010. According to data from the Romanian government, since then there has been a dramatic rise in HIV infections among people who use drugs: in 2013, about 30 percent of new HIV cases were linked to injection drug use compared with just three percent in 2010.

Under the Global Fund’s New Financing Model (NFM), the major change is a reduction in financing to middle income countries. Many EECA countries are now classified as middle income and critics say that while the organisation’s goal of looking to prioritise use of finite resources is sensible, national income data does not always accurately reflect the ability of people to access health care services, nor whether a country has the funds for an adequate disease response.

They point to studies showing disease burdens shifting from low income countries to middle income states, and poverty being greatest in middle income countries. Also, most people living with HIV live in middle income countries.

But some have also dismissed as naive the notion that, as the Global Fund wants, national governments will automatically fill the gap in funding left as the Global Fund cuts back its financing.

Many point to the situation in Ukraine as an example highlighting the problems of the NFM.

According to a report from the Open Society Foundations, Global Fund spending on HIV will drop by more than 50 percent for Ukraine between 2014 and 2015. This includes reductions in unit cost spending for people who use drugs by 37 percent, for sex workers by 24 percent and for men who have sex with men by 50 percent.

Meanwhile, the national HIV prevention budget was slashed by 71 percent in 2014 amid political and economic upheaval.

Lintsova, who lives in central Ukraine, told IPS of the problems drug users are currently facing.

She said that not only are there shortages of the right drugs to treat TB in some parts of the country, but that very few drug users have access to them. Places on opiate substitution treatment (OST) programmes are very limited and waiting times to join them long, sometimes fatally so.

“I know two people who died waiting to get on an OST programme,” she told IPS. “And there are other problems like a lack of needle exchange centres in rural areas, in fact a lack of any harm reduction services in small towns, which leads to high rates of HIV in those places.”

She added that without proper funding, the situation would not improve. “The only solution to these problems is financing,” she said.

But other stakeholders have also privately raised fears that a greater government role in fields such as drug procurement could see authorities looking to save money and procuring larger quantities of cheaper TB drugs of worse quality. Meanwhile, local legislation also makes procurement tenders long and difficult, leading, some health care experts predict, to governments running out of stocks of some essential medicines.

It is unclear how governments will deal with the reduction of Global Fund financing. The transition from Global Fund to domestic funding, although widely announced and anticipated, is not going smoothly in all countries.

Many are often unclear when the Global Fund will actually leave because no straightforward timing plan has been set. There are also specific problems in individual states. In Ukraine, in particular, domestic TB funding has been severely affected by the military conflict, struggling economy and currency fluctuation.

Late last month, these growing fears prompted 24 prominent NGOs in the region to send an open letter to the Global Fund warning of their ‘grave concerns’ over the allocation of funding in the region and calling for it to work with local groups and affected communities.

They specifically asked it to look at each country individually, rather than adopt a “one size fits all” approach.

The Global Fund declined to respond when contacted by IPS.

However, drug users who spoke to IPS said there was little hope of an improvement in the region’s HIV/AIDS and TB epidemics if the Global Fund fails to heed NGOs’ warnings.

Lintsova told IPS: “A lack of reaction to our calls could lead to problems accessing prevention and treatment programmes and a deepening of the EECA’s HIV/AIDS and TB epidemics.”

(Edited by Phil Harris)

Uganda has been hailed as a success story in fighting HIV/AIDS, with prevalence rates dropping from 18 percent in 1992 to 6.4 percent in 2005. But activists fear a new HIV Bill will lead to lead to people shunning testing and treatment. Credit: Amy Fallon/IPS

By Amy Fallon
KAMPALA, Aug 21 2014 (IPS)

HIV/AIDS activists are adamant Uganda will not achieve an “AIDS-free generation” now a “backwards” HIV/AIDS Bill criminalising the “wilful and intentional” transmission of the disease has been signed into law.

The act, they say, will lead to people shunning testing and treatment, but will particularly drive sex workers and gay men underground, and make women more vulnerable to domestic violence.

News that the controversial law, adopted unanimously by Parliament on May 13, and assented to by Uganda’s President Yoweri Museveni on Jul 31, broke on social media only this week on Aug. 19.

The bill also allows medical providers to disclose a patient’s HIV status to others without consent and prescribes mandatory testing for pregnant women, their partners, and victims of sexual offences.

Uganda has been hailed as a success story in fighting HIV/AIDS, with prevalence rates dropping from 18 percent in 1992 to 6.4 percent in 2005.

