Monday 17 June

On 17 June 2010, about 2,000 people representing 16 organisations marched to the United States (US) consulate in Sandton, Johannesburg, to demand that the US leads the way in funding universal access to antiretroviral treatment.

Here is the letter handed over to the US consulate officials.

Ambassador Donald H. Gips
Embassy of the United States of America
South Africa
C/O Mary Fanning
(US Health Attaché to South Africa):

17 June 2010

Dear Ambassador Gips


Thank you for your letter of 7 June 2010 in reply to our letter of 18 May 2010. We appreciate your response. We regret that the short notice you provided made it impossible for us to meet with visiting US representatives. However, we once again request an opportunity to meet with you.

At the outset we would like to state that TAC and our allies acknowledge and appreciate that the US government, particularly via PEPFAR and the US contributions to the Global Fund on AIDS, TB and Malaria (GFATM), has played a leading role in providing treatment, care and prevention for AIDS, as well as TB and malaria. We also acknowledge the benefits of PEPFAR’s technical expertise as well as its financial assistance of the South African Department of Health in the 2009/10 financial year.

However, your letter raises a number of concerns and questions that we hope you will answer:

The right to the highest attainable standard of physical and mental health

1. In South Africa and many other countries the right to health is a legally enforceable human right, vital to dignity, equality and life. While US law does not explicitly recognise that people have a right to health, the US government is a signatory to a number of international agreements that refer to the right to health, including the 2000 Millennium Development Declaration which resolves “to strive for the full protection and promotion in all our countries of civil, political, economic, social and cultural rights for all.”

2. Similarly, the 2001 UNGASS Declaration of Commitment on HIV/AIDS also recognises the right to health.

3. We believe that duties arise for all governments, including ours, from this right.

4. We appreciate that resources are limited and that all governments should contribute more to the health of their populations. However, it is because we regard health as a human right that we are disturbed by the approach that is being adopted by the US government where one set of essential health needs is being sacrificed for another, apparently regardless of the fact that less funding for AIDS will have implications for the lives of millions of people.

5. All aspects of health are intricately linked. HIV may not be the major cause of disease and death in all parts of the world, but it is in ours. Donor funding has assisted our government in particular to meet its obligations to the right to health. Having become instrumental in the delivery of health services in South Africa and elsewhere, we consider it a duty on your part to ensure that these services are not suddenly withdrawn. The sudden withdrawal of funding will violate many people’s rights.

6. We believe that the US, as the most economically powerful and resourced country in the world, should be leading global efforts to develop a plan that assists states to realise the right to health as expressed in the Universal Declaration on Human Rights. Such a plan would seek to engage and leverage all other countries, developing a sustainable model of shared responsibility among states.

7. The coming G20 meeting is an opportunity for the US to call for and support the development of such a plan.

Funding for HIV/AIDS

1.    Your letter refers to proposed funding of $63 billion “over the next six years to help partner developing countries improve the health of their people with an integrated approach” as part of the Global Health Initiative (GHI). The GHI Consultation Document states that from 2009 to 2014, $51 billion of the proposed $63 billion will be made available to AIDS, TB and malaria programmes. We broadly support the principles of the GHI.

2.    We note your statement that “it is not our intention to reduce funding to fight HIV.”

3.    Nevertheless, we continue to be concerned about US funding of health interventions targeting AIDS, TB and malaria, particularly PEPFAR.

4.    For example, it has been brought to our attention that from 2009 to 2010 the increase in PEPFAR funding was only 2.3%. A further 2.3% increase has been requested for 2011. This is approximately equal to the US rate of inflation and lower than the rate of inflation in many developing countries. It is a de facto decrease. Please can you confirm this.

5.    Further we are told that the Lantos-Hyde PEPFAR Reauthorisation of 2008 provided that the US government would contribute $48 billion to alleviating AIDS, TB and malaria for the 5 year period beginning 1 October 2008. The PEPFAR enactments for 2009 and 2010 and its requested amount for 2011 are far short of the amounts envisaged by this legislation, which would need to be in the order of $8 to 10 billion. Do you acknowledge that the 2010 commitment, and 2011 White House proposal, fall far short of the funding levels authorized by the US Congress in PEPFARs reauthorization legislation?

6.    Finally we are informed that PEPFAR’s contribution to the GFATM has been reduced from $1.05 billion in 2010 to $1 billion in 2011. Is this true?

7.    Because of the importance of the US commitment to the GFATM in marshalling the commitment of other countries, this proposed decrease stands to have a compounded effect in further exacerbating the GFATMs funding crisis.

8. How does your administration justify cutting funding to the GFATM at a time when the GFATM estimates that it needs at least $17 billion from 2011 to 2013 in order to maintain and expand its existing commitments and to put the world on track to meet MDGs 4, 5 and 6? Conservatively, this means that the GFATM needs to receive at least $5 billion in 2011 rising to $7 billion in 2013.

9. In our view the US contribution to the Global Fund in proportion to its GDP should be at least $2 billion dollars in 2011, increasing to $2.8 billion in 2013. The European Union, China and Japan also need to increase their contributions and we will be calling on them to do so.

Meeting identified treatment needs

1.    As of December 2008, UNAIDS estimated that about 4 million people were receiving antiretroviral treatment (ART) and that this constituted 42% of need. It is clear that unmet need was large then and remains large now. Last year the WHO issued new guidelines, which South Africa has largely adopted. These guidelines confirm that the greatest benefits ­ in terms of both treatment and prevention of HIV and TB ­ are achieved when adults start treatment at 350 CD4 cells/mm3. Following these guidelines ART is only reaching a third of people in need. Many people are starting treatment with sub-optimal regimens which will limit the long-term benefit, and increase the long-term costs of health care generally and ART particularly.

