Despite Recession, New Funding Stimulates Scientific Research
New research dollars will energize scientific projects, including many focused on HIV prevention strategies, but uncertainty remains about the sustainability of long-term HIV/AIDS funding
By Regina McEnery
In recent years, budgets of the major US government research engines, including the US National Institutes of Health (NIH), have not increased. Tighter budgets have meant more competition for research dollars, much to the chagrin of scientists who rely on government funding to get their projects off the ground. During difficult economic times, all types of discretionary spending, including scientific research budgets, can get squeezed even further. Yet, even in this time of great economic uncertainty, science funding in the US is now actually on the rise. Ironically, the current recession has spurred dramatic levels of new funding for research projects through the US economic stimulus package. This new money, along with a strong commitment to science from US President Barack Obama, has many researchers excited.
Some of the projects that will receive stimulus funding involve HIV prevention strategies, some of which are related to AIDS vaccine research. The Office of AIDS Research (OAR), which coordinates the US government’s AIDS research budget, views HIV prevention as the highest priority. “Disappointing results from recent clinical studies of HIV vaccine and microbicide candidates underscore the need for additional discovery (basic) research of HIV,” the OAR noted when it presented the president’s budget request to lawmakers, adding that, “biomedical and behavioral interventions are urgently needed.”
Apart from the stimulus money, there are also some much smaller increases being doled out to HIV/AIDS research. Obama’s 2010 budget, which is being considered by lawmakers, seeks a US$45 million, or 1.5%, overall increase in HIV/AIDS research, for a total of $3 billion (see Figure 1, below). This includes less than a $1 million, or 1%, increase for AIDS vaccine research and a 3.2% increase for research on microbicides.
Figure 1. Obama's 2010 Proposed Budget for AIDS Research by Program. Prevention of HIV infection is the National Institute of Health's (NIH) highest priority for HIV-related research, according to the Office of AIDS Research. Shown above is a breakdown of the US$3.1 billion NIH budget for AIDS research, by category, in President Obama's proposed 2010 budget. Source: Office of AIDS Research
As the HIV pandemic approaches its third decade, the Obama administration maintains that HIV/AIDS prevention and treatment is a priority, both globally and domestically, and will remain so despite the recession. “In a time of tightening budgets and economic constraints, the 2010 budget request demonstrates commitment to the global fight against HIV/AIDS,” Acting Deputy US Global AIDS Coordinator Thomas Walsh said when he appeared before Congress.
Since promising to return science to its rightful place in government policies, Obama has unveiled several plans to increase research budgets. He has pledged to devote 3% of the US gross domestic product (GDP) to strengthen science and technology—the current level of spending is 2.6% of GDP. This amount of money exceeds the nation’s peak level of spending on science (2.9% of GDP), which occurred in 1964 following President Kennedy’s pledge to put a man on the moon by the end of the decade. If Obama’s man-on-the-moon-style budget pledge pans out, the money will double funding for the National Science Foundation within 10 years and provide more money for the NIH, including nearly $6 billion for cancer research.
“Science is more essential for our prosperity, our security, our health, our environment, and our quality of life than it has ever been before,” Obama said when he laid out his scientific spending agenda during an address in April at the National Academy of Sciences.
This isn’t the only new money being funneled into the NIH. After many years of flat funding, the NIH received a 3% annual budget increase already this year, based on the budget of the previous administration. And in February 2009, under a one-time economic stimulus package known as the American Recovery and Reinvestment Act, the NIH received $10.4 billion more in new funding. The National Institute of Allergy and Infectious Diseases (NIAID) at the NIH, the largest funder of HIV/AIDS research in the world, will receive $1.2 billion of the economic stimulus money. About a third of it will likely go toward funding two-year research grants focused on HIV prevention, says NIAID Director Anthony Fauci. NIAID will use the stimulus money to fund already submitted grant applications, which were previously unfunded because of budget constraints (see Figure 2, below). Some of the stimulus money is going to fund AIDS vaccine-related projects, including research on the use of a synthetic activator of natural killer cells as an adjuvant for mucosal vaccine candidates, and another project studying the impact of helminth parasites on immune responses to HIV vaccine candidates. Another project involves designing and evaluating new immunogens based on the HIV Env trimer.
Figure 2. Stimulus Funds for AIDS Research at the NIH. The National Institutes of Health (NIH), the largest government funder of AIDS research, received US$10.4 billion in economic stimulus money from the American Recovery and Reinvestment Act (ARRA) of 2009. An estimated $559 million is being considered for AIDS-related research across 10 NIH institutes. The National Institute of Allergy and Infectious Diseases (NIAID) will receive approximately $331 million in AIDS-related funding. Source: National Institutes of Health and Office of AIDS Research
But Fauci says he is focusing primarily on three categories of prevention research for the stimulus dollars. Two involve broader applications of antiretrovirals (ARVs). One is studying the delivery of ARVs prior to HIV exposure to prevent infection—a strategy known as pre-exposure prophylaxis (PrEP). The other is looking at the feasibility of providing ARVs to every HIV-infected individual who meets the World Health Organization’s treatment guidelines, a concept known as treatment as prevention, which aims to reduce the spread of HIV. Individuals on ARVs have much lower viral loads and are therefore thought to be less infectious.