But Museveni went against earlier promises to the Joint United Nations Programme on HIV/AIDS (UNAIDS) executive director and campaigners that he wouldn’t back the punitive law.

“This is a populist act,” Kikonyongo Kivumbi of the Uganda Health and Science Press Association (UHSPA-Uganda) told IPS.

“He knows what he’s doing is not the right thing in addressing the general public health concerns in this country.”

Kivumbi pointed out that according to the 2014 UNAIDS Global Progress report, Uganda was now the third country in the world contributing to sustaining the pandemic.

Other campaigners are “heartbroken” and “outraged” after the president approved the HIV Prevention and Control Bill.

The news broke as CSOs were still waiting for an audience with Museveni over the controversial bill, which has been slammed by Uganda’s own AIDS Commission and the AIDS Control programme of the Ministry of Health (MoH).

“Some bad news from Uganda. Please pray for us,” Jacquelyne Alesi, director or programmes at Uganda Network of Young People Living with HIV & AIDS (UNYPA), said in an email to IPS.

The legislation prescribes a maximum 10 years in jail, a fine of about five million Ugandan shillings (1,980 dollars) or both for anyone who “willfully and intentionally transmitting HIV/AIDS to another person”.

Another provision of the law, drafted in 2008, provides for a fine or a maximum five years in jail for those convicted of “attempted transmission”.

According to the 2011 Uganda AIDS Indicator Survey, overall HIV prevalence is higher among women (8.3 percent) than among men (6.1 percent).

“Usually HIV bears the face of a woman,” Dorcas Amoding, policy, advocacy and networking officer for Action Group for Health Human Rights and HIV/AIDS (AGHA-U), told IPS.

“So if she has tested positive and perhaps the husband becomes aware of it…he might treat this as a very negative result as well and she can be attacked.”

Amoding added, “it even brings about a very huge burden in terms of women inheriting property, because some people still think HIV is a death sentence.”

“So if I say ‘I want to have my husband’s property for the children’, people are going to say ‘you’ll die tomorrow, you’re HIV positive.’”

Most LGBT people with HIV/AIDS already “die silently” and many were no longer going for services in the after the passing of the Anti-Homosexual Act, Bernard Ssembatya, from Vinacef Uganda, a sexual health and reproductive NGO focusing on HIV, told IPS. The anti-gay law was, however, declared “null and void” by the constitutional court on a legality earlier this month.

“Some of them are wary of going to health services, some health providers are also scared of delivering services,” Ssembatya said.

There will be “an increase in deaths from HIV, more infections” as a result of the HIV/AIDS law, he warned.

According to AIDS Free World, over 60 countries criminalise the transmission of HIV or the failure to disclose one’s HIV status to sex partners, or both. Global Commission on HIV and the Law members have highlighted Guinea, Senegal and Togo, which they say in recent years have revised existing, or adopted new laws which limit HIV transmission to exceptional cases of wilful transmission.

Guyana also rejected a criminalisation law. In the U.S, 34 states still have HIV specific criminal statutes, however, in May Iowa approved a law revising a HIV specific statute.

Kivumbi pointed out that criminalisation was an “agenda of the U.S. republican right”, who he accused of influencing political and public health appointments in Uganda.

“We need to tell U.S. republican extremists and evangelical Christians to leave managing the HIV pandemic to ourselves,” he said.

“Just because the U.S. gives us money it does not mean [they] can impose their extremist agenda on us.”

Uganda had deliberately chosen to “moralise the pandemic and response, emphasising abstinence at the expense of condom use and other scientifically proven interventions,” Kivumbi said.

“We have had cabinet ministers, parliamentarians and other people at senior government level saying that people who are HIV positive are morally bankrupt,” the activist said.

Kivumbi said there was an “element of politicking” on Museveni’s part in inking his signature on the bill. Uganda will be submitting a “concept note” to the Global Fund to Fight AIDS, Tuberculosis and Malaria on Oct. 15, and wanted to get access to a 90-million-dollar loan from the World Bank that was suspended, he said.

One clause of the HIV/AIDS Bill seeks to set up an AIDS Trust Fund managed by the MoH, with money coming from foreign governments and international agencies, among other means.

Ironically, that loan was put on hold in February, just days after the president approved the Anti-Homosexuality Act.

“I think that the president thought that by signing this law, which [sets up] the AIDS Trust Fund, the World Bank would give him money and the Global Fund would contribute,” said Kivumbi.

“Let the Global Fund and the World Bank not be fooled.

