President's Emergency Plan for AIDS Relief

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The President's Emergency Plan For AIDS Relief (PEPFAR/Emergency Plan) was a commitment of $15 billion over five years (2003–2008) from United States President George W. Bush to fight the global HIV/AIDS pandemic. The program initially aimed to provide antiretroviral treatment (ART) to 2 million HIV-infected people in resource-limited settings, to prevent 7 million new infections, and to support care for 10 million people (the "2–7–10 goals") by 2010. PEPFAR increased the number of Africans receiving ART from 50,000 at the start of the initiative in 2004 to at least 1.2 million in early 2008.[1][2] PEPFAR has been called the largest health initiative ever initiated by one country to address a disease. The budget presented by President Bush for the fiscal year 2008 included a request for $5.4 billion for PEPFAR.[3]

The massive funding increases have made anti-retrovirals widely available, saving millions of lives.[4][5][6] Critics contend that spending a portion of funding on abstinence-until-marriage programs is unjust[1] while others feel that foreign aid is generally inefficient.[2] According to a 2009 study published in Annals of Internal Medicine,[7] the program had averted about 1.1 million deaths in Africa and reduced the death rate due to AIDS in the countries involved by 10%.[8][9]

Contents

History [edit]

The unclassified publication,The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China [10] by the National Intelligence Council had been commissioned by the Bush White House in 2002 and was influential in the founding of PEPFAR. This work was significant because it discussed the mortality associated with the poorly controlled HIV pandemic across several decades and also forecast the impact of that excess mortality on U.S National Security interests.

The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (or the Global AIDS Act) established the State Department Office of the Global AIDS Coordinator to oversee all international AIDS funding and programming. In July 2008, PEPFAR was renewed, revised and expanded as the "Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008". The expansion more than triples the initiative's funds, to $48 billion through 2013.[11] On June 23, 2009, Ambassador Eric Goosby was sworn in as the United States Global AIDS Coordinator.[12]

Focus countries [edit]

PEPFAR prioritizes resource-limited countries with high HIV/AIDS prevalence rates. The 15 current "focus countries" are Botswana, Côte d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. While most of the $15 billion for this program will be spent on these focus countries, $4 billion is allocated for programs elsewhere, and for HIV/AIDS research. (The other $1 billion is contributed to the Global Fund, see below.) See the PEPFAR World Wide Activities Map.

Prevention [edit]

To slow the spread of the epidemic, PEPFAR supports a variety of prevention programs: the ABC approach (Abstain, Be faithful, and correct and consistent use of Condoms); prevention of mother to child transmission (PMTCT) interventions; and programs focusing on blood safety, injection safety, secondary prevention ("prevention with positives"), counseling and education.

Initially, a recommended 20% of the PEPFAR budget was to be spent on prevention, with the remaining 80% going to care and treatment, laboratory support, antiretroviral drugs, TB/HIV services, support for orphans and vulnerable children (OVC), infrastructure, training, and other related services. Of the 20% spent on prevention, one third, or 6.7% of the total, was to be spent on abstinence-until-marriage programs in fiscal years 2006 through 2008, a controversial requirement (see below). The other two thirds was allotted for the widespread array of prevention interventions described above, including counseling, education, injection safety, blood safety and condoms.

The 2008 reauthorization of PEPFAR eliminated the 20% recommendation for prevention efforts, including the requirement for abstinence programs.[13]

Treatment [edit]

In addition to providing antiretroviral therapy (ART), PEPFAR supports prevention and treatment of opportunistic infections, as well as services to prevent and treat malaria, tuberculosis, waterborne illness, and other acute infections. PEPFAR supports training and salaries for personnel (including clinicians, laboratorians, pharmacists, counselors, medical records staff, outreach workers, peer educators, etc.), renovation and refurbishment of health care facilities, updated laboratory equipment and distribution systems, logistics and management for drugs and other commodities. This is intended to ensure the sustainability of PEPFAR services in host countries, enabling long-term management of HIV/AIDS.

PEPFAR-supported care and treatment services are implemented by a wide array of U.S.-based and international groups and agencies. Among the largest "Track 1.0" (treatment) partners are Harvard University,[14] Columbia University's International Center for AIDS Care & Treatment Programs (ICAP),[15] the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF),[16] and the AIDSRelief consortium of Catholic Relief Services.[17]

Care [edit]

For those who have already been infected with HIV/AIDS, PEPFAR provides HIV counseling, resources for maintaining financial stability, etc. Special care is given to orphans and vulnerable children (OVCs) and services are provided that meet the unique needs of women and girls, including victims of sex trafficking, rape, abuse, and exploitation (see fact sheet on Gender and HIV/AIDS). Finally, the Emergency Plan works closely with country leaders, military groups, faith-based organizations, etc. in an attempt to eliminate stigma.