The third category involves the tantalizing prospect of eradicating HIV from infected individuals. Although complete eradication of HIV—essentially curing an infected individual—is considered a long shot, some scientists think it may be possible to achieve a “functional cure” with strategies that could help root out and eliminate HIV from some of the reservoirs of latently infected cells. Although this likely wouldn’t clear out the viral reservoirs completely, it might diminish the virus enough to make it possible for a person’s immune system to keep the residual HIV in check without continually taking ARVs.
University of North Carolina virologist David Margolis is one researcher studying viral eradication. He says the two-year infusion of economic stimulus money will arrive just as scientists are gaining important new insights into latent reservoirs of HIV. In his view, recent setbacks in AIDS vaccine and microbicide research make the question of viral eradication a reasonable one to pose right now. “Given that the area of viral eradication is minimally invested in—there are very few labs looking at this—it is an obvious area to focus on,” says Margolis.
Margolis co-authored an article in Science earlier this year with Martin Delaney, founder of the AIDS service organization Project Inform in San Francisco, as well as other researchers, calling for a collaborative approach to find novel HIV therapeutics that would “purge latent HIV cells” and eliminate the need for ARVs to control replication of the virus (1).
Long-time AIDS activist Peter Staley, the founder of AIDSMeds.com, wrote in a recent blog entry that between the economic stimulus dollars for NIAID and newfound energy among activists and researchers willing to look beyond treatment, the US could be entering the “golden age” of AIDS research. “After many years of basic research and vaccine research we are putting more pieces together on how the immune system interacts with the virus,” says Staley. “At least we have a better idea where to look.”
The projects receiving funding from the economic stimulus plan can be tracked at http://grants.nih.gov/recovery. One drawback to stimulus funding is that researchers lucky enough to receive the extra cash, which must be spent by 2011, may find it difficult to receive funding to continue their projects once these stimulus grants expire. Unless more money is added to NIAID’s annual budget in 2011 to support these additional grants, “it will be a very difficult year for [these] people to secure funding,” says Fauci.
Turning the focus on home
In addition to funneling money to research, Obama administration officials are also focusing extra attention on the static HIV epidemic on their home turf. In April, the Obama administration rolled out a five-year, $45 million multi-media HIV prevention campaign, “Act Against AIDS,” that targets African Americans and Latinos in high-risk neighborhoods in cities such as Washington, D.C. In the US Capital, at least 3% of residents are infected with HIV, according to the city’s health department. The US Centers for Disease Control and Prevention (CDC) oversees this campaign. Former New York City Health Commissioner Thomas Frieden was picked by Obama to oversee the CDC, which until January was led by AIDS infectious disease specialist Julie Gerberding. During his tenure in New York City, Frieden lobbied strongly to make HIV testing a routine part of medical exams and fought to minimize the spread of drug-resistant tuberculosis in the city.
Two other AIDS-related posts have also recently been filled. Jeffrey Crowley, a Georgetown University health policy analyst and former director of the National Association of People with AIDS is heading up the Obama administration’s Office of National AIDS Policy, and Eric Goosby, the chief medical officer of the Pangaea Global AIDS Foundation based in San Francisco is now the US Global AIDS Coordinator in charge of all international HIV/AIDS efforts.
Crowley is playing a key role in developing a National AIDS Strategy, which should provide clear national guidelines on a range of prevention strategies such as circumcision, syringe exchange, counseling and testing, and abstinence-until-marriage. “We are at a crossroads in HIV prevention and we need to be focused on making sure we are doing everything we can to prevent new cases of HIV/AIDS,” says Crowley. “My experience has been that we have spent a lot of money not targeted to populations at the greatest risk for HIV.” Other countries such as South Africa, which has the highest HIV prevalence in the world, already have such national plans, and AIDS advocates in the US have long argued that a government-backed blueprint on how to tackle the epidemic is needed for AIDS organizations to reach their goals.
Judy Auerbach, deputy executive director of science and public policy at the San Francisco AIDS Foundation, says that a National AIDS Strategy should push for more evidence-based AIDS prevention. Obama has already signaled his support for evidence-based policies by lifting the ban on federally funded embryonic stem cell research, and he is considering doing the same for syringe-exchange programs to quell HIV transmission among injection-drug users.
“We can’t keep funding things willy-nilly, which is to some degree how things have gone,” says Auerbach. “More money is always better because it means more science can be conducted. But it shouldn’t just be more science; it has to be the right kind. We need to be more responsible with how we are spending money.”
While the new research money is a boon for scientists, another battle is being waged over US spending on international HIV/AIDS programs. US funding to fight AIDS internationally has grown significantly in recent years due to the President’s Emergency Plan for AIDS Relief (PEPFAR), a program started in 2003 under then-President George W. Bush. PEPFAR started as a $15 billion, five-year program, and was reauthorized last year by the US Congress for $48 billion over five years (or $9.6 billion a year) to fund HIV/AIDS prevention, treatment, and care, as well as tuberculosis and malaria programs.