”This law tramples upon basic civil liberties and cannot be acceptable in a free and democratic society that Uganda aspires to be.”

Dianah Nanjeho, a communications consultant at Uganda Network on Law, Ethics and HIV/AIDS (UGANET), which works with a coalition of 40 organisations, told IPS the activists wanted the contentious clauses in the bill to be amended.

“The act in itself is a good act we don’t condemn it, we just want those one, two three things sorted out.”

She said the positive parts of the law were state obligations to provide care and treatment and the establishment of the AIDS Trust Fund.

Nanjeho said CSOs, who are still hoping to meet Museveni, hadn’t ruled out challenging the law in court, and would make a decision on this in the next few days.

“For now we are all weighing all options,” she said.

Edited by: Nalisha Adams

The writer can be contacted on Twitter @amyfallon 

A CD4 testing machine. Research by the University of Zimbabwe shows that female patients with high CD4 counts have developed a nevirapine toxicity. Credit: Jennifer Mckellar/IPS

By Miriam Gathigah
NAIROBI, May 19 2014 (IPS)

As Africa scales up lifesaving antiretroviral therapy for HIV positive people, concerns are rife that the absence of mass routine viral load testing will hamper extending treatment to the millions who need it.

“Routine viral load testing helps catch people who are failing on treatment before they generate resistance to antiretrovirals and helps keep them less infectious,” explains Teri Roberts, diagnostics adviser at Médecins Sans Frontières (MSF).

Viral load testing, the gold standard in antiretroviral therapy (ART) monitoring, measures HIV levels in the blood, an indicator of the drugs’ success.

The World Health Organisation recommends viral load monitoring six months after starting ART, at 12 months, and every 12 months thereafter.

But a viral load test, although routine in wealthy countries, is scarce and expensive in Africa.

“A viral load test in Kenya is 25 dollars at the National Programme on AIDS, while a similar test in a clinic in Asia costs about 11 dollars,” says Roberts.

In Africa, viral load tests are scarce and expensive. A breakdown of the average cost per viral load test. Courtesy: Médecins Sans Frontières (MSF)

An MSF study on world prices of viral load testing found “a dramatic gap” between the manufacturing cost and the market price African countries pay.

Point of care viral load testing remains largely unavailable in Africa, says the study. Instead, collected blood samples are sent for testing at a central laboratory.

Point of care testing is essential to decentralise care in remote rural Africa, bringing diagnostics closer to the patient and speeding clinical decisions. Though point of care tests are twice as expensive as tests in central laboratories, MSF recommends a mix-and-match combination of solutions that work in a big urban context or in a poor rural district.

HIV experts worry that many women on ARV treatment have never had a viral load test, or it came too late.

“We may have highly infectious mothers on ARVs because they have acquired resistance but are not picked up for lack of proper monitoring,“ says Roberts.

Dr. Dave Muthama, from the Elizabeth Glaser Paediatric AIDS Foundation, tells IPS that “CD4 count does not drop immediately when drugs fail; the CD4 count may remain high for a while and by the time treatment failure is detected, a lot of harm will have been done.”

The World Health Organisation recommends viral load monitoring six months after starting ART, at 12 months, and every 12 months thereafter. Credit: Miriam Gathigah/IPS

Creative solutions

HIV experts are calling on African governments to overcome these challenges.

“While Asia manufactures its own machines and reagents, Africa imports everything,” says Dr. John Ong’ech, assistant director at Kenyatta National Hospital. “We need to explore the option of having locally manufactured viral load testing reagents and machines.”

He warns that the cost of viral load machines could be even higher in Kenya due to the value added tax on imports.

Locally manufactured products will also encounter pitfalls in the form of royalty payments for intellectual property which, according to MSF, can account for up to 65 percent of the manufacturing cost of the tests.

Dorothy Mbori–Ngacha,  senior HIV specialist for East and Southern Africa at the United Nations Children’s Fund (UNICEF), tells IPS that UNITAID, a global health initiative, and UNICEF are trying “to eliminate market monopoly in order to create a competitive market” and make viral load testing technology affordable.

An MSF study on viral load testing in seven African countries assessed options to reduce costs and improve access, such as pooled testing at district level in Malawi and Zimbabwe.

In pooled testing, blood samples from five people are mixed together and only one test is conducted on all five. If it shows a high viral load, individual testing follows.

In Malawi, sample pooling using dried-blood spots collected through easy finger-pricking reduced by 30 percent the number of tests required in a rural district with over 30,000 patients on treatment, saving 207,000 dollars per year.