Programs [edit]

PEPFAR establishes bilateral programs in host countries and also works closely with multilateral partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United Nations program on AIDS (UNAIDS), as well as the Peace Corps and local Faith-Based Organizations PEPFAR_Inter-faith_New_Partners_Initiative. PEPFAR also endorses the international principles of the "Three Ones": — one national plan, one national coordinating authority, and one national monitoring and evaluation system in each of the host countries in which organizations work.

Accountability [edit]

PEPFAR reports to Congress on an annual basis, providing programmatic and financial data as required by law. The Second Annual Report to Congress on the President's Emergency Plan for AIDS Relief is available on the official PEPFAR website,[18] as are more specific reports, financial information and other information.

PEPFAR was exempt from the Mexico City Policy.[19]

Funding data [edit]

Funding data was obtained by the Center for Public Integrity from PEPFAR's own information system COPRS. The data were obtained after CPI sued the U.S. State Department to gain access to the data. The data were shared on the CPI site as well as analyzed by the HIV/AIDS Monitor team at the Center for Global Development, who also share the full dataset.

Criticism [edit]

Controversial requirements [edit]

Some critics of PEPFAR feel that American political and social groups with moral rather than public health agendas are behind several requirements of PEPFAR, pointing to the mandates that one-third of prevention spending in 2006–2008 be directed towards abstinence-until-marriage programs and that all funded organizations sign an anti-prostitution pledge. PEPFAR also does not fund needle exchange programs, which are widely regarded as effective in preventing the spread of HIV.[20] The requirement for prevention spending was lifted with the PEPFAR reauthorization in 2008,[13] but some critics worry that some funds could still be spent on abstinence programs. The Center for Health and Gender Equity and Health GAP outline their criticism of PEPFAR on a website known as PEPFAR Watch. The previous 33% earmark has since been replaced by a requirement that if more than 50% of PEPFAR funds are allocated to non-abstinence promotion measures, the US Global AIDS Coordinator must report to Congress.

Randall L. Tobias [edit]

Critics of PEPFAR found fault with President George W. Bush's selection of former Eli Lilly and Company chief executive Randall L. Tobias as the first Global AIDS Coordinator in charge of PEPFAR, a position in which Tobias served from 2003 until 2006.

Paul Zeitz, executive director of the Global AIDS Alliance, stated that the naming of Tobias raised "serious questions of conflict of interest and the priorities of the White House",[21] while Kate Krauss of the AIDS Policy Project called Tobias "the fox in charge of the henhouse". Ambassador Mark Dybul replaced Tobias as U.S. Global AIDS Coordinator on August 11, 2006.

Generic drugs [edit]

PEPFAR was criticized for initially funding only branded antiretroviral drugs instead of cheaper generic versions, but distribution of generic drugs began in late 2005.[22]

Conditions [edit]

Many have argued that PEPFAR's emphasis on direct funding from the United States to African governments (bilateral programs) have been at the expense of full commitments to multilateral programs such as the Global Fund. Reasons given for this vary, but a major criticism has been that this enables the U.S. "to maximize its leverage with other countries through the funds available for distribution" since the "Global Fund and other multilateral venues do not possess the same top-down leverage as does the United States in demanding fundamental national-level reforms".[23]

Lack of funding [edit]

While the Bush administration had promised to increase funding for PEPFAR, January 2010's Obama administration budget proposes to 'flatline' its funding. This could cause a drought in medicines to people who need them to survive. UNAIDS Executive Director, Michel Sidibé has said that the world is likely to witness ‘our worst nightmare’ if funding for HIV/AIDS medicines falls short of sustaining those already on anti-retroviral medicines.[24]

In 2008, the U.S. Congress authorized the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act providing $48 billion over 5 years ($9.6 billion/year) to PEPFAR. However, President Obama's $63 billion Global Health Initiative allocated $51 billion over 6 years ($8.5 billion/year) resulting in an overall decrease in PEPFAR funding while allocating $12 billion towards other global health initiatives including maternal and child health. Anand Reddi in The Huffington Post argues: "By not providing "new" money towards maternal and child health, President Obama has in de facto pitted HIV/AIDS funding against other global health priorities."[25]

Though Obama had pledged $1.05 billion per year for the Global Fund to Fight AIDS, TB, and Malaria for 2010 and 2011, the actual % contributed were 75% and 60% respectively. Overall funding has decreased by 22.5% between fiscal years 2008 and 2011.[26][27][28]

Dr. Ezekiel Emanuel argues that AIDS funds are not the best use of international health funding. He co-authored a JAMA commentary in 2008, stating: "PEPFAR is not the best use of international health funding," and "fails to address many of the developing world's most serious health issues.".[29] However, there have been numerous studies affirming that AIDS funds can actually advance and synergistically reinforce the overall primary healthcare infrastructure in recipient countries beyond just HIV/AIDS.[25][30][31][32][33]

