Policy Innovations Digital Magazine (2006-2016): Briefings: Preserving PEPFAR

President George W. Bush is fighting to preserve a controversial initiative central to his administration's global war on a deadly scourge. Terrorism? Drugs? Actually, the program in question is PEPFAR, the President's Emergency Plan For AIDS Relief, which has supported life-saving antiretroviral treatments for more than 1.7 million people since its passage in 2004.

During the first three years of the Bush presidency, the United States spent only $3.5 million on global HIV/AIDS relief projects. This year alone, through PEPFAR, the government will spend nearly $6 billion on AIDS prevention, testing, counseling, treatment, and education. With most of this money flowing to Africa, many unlikely voices have offered praise for PEPFAR, and for the president.

Bob Geldof, the Irish singer, television host, and organizer of the Live Aid and Live 8 concerts has been a tireless advocate for African development. In a Time magazine account of his travels through Africa with President Bush he wrote, "The Bush regime has been divisive—but not in Africa. I read it has been incompetent—but not in Africa. It has created bitterness—but not here in Africa. Here, his administration has saved millions of lives."

PEPFAR, hailed by the New York Times as possibly the "most lasting bipartisan accomplishment of the Bush presidency," is up for renewal. Approved by the House of Representatives in April, a group of seven conservative Republicans has blocked the bill's Senate reauthorization. They have expressed concern over the $50 billion price tag as well as the House's removal of a provision earmarking a fixed percentage of PEPFAR funding for abstinence-only prevention programs.

"There is no question that PEPFAR has been the most successful foreign aid program since the Marshall Plan," said Sen. Tom Coburn (R-OK), leader of the GOP bloc opposing renewal. "Will we turn PEPFAR into just another bloated, unmeasured and unmeasurable foreign aid program with no accountability and no real impact?"

By congressional mandate, 33 percent of PEPFAR prevention spending (which constitutes 20 percent of the overall budget) must be reserved for abstinence-only programs. Critics, including the U.S. Government Accountability Office maintain that this limits the flexibility of beneficiary countries to spend prevention money effectively in response to local conditions. These budget restrictions may represent part of what New York Times columnist Nicholas Kristof refers to as a broader "war on condoms."

In fact, condoms are a component of PEPFAR's "ABC" approach to HIV/AIDS prevention: Abstain, Be faithful, or use Condoms. One-third of total prevention funding is allocated to each element of ABC. However, some advocacy groups have argued that women and young girls tend to be at the mercy of their partners when it comes to following these recommendations.

By holding PEPFAR renewal hostage, the GOP Senators have inadvertently generated a significant amount of media attention for a previously obscure program. "In 2003, only 50,000 Africans were on HIV antiretroviral drugs—and they had to pay for their own medicine. Today, 1.3 million are receiving medicines free of charge," wrote Geldof. "So why doesn't America know about this?"

Much of the blame for public ignorance can be traced to the timing of PEPFAR's debut. When the president announced the plan as part of his 2003 State of the Union address, the world was instead focused on the impending invasion of Iraq. Five years on, not much has changed. But it's also true that the program got off to an extremely rocky start.

NGOs and public health activists initially lamented what they saw as the Bush administration's "unilateral" approach to combating the AIDS epidemic, often implying that U.S. money would be better managed by The Global Fund to Fight, AIDS, Tuberculosis and Malaria. While some view PEPFAR and the Global Fund as competitors, this is not a view shared by either organization.

"PEPFAR and other worldwide efforts to fight AIDS are making it possible for those who were on the brink of death to return to productive lives and contribute to the growth of their communities," said Global Fund Executive Director Dr. Michel Kazatchkine in 2007. The United States is the single largest contributor to the Geneva-based Global Fund, having invested $2.5 billion in the initiative since 2001.

Early critics also hammered PEPFAR, and the Office of the Global AIDS Coordinator (USGAC), for moving slowly to purchase generic versions of expensive antiretroviral drugs (ARVs) that had not yet been approved by the Food and Drug Administration (FDA). Congressional critics such as Rep. Henry Waxman (D-CA) accused the administration of bowing to demands from U.S. pharmaceutical companies to block FDA approval of low-cost generic drugs "through the imposition of unnecessary and onerous drug approval standards."

"It is no secret that U.S. pharmaceutical companies, which make brand-name drugs, do not want funds to flow to generic drug companies in India. These pharmaceutical companies are among your strongest political supporters, having contributed over $40 million to your political party in the last five years," Waxman wrote in a 2004 letter to President Bush.

In 2006, however, the USGAC reported to Congress that PEPFAR "remains committed to funding the purchase of the lowest-cost ARVs from any source, regardless of origin, whether copies, generic, or branded, as long as those drugs are proven safe, effective, and of high quality, and their purchase is consistent with international law."

The FDA introduced an expedited drug approval process for PEPFAR in 2004. Since then, 70 generic antiretrovirals have been approved or tentatively approved. Only one is manufactured in the United States. Two are made in South Africa and one in China. The rest are manufactured in India.

"PEPFAR has been a success. But like anything, there is always room for improvement," said Dr. Dennis Nash, director of Monitoring, Evaluation, and Research in the International Center for AIDS Care and treatment Programs (ICAP) at Columbia University's Mailman School of Public Health, which receives funding from PEPFAR.

According to Nash, discontinuation of PEPFAR "would limit the ability for new patients to start treatment and for existing patients to continue on treatment—hundreds of thousands of patients."

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