For quicker and cheaper relaying of results, MSF recommends using mobile phones and electronic health technologies.

Pooling efforts

Roberts stresses the need to push the biggest buyers – the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria purchase nine out of 10 tests – to adopt pooled procurement and get even cheaper prices for all.

But Ong’ech says this may be difficult, because procurement laws differ across countries and even within countries.

“Swaziland uses a generic open platform for procurement of viral load tests, which leads to competition and achieves cheaper prices. Malawi uses a closed platform, which leads to higher prices,” Roberts explains.

A test costs 35 dollars in Swaziland and 25 dollars in Malawi.

In a generic open platform, the elements for viral load testing are sourced from different manufacturers, while in a closed platform, from a single manufacturer.

Nonetheless, as African countries scale up viral load testing, they will gain leverage to negotiate lower prices.

Pushing for transparency with prices among and within countries will help. Roberts tells IPS that in Kenya the same component can cost 24 or 11 dollars depending on who imports it.

Test costs also hinge on the efficient use of viral load machines. According to MSF, the closer to maximal capacity the machine is used, the price per test decreases between 25 and 50 percent.

Viral load testing helps keep people on first line ARVs, which cost a fraction of second and third line.

“The drugs could be failing due to social issues such as stigma and that can be dealt with without changing treatment regime,” Mbori-Ngacha explains.

The MSF study found that in Shiselweni, Swaziland, half of people diagnosed with high viral load improved with adherence counselling and their viral load dropped.

“Mass routine viral load testing is not feasible today due to its cost and complexity,” concludes Roberts.”Complexity has reduced greatly and will reduce more. We must develop strategies to reduce costs.”

Rotarians Against Malaria display one of the insecticide treated mosquito nets being used throughout Papua New Guinea. Credit: Catherine Wilson/IPS

By Jim Lobe
WASHINGTON, Dec 11 2013 (IPS)

Enhanced efforts to fight malaria have saved an estimated 3.3 million lives and nearly halved the disease’s global mortality rate since 2000, according to the latest edition of the World Health Organisation’s (WHO) annual “World Malaria Report”, released Wednesday.

But much more needs to be done to eliminate the disease, which last year killed an estimated 627,000 people worldwide, about 483,000 of whom were children under the age of five. That pace averages one malaria-caused child death almost every minute, according to the 253-page report.

Prevention and control measures by multilateral organisations, national governments, private foundations, business and civil society organisations over the past dozen years have been particularly effective in sub-Saharan Africa, which, along with South Asia, has suffered most from the mosquito-borne illness, the report said.

While malaria mortality rates fell by 45 percent worldwide since 2000, the percentage in Africa was 49 percent and 54 percent among African children under five. Similarly, while malaria infections fell by 29 percent globally, infections in Africa, where about 80 percent of malaria cases are found, were reduced by 31 percent, according to the report.

“The remarkable gains against malaria are still fragile,” Robert Newman, who directs WHO’s Global Malaria Programme, told reporters at the report’s release. Several countries over the past 75 years have come close to eliminating the disease only to see it resurge due to complacency and reductions in funding. “A 50 percent reduction is great, but we can’t get to the endgame with that.”"The greatest threat to continued success in malaria efforts is financial."
-- Robert Newman

“In the next 10-15 years, the world will need innovative tools and technologies, as well as new strategic approaches to sustain and accelerate progress,” he emphasised. “The greatest threat to continued success in malaria efforts is financial: we have less than half of the 5.1 billion dollars needed annually to ensure universal access to life-saving interventions.”

Last year’s toll of malaria deaths might have been fallen even more if funds had been available to procure insecticide-treated bed nets, a major prevention measure, in malaria-endemic countries. But, for the second year in a row, bottlenecks caused by insufficient funding resulted in the delivery of only 70 million new bed nets, far below the 150 million annual target.

In 2013, however, that problem appears to have been overcome, as 136 million nets were delivered, and WHO officials are predicting that some 200 million more will be delivered in 2014.

“We are going to see a much more rapid procurement process,” said Joy Phumaphi, executive secretary of the African Leaders Malaria Alliance, a group that includes 39 African heads of state and a former vice president of the World Bank’s Human Development Network.

Due to a recent restructuring of the Global Fund to Fight AIDS, Tuberculosis and Malaria, she said, the time between fund allocation and actual delivery of nets has fallen from 18-24 months to three months. “This is an example of the new efficiencies that have come with the restructuring” of the Fund, she said.

