Reform AIDS relief plan before reauthorizing

We call upon our political leaders to reform PEPFAR by committing $50 billion for global AIDS, removing conditions that complicate the allocation of funds (the one-third earmark for abstinence-only programs) and targeting funds to the development of human healthcare capacity. The U.S. government has taken leadership in the fight against HIV/AIDS through PEPFAR — the President’s Emergency Plan for AIDS Relief. The plan was introduced by President George W. Bush ’68 on Jan. 28, 2003. $15 billion, the largest sum of money dedicated thus far by the United States to fund international initiatives against a single disease, was committed.

The plan identified 15 focus countries across Africa, Asia and the Caribbean — Botswana, Cote d’Ivoire, Ethipia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Zambia, Guyana, Haiti and one to be determined — that have a heavy HIV/AIDS burden to carry. Most of these countries had declared HIV/AIDS a national emergency and had committed their national leadership to battling the disease. PEPFAR funding highlighted the urgency of the fight while supporting the strategic leadership and priorities that each of these countries had identified.

PEPFAR aims to fund prevention, treatment and care: 55 percent of the funds were allocated to treatment programs, 20 percent to prevention, 15 percent to palliative care and 10 percent to orphans and vulnerable children. The goal was to treat at least 2 million people, prevent 7 million new AIDS infections and provide care to 10 million people impacted by AIDS worldwide.

The “United States Leadership against AIDS, TB, and Malaria” act, through which PEPFAR was authorized, expires January 2008. In May 2007, President Bush announced his plan for PEPFAR reauthorization — PEPFAR II — which will dictate the U.S. funding level and targets for global AIDS from 2009-2013. It’s a good time to reflect on the successes of PEPFAR, analyze its shortcomings and identify opportunities for further impact through PEPFAR II.

Currently, one-third of all funding for prevention is restricted to abstinence-only programs, denying funding to any program that offers condoms as an option. The built-in “Prostitution Loyalty Oath” condition prevents funds from being used to provide assistance to any group that does not explicitly oppose prostitution and sex trafficking. Additionally, PEPFAR funds cannot be used for needle- or syringe-exchange programs, on the premise that these programs encourage drug use. These conditions undermine the integration of HIV/AIDS prevention programs into other health programs. They also limit the ability of projects to respond to local needs — one of the goals PEPFAR sought to achieve.

The plan focuses on training existing healthcare workers to deliver AIDS care; in effect, pulling doctors and nurses away from locally run clinics and hospitals. This hurts the local health system. In the absence of adequate compensation, some of the now better-trained workers choose to move to other, more developed countries. And thus PEPFAR needs a concrete proposal to invest in human healthcare capacity-building by training new workers and offering them better compensation as an incentive to stay.

President Bush has proposed $30 billion for PEPFAR II, an apparent doubling of the initial pledge. However, annual funding started at $2.3 billion in 2004 and steadily scaled up to $5.95 billion by 2008. Therefore, President Bush’s pledge to double funding to $30 billion is based on flat funding from the 2008 level. Moreover, this amount falls short of the WHO’s estimate of the United States’ fair share — based on GDP — which is $50 billion. The proposed funding will result in scaling down of all the treatment, prevention and care goals set by PEPFAR I.

While developing PEPFAR I, the responsible committee stated:

“This strategy has been carefully, thoughtfully yet urgently developed. Clearly, we do not have answers to every question we have identified. Working closely with host governments, U.S. government teams in the field, our various partners and those living with AIDS, we will continue to learn and to develop new or more comprehensive approaches. Our strategy will evolve as we engage new partners and respond to innovation, input, experience and outcomes. It must be a living document — always a work in progress.”

Important changes need to be made to the plan before its reauthorization. We call upon our political leaders to reform PEPFAR by committing $50 billion for global AIDS, removing conditions that complicate the allocation of funds (the one-third earmark for abstinence-only programs) and targeting funds to the development of human healthcare capacity.

Grace Waruchu Wanjiku is a first-year graduate student at the Yale School of Medicine. She writes on behalf of the medical school’s AIDS Week Planning Committee.

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