Obama’s budget proposal includes a $6.6 billion allocation for PEPFAR in 2010, an increase of $165 million over the amount being spent this year. This is significantly less than the $1 billion increase per year that Obama promised during his campaign. As a presidential candidate he also promised to spend $50 billion over five years on PEPFAR, and though he says he still intends to spend that amount, he says it will be over six years rather than five.
This drew criticism from AIDS advocates. “To not put the resources in will create a worse epidemic down the road,” countered Ken Mayer, a professor of medicine at Brown University and co-chairman of the scientific advisory committee of the Infectious Diseases Center for Global Health Policy and Advocacy. “And there are a lot of other ways in which an uncontrolled AIDS epidemic will jeopardize health in very serious ways, whether it’s creating more AIDS orphans or spreading multi-drug resistant tuberculosis. HIV is clearly more than just treating HIV.”
Others say that Obama’s failure to fund PEPFAR at the level he previously promised will also hamper HIV prevention efforts. “People now are coming in for testing in huge numbers because there is the hope of getting treated if they are infected. If that hope is no longer there, people will not seek testing,” says Peter Mugyenyi, director of the HIV/AIDS Joint Clinical Research Centre in Uganda, which is a PEPFAR recipient. “Without testing, you can’t have effective prevention.”
According to the Global AIDS Alliance, about 2.9 million people in developing countries are currently receiving ARV therapy—only a third of the 9.7 million who need it. PEPFAR has brought ARVs to more than two million people in 15 target countries—most of them in Africa—but has not reduced the rate of new HIV infections, according to a recent study (2). By plugging UNAIDS data into mathematical models, researchers at Stanford University compared epidemiological data from 12 PEPFAR-recipient countries in sub-Saharan Africa with 29 countries from the same region that have a generalized epidemic—an HIV prevalence higher than 1% in antenatal clinics and where the primary mode of transmission was heterosexual sex. Though HIV-related deaths declined in countries receiving PEPFAR funding, there were no changes in HIV prevalence trends between the 12 PEPFAR-funded countries and the 29 others.
“Projections suggest that the gap between the available funds and those needed will continue to increase unless the incidence of HIV in Africa is substantially reduced,” said Eran Bendavid and Jayanta Bhattacharya, the Stanford University researchers who conducted the study.
In testimony before US lawmakers, Walsh said, “PEPFAR will redouble the focus on prevention.” He called this one of the highest priorities for the program, adding that, “While treatment is incredibly important, we cannot beat this epidemic with treatment alone.”
Obama has praised PEPFAR’s goals but is also interested in a more integrated approach to tackling global health problems. In May, he introduced plans to meld PEPFAR into a $63 billion Global Health Initiative, which will support global health more broadly, including programs related to maternal and infant health and immunization. “We cannot simply confront individual preventable illnesses in isolation,” said Obama when he announced the initiative. “The world is interconnected, and that demands an integrated approach to global health.”
In a commentary published last year Ezekiel Emanuel, brother to Obama's chief-of-staff Rahm Emanuel and currently an advisor to Obama on health care reform, said doubling or tripling PEPFAR's allocation is not the best use of international health funds (3). "In focusing so heavily on HIV/AIDS treatments, the United States misses huge opportunities. By extending funds to simple but more deadly diseases, such as respiratory and diarrheal illnesses, the US government could save more lives—especially young lives—at substantially lower cost," wrote Emanuel and co-author Colleen Denny, both bioethics researchers at the NIH.
Forecasting the future
In addition to the less-than-expected allotment in Obama’s budget for PEPFAR, AIDS activists and public health experts have raised concerns that the sour economy could pose a threat to the sustainability of global AIDS funding in the future for many programs. In a recent address, Secretary General of the United Nations Ban Ki-moon called on governments to not use the economic crisis as a reason for cutting AIDS funding.
“Despite lack of resources being a major challenge, failure to continue a scale-up [of] investments in health will betray the trust of millions of people who have been given hope of survival from deadly diseases by the promises of the international community,” says Michel Kazatchkine, executive director of The Global Fund to Fight AIDS, Tuberculosis and Malaria. The Global Fund depends on annual contributions from many wealthy countries to fund its treatment and prevention programs. Obama’s budget calls for $900 million for The Global Fund in 2010, the same amount that was authorized by the US Congress for 2009.
Although lower prices have been negotiated for many ARVs, overall treatment costs continue escalating as more and more HIV-infected people require treatment and more people become newly infected. The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimates that by 2015 it will cost approximately $54 billion a year to provide comprehensive HIV programs in low- and middle-income countries. These programs include adminsitration of ARVs, distribution of condoms, as well as palliative care and treatment of opportunistic infections in HIV-infected individuals. It is unclear exactly how much of the funding is spent on ARVs. The world is currently spending $5.5 billion on HIV treatment, according to the latest UNAIDS estimates.
Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations, says there is already fatigue among some international donors and that two decades from now the money to sustain these AIDS treatment programs may not be there. “Either you have a fantasy in which somehow a series of drug [regimens] are available for pennies, or you have to start really focusing on prevention.”