The Fund, a multilateral agency that is by far the most important single source of funds for anti-malaria projects, received a boost earlier this month when donor countries pledged a record 12 billion dollars to its fourth replenishment, which will take it through 2016.

While that total fell short of the 15-billion-dollar goal that the Fund set for itself, it marked a three-billion-dollar increase from its third replenishment in 2009.

That amount should help the global anti-malaria effort come close to the goal of reducing malaria mortality rates for children under five by 75 percent from 2000 levels. The WHO report estimated that if the annual rate of decrease that has occurred over the past 12 years is maintained through 2014, then mortality rates should decrease by 56 percent in all ages and 63 percent for children under five.

Currently 59 countries are on track to meet the 75 percent goal, but they account for only four percent of total estimated malaria cases. That goal will be much harder to reach in the 18 most-affected countries, which include 17 African nations and India. Two African countries – Nigeria and the Democratic Republic of the Congo, whose sheer size makes it difficult to track malaria cases – account for fully 40 percent of all malaria deaths worldwide.

“We can reach 75 percent, but it’s going to take efforts by all of us,” said Newman.

International spending for malaria control rose from 100 million dollars in 2000 to just shy of two billion dollars in 2013, while national governments of affected countries have also increased their funding since 2004. In 2012, they contributed an estimated 522 million dollars.

“The vote of confidence shown by donors last week at the replenishment conference for the Global Fund is testimony to the success of the global partnership,” said Fatoumata Nafo-Traore, executive director of the Roll Back campaign. “But we must fill the annual gap of 2.6 billion dollars to achieve universal coverage and prevent malaria deaths. This is our historic opportunity to defeat malaria.”

In addition to the distribution of bed nets, the most effective interventions now in use include indoor residual spraying (IRS), diagnostic testing, and artemisinin-based combinations therapies (ACTS), which are recommended as the first-line treatment for the most deadly form of malaria.

The proportion of the at-risk population in sub-Saharan Africa sleeping under a bed net in 2013 was 36 percent in 2013, according to the report, which cited studies showing that 86 percent of the population with access to a net actually used it.

IRSs were much less prevalent, accounting for only eight percent of the at-risk population. Mosquito resistance to at least one insecticide used for malaria control has been identified in 64 countries worldwide and represents a major challenge in the anti-malaria fight.

Meanwhile, diagnostic testing to determine whether a patient who shows symptoms of malaria actually has the disease and is treated accordingly and ACTS have been increasing rapidly. In 2012, 331 million ACT courses were procured by public and private facilities in endemic countries – up from only 11 million in 2005.

In addition to ensuring increasing access to these tools, Newman stressed the need for improving surveillance and monitoring systems in most-affected countries. Much more funding is also needed for research and development (R&D) of new insecticides and drugs to overcome resistance to existing products by mosquitoes and the parasite itself.

He also noted the importance of R&D into malaria vaccines, one of which – RTS,S – was shown to almost halve the number of malaria cases in young children (aged 5-17 months at first vaccination) and to reduce the number of cases by about a quarter in infants in late-stage trials in Africa announced in October.

In Swaziland, which has been hard-hit by the AIDS pandemic, an HIV-positive mother sits next to her 18-month-old baby girl. Credit: Mantoe Phakathi/IPS

By Jim Lobe
WASHINGTON, Dec 3 2013 (IPS)

The gap in health standards between the world’s poorest countries and the more advanced middle-income nations could close by the year 2035, according to a major new report published Tuesday by Britain’s The Lancet medical journal.

Written by a group of 25 of the world’s top global-health experts and international economists, Global Health 2035: A World Converging Within a Generation makes the case for the international community, governments and key donors, such as the Bill and Melinda Gates Foundation, to increase investments in health to meet the target.

“Now, for the first time in human history, we are on the verge of being able to achieve a milestone for humanity: eliminating major health inequalities, particularly inequalities in maternal and child health, so that every person on earth has an equal chance at a healthy and productive life,” according to Harvard University professor and former U.S. Treasury Secretary, Lawrence Summers.

“The powerful drugs and vaccines now available make reaching this milestone affordable. It is our generation’s unique opportunity to invest in making this vision real,” said Summers, who 20 years oversaw the preparation of the only ‘World Development Report’ (WDR) devoted to global health when he served as the World Bank’s chief economist.

