Reevaluating PEPFAR

In an effort to recast himself as a “compassionate conservative,” President Bush often invokes HIV/AIDS relief as a key component of his foreign policy. Amid a history of strong-armed diplomacy, this altruistic endeavor is distinct. Launched during the 2003 State of the Union, “The President’s Emergency Plan For AIDS Relief” (PEPFAR) garnered rousing bipartisan applause and was awarded legislative authorization just three months later. At $15 billion in funding, PEPFAR shattered records as the largest commitment by any nation to focus on a single disease. Yet exceptional funding warrants ambitious expectations. Anticipating as much, The Emergency Plan sought to develop leadership at all levels, utilizing its resources to build lasting public-private partnerships and to coordinate diverse programming to counter the HIV/AIDS epidemic. Despite mixed results, after three years, PEPFAR’s expansion is now an imminent reality. On May 30, President Bush reaffirmed his commitment to combat HIV/AIDS in a proposal to double the initial appropriation to PEPFAR through a new $30 billion budget. The White House, eager to avoid past shortfalls, presented a revamped strategy.

Mixed Success At first glance, there are undeniable benefits from this program. PEPFAR is a pioneer in the push for increased public sector humanitarian assistance. Since its inception, the United Kingdom and other G8 states have followed suit in expanding their own focus on HIV/AIDS. Under the auspices of the Office of the Global AIDS Coordinator (OGAC), the US is a strong advocate of UNAIDS, which mediates between wealthy potential donors and countries afflicted by the HIV/AIDS pandemic. For an administration accustomed to unilateral action, empowering an international institution is a major stride forward, and any sustainable campaign must maintain this multilateral approach. Kate Hofler, a researcher for the HIV/AIDS Task Force at the Center for Strategic and International Studies echoes this sentiment: “What we hear all of the time from African leaders and from citizens in recipient countries is that PEPFAR has changed communities and has set an international precedent.”

Moreover, PEPFAR has done wonders in documenting a global health crisis. By constantly monitoring and evaluating its own programming PEPFAR has made tremendous contributions to the body of knowledge available on HIV/AIDS prevention, treatment, and care. But this emphasis on accountability arms activists with incontrovertible data that only further highlights the need for significant adjustments to elements of the president’s approach. While PEPFAR may be riddled with inefficiencies, its mere existence is an inherent recognition of the United States’ key role and its potential as a humanitarian leader. The reality that one can even contemplate the mass distribution of anti-retroviral drugs is a marked improvement from generations past. Noting these achievements, how can the US build from its mistakes and ensure that PEPFAR’s next five years are even more productive?

A Mandate for Change Ambassador Mark Dybul, who serves as the United States Global AIDS Coordinator, maintains that to date PEPFAR has achieved all of its original goals and is on track to meet its future objectives. But certain aspects of the Emergency Plan continue to draw heavy criticism. Most noted is the ambiguity of the “ABC” approach to HIV/AIDS prevention. The “ABC” strategy, which distributes one-third of its funding to each element, emphasizes (A) abstinence for youth or a delay of sexual activities until marriage, (B) being tested for HIV and being faithful to your sexual partner, and (C) correct and consistent use of condoms. Within this breakdown, ten percent of PEPFAR’s overall budget is earmarked for programs for orphans and vulnerable children. This intransigent approach has become the bedrock of AIDS prevention strategies since its successful application in Uganda in the 1990s. Although the methodology appears to be rather simple, the lack of emphasis on clarifying the program’s three pillars causes great confusion. Specifically, in some rural communities, the call for being faithful, or monogamous, is misinterpreted as a demand by PEPFAR for greater religious piety. The failure to convert priorities into understandable or even realistic terms prevents their successful application. According to Hayley Hathaway, Grassroots Coordinator for the Student Global AIDS Alliance, “a focus on abstinence is unrealistic when the vast majority of new HIV cases internationally (estimated 80%) are among married women or women in monogamous relationships.” Presumably the “C” clause does promote the use of contraception. But lack of availability and the emphasis of use only in “high risk” situations mitigate its effectiveness. This reality exposes PEPFAR to charges that its missionary methods hinder not only prevention efforts but also, by extension, expand the need for treatment and care.

Where do we go from here? Already fives year old, PEPFAR now stands at a critical juncture. Under the firm paradigm of ABC, the renewed program would be incapable of developing a multifaceted long-term prevention strategy that builds from it shortfalls. This reality prompted a strong contingent of policy minds and activists to join forces in proposing various adjustments to the legislation. Flexible solutions are necessary to solve such complex issues. Hathaway asserts that the US should target the “root causes for the AIDS crisis and look toward more significant debt cancellation, an end to conditionality in IMF programs, just trade policies, and greater investment in human capital.” Converting the ABC structure from an allocation system to one with overarching guidelines would make efforts toward prevention more effective. This would in turn allow for greater investment to empower women and girls through increased educational initiatives, a proven prevention tactic. Currently, institutional measures limit marginalized subgroups, like sex workers, from accessing equal benefits. Additionally, PEPFAR should augment its domestic collaboration by incentivizing the national workforce through increased education and training programs for new health care workers. The proposed two-fold increase in funding would enable PEPFAR to expand the scope of prevention, while still maintaining treatment for those already under its care. Ideally, however, an even larger budget is necessary to enlarge access to treatment. It seems that PEPFAR’s success will be gauged largely by its ability to build lasting partnerships with host governments and to bolster accountability and synchronize the effective use of both national and international funds. Hofler speculates that theoretically “there will be a move away from the terms ‘recipient country’ to denote more of a partnership and mutual responsibility.” Should this be achieved, PEPFAR could shift resources away from annual Country Operational Plans—which are extremely costly in terms of both economic and human capital—and instead pursue the above initiatives.

“Regardless of whether media pundits criticize Bush for mobilizing PEPFAR as an attempt to rebuild his image as a compassionate conservative, PEPFAR has been a success…and prevented millions of infections already” claims Hofler. Historically, HIV/AIDS legislation has enjoyed bipartisan acclaim. Yet given PEPFAR’s visible deficiencies and a tense political climate, Congress will likely place the bill under heavy scrutiny. The reauthorization process is a test of Bush’s ability to respond to critics, either through constructive and necessary adjustments or with an obstinate aversion to change. Engaging the Emergency Plan’s flaws will earn the President not only a rare check in the “success column” but also a true, sustainable boost to the fight against HIV/AIDS.