A single line often inverts meaning once you see what it
answers, so neighbouring messages are always shown.
-
Oct. 24, 2011 - Met again at the WH (EEOB 439) with the usual cast of characters. Gayle Smith chaired the meeting. Denis McDonough not there. Main issues again is the reluctance of USAID (Ariel) to buy into the idea of expanding treatment as a way to "tip the curve". He suggested moving the money from the efficiencies of PEPFAR treatment (see above) to non-treatment prevention modalities. Eric Goosby tried to explain that the non-treatment prevention modalities (PMTCT, AMMC - adult medical male circumcision) are already maxing out and any increasing or not are due to other issues besides resources. I arguing strongly against Ariel and reminded people that this was a POTUS initiative to increase Tx. Below is an e-mail that I sent to Gayle Smith after the meeting clarifying my stance on this. Gayle: Thanks for running an important and sometimes contentious meeting today. You do it masterfully. Please read my comments below and then you can either accept them or throw them out if you wish and I will still be your friend. Here goes... Eric, Ariel, and I, and hopefully Tom Frieden will get together by phone tomorrow to try and hash out and hopefully resolve the issues that were brought up today regarding standard prevention versus treatment as prevention. It appears that Ariel and USAID feel that in an arena of a flat budget, the money saved by efficiencies in treatment should be turned over to standard prevention modalities as opposed to expanding the number of people on treatment (which is also prevention). As Eric will explain to Ariel tomorrow on our phone call, the model that has been developed takes all of these issues into account and the standard prevention modalities such as adult male circumcision and PMTCT to which Ariel is referring can be maximized in a number of ways without significant increases in resources, whereas putting more people on treatment clearly requires more money. You can treat the same number of people with less money by efficiencies, but the only way to get more people on treatment with a flat budget is to use the savings from efficiencies. As we have been discussing, this will have the effect of preventing more infections at the same time as saving the lives of the infected people who would now be receiving treatment. This also results in other economic and social benefits. Although you are trying to be fair to all points of view, in my humble opinion, if we go to the Principals giving them a choice of the two approaches, we will confuse them. I believe that they need to look at a single proposal that we have already agreed upon in our discussions and decide if they are comfortable with it. Another point that seems to have gotten lost by some in today's discussion in the fact that, as I mentioned at the end, we are talking about a potential game changing initiative by the POTUS that could be a legacy. We are not talking about competition for limited money that might go to other areas. Another issue is that the activist community would support the POTUS in an initiative with no new money, but that includes a plan to increase the numbers of people on treatment by the mechanisms that we had discussed with you and Denis. If he comes out with a plan to divert savings from treatment efficiencies to non-treatment programs, the constituencies will be infuriated. Sorry for taking your time with this e-mail. I just felt that I needed to express my thoughts to you. Talk to you soon. Best regards, Tony ple
-
Oct. 25, 2011 - Raj Shah (Administrator of USAID) called me at 1:30 PM to get a better feel of my position on treatment as prevention. I thought that he would have a problem with it, but he was really asking if it was better to target people with very early infection since they are most likely to spread infection. I explained to him that although this was the case, they represent a relatively small fraction of infected people and they are very difficult to identify at this early stage. I found out later in the day from Cheryl Mills (Chief-of -Staff to Hillary Clinton) that Bill Gates had told Hillary that treatment as prevention was a waste of money and would not work. Hillery (HRC) heard from Eric that Bill Gates is probably the only person in the world who felt this way and that is exactly what I told Cheryl (see my breakfast with Bill Gates above). It seems that HRC is to meet with Raj today to get his opinion and so that is why Raj called me. Also, HRC will come to NIH on my suggestion to give speech on this subject on Nov. 8. I helped drafting her speech.
-
Oct. 26, 2011 - Conference call with Eric, Ariel, me, Charles Holman and various people from USAID, PEPFAR, and CDC (Tom Frieden) trying to hash out the difference between Eric/me/Tom and USAID. It appears (maybe) that we have convinced Ariel that our model is valid. More to come.