The 58-page report, which calls for government policymakers to adopt a new approach to measuring the importance of health to their national economies, is being published as the Global Fund to Fight AIDS, Tuberculosis and Malaria – a unique multilateral agency that has approved 29 billion dollars in grants since its founding in 2002 – is meeting here this week to gain new donor commitments for its fourth three-year replenishment.

The three diseases are among the biggest health challenges faced by the world’s poorest countries and poorest people in middle-income nations.

The Fund’s leadership got a big lift here Monday when, at a World AIDS Day ceremony, President Barack Obama pledged continued U.S. support for the Fund, promising to provide one dollar for every two dollars committed by other donors over the next three years, up to a total of five billion dollars.

Bill Gates also announced that his foundation – the single biggest private funder of global health initiatives – will provide up to 500 million dollars through 2016, including 300 million dollars that was previously committed and up to 200 million dollars in new matching grants.

“Don’t leave our money on the table,” Obama said, speaking to many of the delegates who have gathered here for the pledging conference. “Now is the time to replenish the Global Fund.”

The Fund’s new executive director, Mark Dybul, said he was confident that this week’s pledging would significantly exceed the 9.2 billion dollars that was committed at the last replenishment in 2010.

The Lancet report offers what it calls a “roadmap to achieving dramatic gains in global health through a grand convergence around infectious, child and maternal mortality; major reductions in the incidence and consequences of non-communicable diseases (NCDs), and injuries; and the promise of ‘pro-poor’ universal health coverage.”

If followed, the roadmap could result in averting some 10 million deaths across the target countries in 2035 alone, according to the report.

It points to the experience of the “4C countries” – Chile, China, Costa Rica, and Cuba — as models for poor and lower-middle-income countries. All four started off at similar levels of income and mortality as today’s poor countries but, by 2011, had become among the best-performing middle-income nations.

Among the specific goals, according to the report, are reducing under-five mortality to 16 per 1,000 livebirths, and reducing annual AIDS-caused and TB-caused deaths to eight and four per 100,000, respectively.

To achieve these and other aims, the report calls for “aggressively scaling up” efforts to fight HIV/AIDS, TB, and malaria as well as improve maternal- and child-health conditions which were a major focus of the Millennium Development Goals (MDGs); strengthening health systems to focus on the most problematic sectors, including poor rural sub-populations of middle-income countries that are disproportionately affected by infectious diseases; and devoting more and earlier investment to family planning.

In addition, government should be encouraged to pursue fiscal policies – notably by heavily taxing tobacco and other harmful substances, such as alcohol, that can sharply reduce NCDs and injuries, as well as leverage significant new revenue for low- and middle-income countries that can, in turn be used to reduce subsidies on items, such as fossil fuels that produce air pollution which in turn cause NCDs.

Such savings will provide most countries with enough funds to finance many of the steps urged in the report. It thus urges that, while donor countries, which hopefully will include emerging economies, should increase their investment into research and development to produce new drugs, vaccines, and other health technologies.

The report calls for at least a doubling in health R&D from current annual spending of around three billion dollars to six billion dollars by 2020, with half of the increment coming from middle-income countries.

The report argues that the economic returns from investments in health are “much greater” than policy-makers have previously assumed.

The 1993 WDR found considerable evidence that improvements in health increased gross domestic product (GDP) per capita by enhancing childhood educational advances and adult worker productivity, as well as increasing access to natural resources and foreign investment that are encouraged by controlling diseases like malaria.

But the GDP analysis, the Lancet report asserts, measures only the impact of health improvements on economic productivity. It fails to capture the intrinsic value people place on their own improved health, including their greater life expectancy.

A full-income approach combines growth in national income with the value of additional life years (VLY). The report estimates that, on average, across low- and middle-income countries, one VLY – a one-year increase in life-expectancy – is about 2.3 times greater than per capita income.

Using that approach, the report found that, between 2000 and 2011, 24 percent of the growth in full income in those countries resulted from health improvements; that is, in VLYs gained. By the same token, setbacks to life expectancy, such as in countries hit hard by the HIV/AIDS pandemic, resulted in a far greater adverse impact than the impact on GDP per capita would suggest.

“We believe that if nations worldwide adopt a full-income approach to economic planning, the human returns to investing in health can be brought into resource allocation decisions,” said Dean Jamison, a University of Washington professor who co-chaired the Commission with Summers.

“People value a longer and healthier life, and the notion of full income simply places that value in monetary terms. While it does not put a monetary value on an individual’s life, it does place a value on changing mortality risk, which traditional notions of GDP neglect,” he added.