Less diversion. One clearly good choice PEPFAR made was to work through MAUL instead of through the system the Ugandan government uses, the
National Medical Stores (NMS). Previous programs haven't been as lucky: In 2002, fluconazole pills donated by Pfizer to the
government of Uganda—and intended for distribution through NMS to health facilities—were diverted and ended up for sale on
pharmacy shelves. And in 2003, NMS tried to sell GSK-supplied Combivir to a local company, Eris, which was a buyer for Landmark
Pharmaceuticals, which was then free to sell the products at profit to other markets. MAUL, to date, has had no similar problems.
It's working. Finally, PEPFAR proponents say, although the system isn't perfect, it is already operational—unlike the Global Fund grants
that were promised in 2002 but have not yet been dispersed. "It is not bogged down by bureaucracy," says Emmanuel Luyirika,
the medical director of Mildmay Centre, a specialist outpatient referral center set up by international donors for people
with HIV/AIDS. "The system PEPFAR uses is much faster than the government system. In fact, the PEPFAR program is the one that
has made the biggest impact in our city here, in terms of free care. Within six months, we already have 700 patients on ARVs.
We hope by the end of March 2005, we will have about 1,400 receiving free care through PEPFAR. That is our only source of
On the negative side:
US money for US drugs. Despite the MAP debacle, there is a rising resentment toward the Bush government for refusing to purchase generic ARVs. That
sentiment is being fueled by providers as they gain experience with generics and report good results and as more data about
generics becomes available. One example is the Médecins Sans Frontières (MSF) study published in the Lancet that found Cipla's FDC Triomune performed as well as brand-name drugs.
"Bilateral plans are turning into a slush fund for Big Pharma," says Asia Russel, coordinator for international policy at
HealthGAP, a US-based activist organization.
Parallel systems. PEPFAR's separate and specialized distribution system doesn't support most countries' national scale-up strategies and works
outside the Ugandan healthcare system. That's causing confusion inside clinics among physicians and other providers, who must
keep funding sources, patients, and pills separate.
"In Rwanda, where we have both MPTCT Plus programs and PEPFAR-funded programs at the same clinic, there's stress that the
two different sources look different," says David Hoos, MD, assistant professor at the Columbia University Mailman School
of Public Health, and chair of the Global Fund's procurement advisory panel. "They have to keep the stock in separate places
so that the parallel system causes distress at the clinical level and it confuses patients. Because they don't know that there
are different funding sources and different products, they are asking: 'Why does my drug look different than this person's
Not uplifting general system. Nsubuga, who uses NMS to distribute the World Bank's ARVs, says PEPFAR grants also do nothing to uplift, strengthen, and expand
the general medical care system, which is collapsing under the weight of the epidemic. Although PEPFAR money is only awarded
to programs focused specifically on HIV, the prevalence of AIDS in Uganda (estimates peg it anywhere from 4.1-17 percent)
is such that the disease affects all aspects of healthcare—from general practitioners to TB wards. In addition, PEPFAR-funded
programs attract the country's skilled manpower with high salaries, which further detracts from the Ugandan system and will
have implications when PEPFAR disappears in 2008.
From Infrastructure to Price
The pharma industry has been a moving target in the AIDS epidemic. "The debate has gone from being one of patents that kill
to prices that kill, to where it is now, which is much more about the whole area of lack of healthcare infrastructure," says
Jon Pender, director of external relations, global access issues for GlaxoSmithKline.