-
Oct. 31, 2011 - Another WH (EEOB 430A) meeting regarding above topic. Chaired by Gayle Smith. Also there was Amy Batson (USAID), Lois Quam, and Tom Frieden by phone. Cold crisp day in DC. Fall is here! Again the tension between USAID goals and PEPFAR goals become clear. USAID is trying to enhance their own agenda, which in my opinion has failed with their spending millions on prevention messages that do not work. They are trying to derail the PEPFAR "scale up by efficiencies" initiative. Ariel is turning out to either be naïve or nefarious. I always heard that he was a good guy, but he and USAID team keep insisting that the efficiency money should go either to a broader GHI or to enhancing the non-treatment prevention agenda (PMTCT, AMMC, condoms, etc.). The PEPFAR/Fauci/CDC agenda is to use the efficiencies to scale up Tx from 4.2 million by 2013 to 6+ million by 2013. This should reach 8 million by 2015 without any additional funds. If you go to "blue Sky" of +$2.5 billion from 2013 to 2015, you will go from 8 million in 2013 to 10 million in 2015. The PEPFAR model also assumes and enacts a maxing out of the non-treatment prevention modalities. USAID disagrees and want to use efficiency money to favor non-treatment as Prevention. This is what Ariel is saying. After meeting with Eric Goosby, Ariel seems more convinced that the PEPFAR model may be OK. However, what does Raj Shah think????
-
2011-11-01 00:00
Anthony S. Fauci
Nov. 1, 2011 - Dinner with Rick Klausner at Matisse Restaurant on Wisconsin Avenue and Fessenden. Discuss the Qatar initiative, see above and below. But, conversation turned to Raj Shah and the PEPFAR/USAID story. Bottom line is that Raj has been talking with Rick and it appears from Rick and my prior conversation with Raj that Raj is not against treatment as prevention (TAP); however, he does not like the model and want to do it differently. (More on Qatar later - stick with USAID/PEPFAR for now)
-
Nov. 2, 2011 - 7:30 AM Get call from Rick Klausner who is having breakfast with Raj Shah and Rick wants to set up teleconference with the 3 of us at 11:00 AM to discuss the above issues. On the call Raj dances around a bit, but what he really wants is a big initiative using PEPFAR money. He does not say so explicitly, but that is really what he wants. He does not want the efficiency money to pay for 6 million of TAP by 2013; he want 5.5 million for TAP and the rest for a full-court-press initiative to see in a selected 3 countries if maximizing both non-TAP and TAP prevention will actually end the pandemic. I explain that there is not enough money to do this, and besides, the expectation is to TAP, not do a study to prove that it could be done. He agrees with me that we should do both within the constraints of budget. He is sure that the POTUS will like this initiative since it is a scientifically-based approach (give me a break!!!). The big elephant in the room is that USAID has been wasting $100s of millions on prevention approaches (like behavior change) that do not work. They should use this $ to do their proof of concept full-court-press approach, not try to siphon off PEPFAR money (I did not say that, but this clearly was the elephant). Raj wants the have Eric, himself and I put together another proposal to this effect. After the call Rick e-mailed me and asked for a follow-up call. On that call Rick explained that what Raj really wants is to spend all of the efficiency money on the 3 country demonstration project and that this would be the POTUS initiative. They (Rick and Raj) just do not believe that PEPFAR/CDC model. Also, (amazingly), Raj admits to Rick that the USAID has been wasting $100s of millions, but he is not up to taking on the USAID bureaucracy. Rick is disappointed in him and thinks that he is being weak and has told him so. However, rick is in favor of the concept since he has issues with PEPFAR. Based on this, I arranged a teleconference with Tom Frieden (at Atlanta airport), Eric, Charles Holmes, and some PEPFAR people and CDC people to discuss all of this. Tom Frieden was furious at USAID. He says that they have been wasting $ for years and now they question what CDC proposes, when CDC has been saying for years that they should have been scaling up AMMC and PMTCT instead of wasting money on