Recruitment of locals [edit]

PEPFAR has been criticized for having a negative impact on the health systems in regions receiving its funding through its recruitment practices. Although Congress made attempts to limit its impact by prohibiting "topping off" salaries and limiting funding for healthcare worker training (thereby eliminating per diems as a method of augmenting salaries), PEPFAR funded programs effectively paid its local staff up to a hundred times more than that of the local healthcare structure.[34]

Rather than strictly through salaries, program staff received benefits such as housing and education subsidies. Countries, already stressed by the number of trained physicians and nurses emigrating to western nations, have seen the presence of PEPFAR programs significantly decrease the number of skilled medical professionals willing to work within the domestic healthcare infrastructure. As a result, the overall health of these communities are placed in jeopardy, but funds, physicians, and nurses are diverted to combat HIV/AIDS exclusively within the framework of PEPFAR.

Harm reduction [edit]

Advocates for harm reduction believe that better results would be achieved globally if PEPFAR revamped their approach to reducing the spread of HIV rather than trying to prevent it all together. They believe that PEPFAR does not thoroughly take into account the prevalence of challenges against effective harm prevention. Although it is ideal, it is impossible to completely prevent drug use, prostitution and rape from occurring globally. By "reducing" the high-risks associated with HIV transmission, advocates believe their approach provides to be more effective in terms of results than harm prevention.[1]

Faith-Based Organizations (FBOs) [edit]

FBOs and their missions of faith being intertwined within PEPFARs AIDS relief has been a sore spot for many.[who?] Opposition lies within the fact that many of the places where HIV/AIDS is prevalent do not adhere to the same religious doctrines as the FBOs are providing. [2]

Investigations by the Department of Health and Human Services Office of Inspector General (OIG) [edit]

On the 15 June 2011, the OIG published a report critical of the Centers for Disease Control and Prevention’s (CDC's) failure to oversee recipients’ use of PEPFAR funds.[35] The report read in part:

Our review found that CDC did not always monitor recipients’ use of President’s Emergency Plan for AIDS Relief (PEPFAR) funds in accordance with departmental and other Federal requirements. CDC implements PEPFAR, working with ministries of health and other public health partners to combat HIV/AIDS by strengthening health systems and building sustainable HIV/AIDS programs in more than 75 countries in Africa, Asia, Central and South America, and the Caribbean. HHS receives PEPFAR funds from the Department of State through a memorandum of agreement.

There was evidence that CDC performed some monitoring of recipients’ use of PEPFAR funds. However, most of the award files did not include all required documents or evidence to demonstrate that CDC performed required monitoring on all cooperative agreements. Of the 30 cooperative agreements in our sample, the award file for only 1 agreement contained all required documents. The remaining 29 award files were incomplete. In addition, 14 of 21 files were missing audit reports. (A report was not yet due for 9 of the 30 cooperative agreements.) The lack of required documentation demonstrates that CDC has not exercised proper stewardship over Federal PEPFAR funds because it did not consistently follow departmental and other Federal requirements in monitoring PEPFAR recipients.

“
”

On the 19 November 2012, the OIG published a report critical of the CDC Namibia Office's failure to properly monitor recipients' use of PEPFAR funds.[36] The report read in part:

CDC's office in Windhoek, Namibia (CDC Namibia), is responsible for PEPFAR funds awarded to government agencies and for-profit and nonprofit organizations (recipients) in Namibia.

Our audit found that CDC Namibia did not always monitor recipients' use of PEPFAR funds in accordance with HHS and other Federal requirements. There was evidence that CDC Namibia performed some monitoring of recipients' use of PEPFAR funds. However, most of the recipient cooperative agreement files did not include required documents or evidence that CDC Namibia had monitored all cooperative agreements. CDC Namibia did not consistently monitor the cooperative agreements in accordance with HHS and other Federal requirements because it did not have written policies and procedures for the monitoring process. As a result, CDC Namibia did not have assurance that PEPFAR funds were used as intended by law.

We recommended that CDC Namibia implement standard operating procedures for monitoring recipients' use of PEPFAR funds. CDC concurred with our recommendation.

