If there were a new AIDS vaccine that could lower infections in women by 30% and in men by 2/3, we'd be hailing a global breakthrough. But there may be a more prosaic strategy that can achieve these reductions: circumcision.

According to the New York Times, circumcision has demonstrated, through admittedly incomplete tests, to be a powerful preventative measure. A 2002 USAID analysys reviewing 28 studies suggested a 50% reduction in infections among circumcised men. A French government study in South Africa suggested a two thirds reduction. A WHO study involving 8,000 people in Kenya and Uganda is currently underway, with preliminary results as early as June.

The fact that circumcision is unglamorous compared to vaccine or other interventions shouldn't stop us from moving the study of circumcision to the very top of the AIDS prevention research agenda.

The General Accounting Office yesterday issued a review of PEPFAR prevention programs. Titled "Spending Requirement Presents Challenges for Allocating Prevention Funding under the President’s Emergency Plan for AIDS Relief", the report reviews the PEPFAR requirement that 33% of prevention funding be spent on abstinence programs. The report highlights implementation problems this creates, and suggests additional reporting rules as well as limitations to the laws application.

President Bush alluded to AIDS six times in Tuesday's State of the Union address. While many commentators were disappointed by his limited discussion of global AIDS, a half dozen uses of the word "AIDS" does mark improvement from recent years:

• 2006: 6
• 2005: 1
• 2004: 0
• 2003: 11
• 2002: 0

This list also suggests that 2003, and the launch of PEPFAR, was unfortunately an anomaly with respect to White House attention and not the start of increased, steady attention as many had hoped.

The Global Fund is seeking technical experts in AIDS, malaria and tuberculosis to serve on their Technical Review Panel, a key element in the Fund's grantmaking decisions.

Is World AIDS Day losing visibility? In a year when more people died of AIDS and more people were infected with HIV than ever before, World AIDS Day came and went two weeks ago with little attention.

The New York Times, as one proxy for the media, mentioned World AIDS Day only five times this year, which is the lowest number (and half the average) of the last ten years. A Google News search shows "World AIDS Day" mentioned 5100 times, about 1/8th the level of "terrorism" or 1/30th the level of "Iraq". At the very moment when we would hope global AIDS to be receiving top billing, the international media appears to have lost interest.

PEPFAR is governed by legislation which mandates funding for abstinence and fidelity programs, although PEPFAR's operational guidelines for organizations have been ambiguous at best. This apparently is changing. The Baltimore Sun reports that new internal guidelines at PEPFAR establish at 66% the minimum level of AIDS prevention funding that is to be used for abstinence and fidelity programs. This focus on abstinence and fidelity, and lessening of support for other prevention measures, has raised concern in the public health community. Duff Gillespie, former head of AIDS programs at USAID, comments:

It's outrageous and stupid. From a public health point of view, it's irresponsible.

PEPFAR has not yet posted the new guidelines.

Readers of this blog know that I comment periodically on PEPFAR, the world's largest AIDS program which is all but invisible online. In August of 2004 I listed six suggestions for PEPFAR's communications strategy (none of which has been implemented). In December of 2004, PEPFAR led the list of ten information resources requiring improvement.

Perhaps the most amazing fact about PEPFAR online is that the main PEPFAR page, the Office of the U.S. Global AIDS Coordinator, is almost impossible to find through the search engines. It doesn't appear in the top 300 listings for a Google search on "PEPFAR". There are two reasons for its invisibility. First, relatively few other sites link to it (Google shows only 138 linking domains, compared to 208 to this little blog site, or over 1200 for the Global Fund). Second, and more consequential, the "PEPFAR home page" doesn't mention the word "PEPFAR" -- only the "President's Emergency Program for AIDS Relief". Thus anyone searching on "PEPFAR" won't find it.

It is hard to imagine PEPFAR being programmatically or politically successful without a better online strategy. The good news is that the information problems which plague PEPFAR are relatively easy to fix. Once there is a will, there is clearly a way.

Owen Barder offers an excellent review of progress and missed opportunity in international development in 2005, the "Year of Development". He notes a number of significant accomplishments, including debt relief and support for immunizations for developing countries. He also catalogs a frustrating list of squandered opportunities, including shortcomings on MDG targets and failure of donors to meet HIV/AIDS 3x5 obligations.

