As we pause this week to mark the twenty-sixth recognition of World AIDS Day, it would also be appropriate to acknowledge the tenth anniversary of the President’s Emergency Plan for AIDS Relief (PEPFAR). In May 2003 this health initiative committed the United States to spend fifteen billion dollars over five years for international programs in HIV/AIDS treatment, prevention, and care. It was the largest international health initiative ever undertaken by the United States, or by any other country for that matter. What would become known as PEPFAR was first announced in President George W. Bush’s January 2003 State of the Union message, and after vigorous promotion by the White House was passed with bipartisan support in Congress. PEPFAR has been considered by many as President Bush’s greatest achievement, and it well may be. It aimed to dispense antiretroviral (ARV) treatment to two million people in fifteen target countries, to prevent seven million new infections, and to provide supportive care for ten million people (the “2-7-10” goals) by 2010. PEPFAR was renewed and extended in July 2008 to the tune of a projected thirty-nine billion more through 2013. In May 2009 the Obama administration launched a sixty-three billion dollar Global Health Initiative with PEPFAR as a major component. As rock star and international AIDS activist Bono put it, Bush’s initiative was “great news when good news is hard to find.”

But PEPFAR has had its detractors as well as its admirers. Some have suggested that the United States was pressured into it because a growing international momentum for major AIDS interventions was already underway and the U.S. was clearly lagging rather than leading. In 1996 the Joint United Nations Program on HIV/AIDS created a collaboration between WHO, UNICEF, UNESCO, the World Bank and other international agencies which undertook to develop comprehensive, coordinated programs. In June 2001, the UN General Assembly declared HIV/AIDS a “global emergency” and asked member states to meet new targets for AIDS prevention and care. Also in 2001, one hundred and eighty-nine countries and major international agencies agreed to eight Millennium Development Goals, the sixth of which was to “combat HIV/AIDS, malaria, and other diseases” with specific targets for AIDS including greatly improved condom use and greater access to ARVs. In 2002 the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria was launched to “fight three of the world’s most devastating diseases, and to direct [its] resources to areas of greatest need.” For AIDS this meant improved access to ARVs, preferably in generic form. The U.S. was under pressure to share the global AIDS burden, and this would have required it to pursue certain policies, such as the promotion of safer sex through condom use and easier access to generic drugs, which were not popular with President Bush’s political base or his industry supporters. By unilaterally seizing the initiative with PEPFAR he hoped to deflect these pressures and redirect global AIDS efforts to a different set of priorities. President Bush also hoped to put an American stamp on a broadly popular global health initiative at the very time that he was promoting an unpopular war in Iraq, thus softening the U.S. diplomatic image by something of a sleight of hand. 

Although many in the international health community were overjoyed by the U.S.’s new and substantial commitment, certain critics pointed to PEPFAR’s shortcomings as it was initially launched. Relying on that old adage “the devil is in the details,” they observed, for example, that most American funding for ARVs wound up in the coffers of American pharmaceutical companies because the Bush administration stipulated that only name brand drugs be purchased in order to protect U.S. profits and patent rights. Also, President Bush appointed the former chairman of Eli Lilly as U.S. Global AIDS coordinator despite him having no prior experience with AIDS. Even more troubling to many were other Bush administration stipulations that one-third of PEPFAR prevention funds be spent on abstinence-only and monogamy-fidelity education programs, which meant in practice that a considerable portion of the resources went to “Christian morality”-based programs despite clear evidence that such programs had high failure rates. Yet another Bush administration requirement was that any group receiving PEPFAR prevention funds had to have an explicit written policy opposing prostitution, which meant that many groups assisting sex workers through harm reduction interventions were barred from funding. These stipulations led the Brazilian government to refuse forty million dollars in aid, prompting the U.S. General Accounting Office to conclude that the U.S. conditions undermined the ability of developing nations to design “interventions that are responsive to local epidemiology and social outcomes.”

A 2007 report in Ethics and International Affairs noted the following: “Many observers view U.S. programs as employing leverage to spread conservative moral and religious views. … Top U.S. officials are aggressively booed and heckled at international AIDS conferences. Administration policy choices have reconfirmed global views of the United States as a unilateral power imposing its views on others. If the [Bush] administration saw AIDS programs as a way to improve the country’s world image, they have failed miserably.”

An intensive six-month evaluation published in Science in 2008 added the sobering recognition that, overall, PEPFAR was proving ineffective as a public health intervention. Although more AIDS patients in the target countries were now being treated with ARVs, many more new cases developed every day because of ineffective prevention strategies. Newly infected individuals far outnumbered those being treated at a three-to-one ratio, and the hard data demonstrated that AIDS numbers continued to grow worldwide, especially in Sub-Saharan Africa. According to recent WHO data, there are approximately thirty-five million people currently living with HIV/AIDS and around twenty-four million are in Africa with less than one-third of them presently receiving ARV treatment. In response to these realities, Congress in 2008 and the Obama administration beginning in 2009 made important changes in PEPFAR. The emphasis shifted away from selected “focus countries,” abstinence and fidelity-based prevention strategies, and reliance on brand name ARVs. He introduced greater flexibility in program structure and staffing and more attention was paid to recipient countries’ own priorities. In February 2013, our prestigious national Institute of Medicine issued its Congress-mandated evaluation of the PEPFAR program. The upbeat evaluation, which had taken over four years to complete, was based on quantitative and qualitative data and over 400 interviews in PEPFAR partner countries. The general conclusion was as follows: “PEPFAR has been globally transformative. Across partner countries, PEPFAR was described as a lifeline, and people credit PEPFAR for restoring hope. … PEPFAR will gradually cede control, as partner countries take on more central roles in accountability and setting strategic priorities for investment in their HIV response. The pace of transition will vary by nation, but such an evolution in PEPFAR’s mission is vital.”  

The most important takeaway from all this is distilled in these terms: unlike PEPFAR in its first iteration, our national initiatives in international health should be driven by global health needs and priorities, must be sensitive to and respectful of local values and perceptions, and need to be inspired by idealism and true humanitarianism rather than by narrow U.S. ideological beliefs, political calculation, and barely disguised self-interest.

Dr. Brown is the Charles E. and Dale L. Phelps Professor of Public Health and Policy.

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