behavior. Clearly, Raj is a young, brilliant guy who is extremely ambitious (that is OK), but he wants control of PEPFAR resources. Frieden is dead against this PEPFAR is obviously against this. So am I. The original question was to use efficiencies to scale up TAP, not to try something that USAID should have been doing all along with their own $. The idea of nailing down whether we can end the pandemic with a full-court press (FCP) is a good one, but there are no resources available. I propose that we do both the PEPFAR plan and the FCP, the latter with $ that we get from additional sources. White House meeting scheduled for Nov. 9. Everyone wants me there, but HHS will have to decide who the "Plus one" is with Sebelius. Of note, I am scheduled to go to Seattle on Nov. 9 for a town hall meeting and a seminar sponsored by Lee Hood and the Institute for Systems Biology. Bill Gates is trying to undermine the initiative on upscaling TAP. See e-mail below from MSF to me sent on 11/02/11: Dr. Fauci, Congratulations on getting NIH-supported HIV research the airing it deserves at the highest levels of government. We are all looking forward to Secretary Clinton's speech at the NIH next week. We are trying to use the USG momentum to leverage new commitments from the UK for World AIDS Day. So far DfID and other government actors are interested in a "step up" initiative that we have also been pitching to USG, South Africa, and Germany to pay for implementation of accelerated treatment. Today we had a bit of a minor set back: the Secretary for Development Andrew Mitchell just heard from Bill Gates at a Tory event "Friends of International Development" that HPTN 052 will not yield great effects and the role of ART in limiting incidence is more limited than what is being portrayed. It was unfortunate. It would help greatly if the policy makers in government could hear the science themselves. If the All-Party Parliamentary Group on AIDS invited you to give a briefing, and we arranged for high-level meetings, could you attend? Would an invitation by civil society and MSF suffice? And, hardest question of all-- do you have any free days where you could be in London in November? Thank you, Sharonann -- Sharonann Lynch HIV/AIDS Policy Advisor Access to Essential Medicines Campaign Médecins Sans Frontières (MSF) Tel: +1.646.824.3066 Email: sharonann.lynch@msf.org Also see below e-mail from Nov. 3 from Michael Iskowitz describing what the community actually is hearing about. It is amazing how things leak sinceI have told no one what I am doing regarding USAID, PEPFAR and the WH. Finally, tonight (11/02/11) went to Book Signing party at Hay-Adams Hotel for Chris Matthews on his new book "Jack Kennedy - Elusive Hero". Another example of the A group of Washington. It is clear that at age 70, being on the public/political/media scene for >30 years, I am extremely well-known and even friends with so many public figures, who merely on the basis of my being on TV/Radio/newspapers, etc. and the fact that we run into each other at so many of these functions have gotten to know me well. Just a sampling of people at event: Andrea Mitchell; Alan Greenspan; Sens. Chris Dodd, John Kerry; Rep. Ed Markey, Jim Moran; Howard Feinman; Murrey Jacobson; Luke Russert; Gloria Borger; Joe Scarborough; etc. Had animated conversation with my friend Ed Markey regarding the disgraceful conduct of the Banking Industry and Wall Street. The "Occupy Wall Street" movement is gaining momentum. The Republican scramble for the nomination is hot and heavy
-
Nov. 3, 2011 - Incredible day. Theme is my trying to hold together the evolving proposal to scale up combination prevention with treatment as prevention (TAP) being a major component of the scale-up as described above. Tension is USAID and Raj want to spend most of the efficiency money on concentrating and ending the epidemic in 3 chosen countries as opposed to going with the PEPFAR/CDC/FAUCI plan of scaling up combination prevention across the board and doing a demonstration full court press (FCP)in selected pockets of the countries that we have selected: Botswana for CDC; Zambia and South Africa for NIH; Tanzania for USAID. Spent all day on calls individually with Tom Frieden, Eric Goosby, Mark Dybul, Raj Shah (in the evening). Raj