We have commented previously on PEPFAR's requirement that all recipient groups sign a pledge opposing prostitution. Unfortunately, PEPFAR doesn't make the language of their restrictions readily available (we have posted some language here). As far as we know, PEPFAR also has yet to issue additional guidance concerning this policy.

PEPFAR may now need to address the issue directly. This week the Open Society Institute announced a lawsuit against USAID, claiming the policy to be unconstitutional. As the lawsuit moves forward, USAID will by necessity be required to explain and defend its policies.

The July 28th issue of the Economist has a number of excellent articles discussing global AIDS, including a review of the IAS pathogenesis and treatment conference in Rio de Janeiro.

The most significant article, however, addresses the success Brazil has had in AIDS prevention efforts (available here for subscribers). Four principles underpin this success:

• Don't let morality get in the way: distribute condoms, distribute needles, and treat sex workers;
• Treat freely: provide screening and treatment at no cost;
• Encourage NGO participation: NGOs are more effective overall than government agencies;
• Account for cost savings: "If you think action is expensive, try inaction".

As sensible as this list is, it unfortunately characterizes the programs of only a small number of countries (or aid agencies) worldwide.

The Global Fund announced the selection of Richard Burzynski of ICASO to serve as the Developed Country NGO Communication Focal Point (read announcement here). This follows a call for applicants in May which outlined requirements for the position.

While the job is no more important than many other important roles at the Global Fund, it is noteworthy nonetheless the effort the Global Fund makes in genuinely engaging with the NGO community in policy and administrative issues. The Global Fund is unique among donors in its efforts at networking -- a laudable example others should emulate.

Alan Whiteside and Sabrina Lee have published an article in the August issue of PLoS Medicine entitled "The “Free by 5” Campaign for Universal, Free Antiretroviral Therapy". While we've commented previously on the initiative, this article provides updated information and rationale for providing free ARV therapy.

The August issue also includes many other articles relevant to global AIDS.

The lead up to the G8 Summit highlighted the divergence in views between the leadership of the UK and the US regarding foreign aid. Tony Blair is the leading proponent for significant increases in support for Africa, including AIDS spending. George Bush is the world leader most constantly pushing back. Against this dichotomy, a survey released last week by the Kaiser Family Foundation is notable in showing how similar public opinion is in England and the US regarding AIDS spending. Of 7000 respondents in 7 countries, those in the UK and US diverged almost not at all, unlike their elected leaders.

In his June 2nd speech to the UN General Assembly high-level meeting, Peter Piot, Executive Director of UNAIDS, outlined "four milestones" necessary for the successful response to the AIDS crisis:

• Comparable attention to other threats to global security;
• Universal access to prevention and treatment services;
• Sufficient resources;
• Long-term planning horizon

Piot, to his credit, repeatedly returns to the theme of why AIDS is exceptional. Unfortunately, few political leaders adopt his language of urgency concerning AIDS. He notes in his closing remark:

My respectful call to you is that when this Assembly meets a year from now that it will not be to discuss what has not been done on AIDS, but to agree on action to address the material, and dare I say political, obstacles in the path to universal access to HIV prevention and treatment. We cannot afford to rest before this is achieved.

In global AIDS programs, it is easier to measure inputs than results. Current calls for doubling of aid to Africa, and the US refusal to agree, represent the focus on inputs. India's recent vacillating numbers of AIDS cases represent the difficulty in measuring results.

There will soon be a major new initiative to try to shift the focus from inputs to results. The San Francisco Chronicle and the Harvard Crimson both report that Larry Ellison, founder and CEO of Oracle, will soon make a major gift to Harvard University to establish a research center for global health monitoring. The gift, reported to be approximately $115 million, would be the largest ever received by Harvard. According to Ellison:

"We measure philanthropy the wrong way. We measure the input -- how much someone gives. It's better to measure how many lives we save."

The research center reportedly will address needs articulated by Harvard Professor Christopher Murray, who wrote last fall in the British Medical Journal of the need for a global health monitoring organization independent of the WHO and government influences.

The objective of this body would be to report regularly to the world on what is spent on health, what health services are delivered, and the impact of these efforts on population health.