2.    To achieve universal access to treatment, there needs to be a significant increase in funding for ART.

3.    As you are aware, besides dramatically improving life-expectancy, increased access to ART will help reduce the number of new HIV infections, maternal mortality, child mortality and the incidence of TB. Scaling up ART in hyper endemic countries, including South Africa, will therefore have a substantial impact on achieving all of the MDGs, the importance of which you noted in your letter.

4.    PEPFAR and the GFATM have been the leading funders of AIDS, TB and malaria treatment programmes in poor countries, with PEPFAR covering the cost of ART for 2.4 million people. PEPFAR funding grew from $2.3 billion in 2004 to $6.8 billion in 2010. It has been by far the largest fund of its kind globally. Both PEPFAR and the GFATM can demonstrate that they are initiatives that have saved millions of lives, so the question we have is why retreat from a model that is working, rather than improve the efficiency of the model while expanding its capacity?

Transition to Technical Assistance

1.     Your letter refers to transitioning from “service delivery” to “technical assistance.” This is an important aim, but because of the poor quality of our health systems at this point, many facilities are unable to carry the load.

2.     Do you accept the veracity of reports produced by Médecins Sans Frontières (MSF) and others that this approach is in fact leading to declining enrolment on treatment, treatment interruption and uncertainty for both patients and service providers?

3.    In this respect, please supply us with the joint Partnership Agreement with the SA Government to which you refer. Unfortunately this has been developed without any input from civil society, despite the fact that partnership between government and civil society is enshrined in the South African constitution and had been heralded as a cornerstone of the PEPFAR approach.

Shared Responsibilities and Duties

1.    Finally let us make it clear that our concern is not confined to South Africa. Indeed, South Africa in contrast to other Sub-Saharan African countries is better able to cover a significant part of the cost of AIDS, TB and malaria treatment, prevention and care from our own fiscus.

2.    But for historical reasons most developing countries are unable to finance the health needs of their population. The global AIDS epidemic has vividly illustrated this.

3.    Nonetheless we fully agree that much more needs to be devoted from developing country budgets to health; that there is a need for ownership and responsibility for health programmes, better monitoring, evaluation and efficiency.

4.    In South Africa these are commitments that TAC and our partners demand from our government and will continue to do so. We will continue to campaign for countries to meet their obligations, including the commitments of the 2001 Abuja Declaration.

5.    However because of global inequality a large part of the resources that are needed to realise the right to health (and for people with HIV/AIDS this includes access to treatment) must come from developed countries and China, supported with significant contributions from private donors, most notably the Bill & Melinda Gates Foundation.

6.    This is why we are calling on President Obama to provide visionary leadership on health and AIDS, in the way that he is seeking to do on climate change and nuclear disarmament. At the moment we fear that US leadership is providing excuses for a global retreat from health care that will have dreadful consequences.

Our Requests

1.    We therefore call on the US government to:

a. Increase PEPFAR funding to an amount that is consistent with the Lantos-Hyde legislation beginning in 2011.

b. Increase your 2011 contribution to the GFATM to $2 billion, rising to an annual contribution of $2.8 billion by 2013.

c. Call on the Member States of the European Union and other countries including China, Japan and Canada to increase their contributions proportionate to this increased contribution.

d. Call on members of the African Union countries to meet their Abuja commitment to increase health expenditure to at least 15% of their annual budgets.

e. Build a partnership with South Africa to press for health MDGs and for GFATM replenishment to be on the agenda of the coming G20 meeting.

2.    We ask you to indicate your response to each of the requests above as well as other questions we pose in this letter.

Yes We Can!

1.     We are part of a global movement of people who believe in human rights, democracy and development. We are convinced that the right to health care is realisable across the world. We are resolutely opposed to policies that undermine this right. We seek a partnership with the US government to ensure we achieve Millennium Development Goal 6 and universal access to HIV treatment.

2.     In this light, we ask you to respond seriously to the issues we have raised in this letter.

Yours sincerely
Vuyiseka Dubula

On behalf of:
1. The Treatment Action Campaign (TAC)
2. Congress of South African Trade Unions (COSATU)
3. SECTION27, incorporating the AIDS Law Project
4. Médecins Sans Frontières (MSF)
5. World AIDs Campaign ( WAC)
6. International Treatment Preparedness Coalition (ITPC)
7. AIDS Rights Alliance of Southern Africa (ARASA)
8. Community Media Trust (CMT)
9. Southern African AIDS Information Dissemination Service( SAFAIDS)
10. The AIDS Consortium (AC)
11. Rural Health Advocacy Project (RHAP)
12. Childrens Rights Centre (CRC)
13. AIDS Response
14. Social Justice Coalition( SJC)
15. Equal Education (EE)
16. Bigshoes Foundation

CC: Dr Aaron Motsoaledi, Minister of Health
Mr Kgalema Motlanthe, Chairperson South African National AIDS Council
Dr Pravin Gordhan, Minister of Finance
Mr Michel Sidibe, Executive Director UNAIDS
Mr Michel Kazatchine, Executive Director, GFATM

Note: This version of the letter (updated on 18 June 2010) corrects several typing mistakes in the first version. Please cite and use this version.