call was at the suggestion of Rick Klausner who says that I am the only person who can broker a deal between PEPFAR and USAID. We need USAID to support our proposal at the WH meeting next week (Nov. 8 - the evening of Secretary's Clinton's speech at NIH. I have cancelled Seattle to ne at the WH meeting. WH house wants me and Frieden to represent HHS, i.e. "plus 2". Mark Dybul agrees somewhat with the need to have a bold announcement as per Raj, but we all know that there is no new money. Rick also feels that way. However, what neither of them fully appreciate is that the "demonstration project" described above is in reality a FCP in a selected group within countries. I had important call with Raj. I leveled with him and said that although he is proposing putting all of the PEPFAR efficiencies towards a FCP in 3 countries and scrapping the PEPFAR Plan, he should look to "clean his own house" and create efficiencies within USAID and use that money to scale up the 3 country approach and make it more of a FCP, i.e. I am proposing a "hybrid" of the PEPFAR plan and the USAID plan since we all need each other and we need to provide the POTUS with a proposal that is scientifically sound, bold, yet not unrealistic, and that does not require significant new money. Of note, Hillary Clinton will propose $60 million of her money to beef up that "demonstration project" I called for a meeting tomorrow to see if Raj, Eric, Tom and I could figure out a compromise with me as the referee. Also see below e-mail from Nov. 3 from Michael Iskowitz describing what the community actually is hearing about. It is amazing how things leak since I have told no one what I am doing regarding USAID, PEPFAR and the WH. tony dearest. i just wanted to thank you for helping to create and drive another landmark moment in AIDS history. i continue to do consulting with eric -- who remains forever grateful for your friendship and extraordinary leadership. i am honored to have have many decades now of watching you work your magic -- forever urging that if we remain steadfast and follow the science, together we will win. bless you for -- behind the scenes and in front of the cameras -- shaping another historic moment. know that i talk with eric frequently and if there is anything i can for you directly -- please know i always stand ready. thank you for being you and for all you do for the world, if i am not at the NIH on tuesday -- i am certainly there in spirit! much love, michael
-
Nov. 4, 2011 - I cancelled most of my AM calendar to attend meeting at 8:00 AM in Eric's OGAC (Office of Global AIDS Coordinator) office at 2100 Pennsylvania Ave, N.W. (suite 200). At meeting was the 4 of us. After about 90 minutes I got everyone to accept the "Fauci hybrid plan". Raj agreed (as I suggested last evening) that he come up with about a few hundred million in efficiencies from USAID. Eric will try to find more efficiencies from the PEPFAR "Pipeline", all to beef up the demonstration project and perhaps include another country such as Nigeria. However, we will all need to see if our respective demonstration projects could effectively absorb an additional few hundred million $. We will work on this over the weekend. More to come. Also today met with Dr. Abdelali Haoudi, VP for Research of the Qatar Foundation at the recommendation of Rick Klausner with whom I had dinner on Nov. 1. Great meeting with Abdelali. Introduced him to JJ McGowan, Kathy Zoon and Marv Kalt to help him with using the NIAID model to get his Qatar intramural and extramural program set up. I think that we could turn out to be friends.
-
Nov. 5-6, 2011 - Continued strain between USAID (Raj) and PEPFAR (Eric and Charles) in that Raj just does not want to give in about pushing for "doing things differently". Nov. 5-6 is the weekend and Department of State (Lorrie McHugh - communications) as well as Cheryl Mills are lining up people (activists, etc.) to write blogs in anticipation of Sec. Clinton's Speech at NIH. Her speech (which I have been deeply involved in writing follows the PEPFAR model, not the USAID model. They have asked me to do an editorial for the NY Times giving the scientific basis HRC's speech. I worked all weekend and got a great piece which I have circulated to Cheryl Mills, Burklow (NIH), HHS, etc.