Diary Prequel Package — page 256

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