“
”

See also [edit]

References [edit]

  1. ^ a b "In Tanzania, Bush urges Congress to renew AIDS relief program as it is. Dems argue for less focus on abstinence, maybe more funding" SFGate, from James Gerstenzang, The Los Angeles Times, 18 February 2008.
  2. ^ a b "In Global Battle on AIDS, Bush Creates Legacy" Sheryl Gay Stolberg, The New York Times, 05 January 2008.
  3. ^ De Capua, Joe (2008-12-24). "President Bush Requests $5.4 Billion for PEPFAR in 2008". Voice of America. Retrieved 2009-01-03. 
  4. ^ Caryl, Christian, What George W. Bush Did Right, Foreign Policy, February 14, 2013.
  5. ^ Plout, Martin (January 16, 2009). "Has Bush been Africa's best friend?". BBC. Retrieved 2009-02-05. 
  6. ^ http://www.msnbc.msn.com/id/28605888/
  7. ^ Bendavid, Eran (May 2009). "The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes". Annals of Internal Medicine. 
  8. ^ Samuels, Diana (April 6, 2009). "Bush's 'PEPFAR' AIDS treatment program saved a million lives in Africa, Stanford researchers say". San Jose Mercury News. Retrieved 2009-04-07. 
  9. ^ "Stanford study first ever to show US AIDS Relief program saved a million lives". EurekAlert!. April 6, 2009. Retrieved 2009-04-07. 
  10. ^ The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China
  11. ^ "Bush signs expansion of global AIDS programs" Will Dunham, Reuters, Washington, 30 July 2008. Accessed 02 October 2008.
  12. ^ Dr. Eric Goosby Assumes the Role of U.S. Global AIDS Coordinator
  13. ^ a b "International HIV/AIDS, Tuberculosis, and Malaria: Key Changes to U.S. Programs and Funding" (PDF). Congressional Research Service, 25 August 2008.
  14. ^ http://www.harvard.edu
  15. ^ http://columbia-icap.org
  16. ^ http://www.pedaids.org
  17. ^ http://www.crs.org
  18. ^ http://www.pepfar.gov
  19. ^ http://www.populationaction.org/resources/publications/globalgagrule/GagRule_AIDS/GGRandHIV-AIDSbrochure.pdf[dead link]
  20. ^ Hellevik, Siri Bjerkrem: Does Obama Bring Change to US HIV/AIDS Policy? NIBR International Blog 02.03.2010
  21. ^ "Bush's 'surreal' choice for AIDS czar". Asia Times, July 4, 2003.
  22. ^ http://www.avert.org/pepfar.htm
  23. ^ "Fighting the Axis of Illness: HIV/AIDs, Human Rights, and U.S. Foreign Policy" (PDF). The Harvard Human Rights Journal, Spring 2004.
  24. ^ Hellevik, Siri Bjerkreim: Can Lazarus, Shopping, and Running Help Us Save More People from Dying of HIV and AIDS?, NIBR International Blog 08.10.2010.
  25. ^ a b Anand Reddi, Truth and Reconciliation: President Obama's Global Health Initiative and HIV/AIDS -- Raising the Bar, The Huffington Post, July 27, 2010 http://www.huffingtonpost.com/anand-reddi/truth-and-reconciliation_b_660586.html
  26. ^ Tutu, Desmond (20 July 2010). "Obama's Overdue AIDS Bill". The New York Times. 
  27. ^ http://www.theglobalfund.org/documents/core/financial/Core_PledgesContributions_List_en/
  28. ^ Reddi, Anand (12 August 2010). "United States Global Health Policy: HIV/AIDS Treatment Funding At Risk Under President Obama". Huffington Post. 
  29. ^ http://www.who.int/pmnch/media/JAMA-Nov7-2008.pdf
  30. ^ Sarah Leeper and Anand Reddi. United States Global Health Policy: HIV/AIDS, maternal and child health, and The President's Emergency Plan for AIDS Relief (PEPFAR) AIDS. 2010 Sep 10;24(14):2145-9. PubMed PMID 20606571. http://journals.lww.com/aidsonline/Fulltext/2010/09100/United_States_global_health_policy__HIV_AIDS,.1.aspx
  31. ^ Anand Reddi, United States Global Health Policy: HIV/AIDS Treatment Funding At Risk Under President Obama, The Huffington Post, July 21, 2010 http://www.huffingtonpost.com/anand-reddi/united-states-global-heal_b_654002.html
  32. ^ http://www.ncbi.nlm.nih.gov/pubmed/22404862
  33. ^ Eran Bendavid, Charles B. Holmes; Jay Bhattacharya; Grant Miller HIV Development Assistance and Adult Mortality in Africa JAMA. 2012;307(19):2060-2067. doi:10.1001/jama.2012.2001http://jama.jamanetwork.com/article.aspx?articleid=1157487
  34. ^ Garrett, Laurie. 2007. The Challenge of Global Health. Foreign Affairs 86 (1):14-38.
  35. ^ "Review of the Centers for Disease Control and Prevention’s Oversight of the President’s Emergency Plan for AIDS Relief Funds for Fiscal Years 2007 Through 2009 (A-04-10-04006)". June 2011. Retrieved 2011-06-25. 
  36. ^ "The Centers for Disease Control and Prevention's Namibia Office Did Not Always Properly Monitor Recipients' Use of the President's Emergency Plan for AIDS Relief Funds (A-04-12-04020)". November 2012. Retrieved 2012-12-07. 

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