PEPFAR Reauthorization: Issues for Consideration

On May 30, after speaking on the President's Emergency Plan for AIDS Relief in the Rose Garden of the White House in Washington, D.C., President Bush (right) urged lawmakers to set aside 30 billion dollars over five years for the global fight against AIDS. (Photo: Mandel Ngan / AFP-Getty Images)

The four-year-old President's Emergency Plan for AIDS Relief (PEPFAR) is now before Congress for reauthorization. In May 2007, President Bush announced that the government would double its commitment to the global fight against H.I.V./AIDS with a new five-year funding proposal of $30 billion, thereby doubling the $15-billion five-year legislation passed by Congress in 2003. By most accounts, the PEPFAR program, which expires in September 2008,  has been a significant boost to AIDS remedial efforts. However, as the reauthorization process commences in the Congress, there are important issues that deserve serious consideration. These issues address how best to deploy resources for the second phase of United States support for H.I.V./AIDS, tuberculosis and malaria (PEPFAR 2). I briefly discuss these issues.

The Significant Impact of PEPFAR

The Leadership Against H.I.V./AIDS, Tuberculosis, and Malaria Act of 2003 that authorized the PEPFAR program is widely believed to have made significant impacts in the 15 focus countries. According to the background information for the pending reauthorization legislation authored by Senator Richard Lugar, PEPFAR is responsible for one million Africans now being on antiretroviral therapy. PEPFAR is also on track to achieve its five-year triple goals of supporting treatment for two million individuals in the focus countries, preventing seven million new infections, and providing supportive care to 10 million people at risk. These individuals include orphans and children at risk. The capacity of PEPFAR to deploy significant resources in a specific country is a major factor in the program's considerable influence in the fight against H.I.V./AIDS.

PEPFAR in its three-and-a-half year's existence has attracted considerable attention from domestic and international stakeholders. Its policy on H.I.V. prevention, the transmission of other sexual diseases, and AIDS treatment continues to attract considerable attention, scrutiny, praise, as well as criticism. Supporters of a multilateral approach to development assistance remain worried and vigilant regarding the bilateral thrust of PEPFAR.

One of the most important contributions of PEPFAR is the perceived one-two punch with the Global Fund to Fight AIDS, Tuberculosis, and Malaria regarding the capacity of both organizations to use their economies of scale as leverage for accelerated action in the area of procurement of health goods and services. The Global Fund has reported that it has committed $8.4 billion in 136 countries as of October 2007. The two organizations can deploy significant resources to address specific problems in a relatively short time span, an unthinkable scenario six years ago in the global fight against H.I.V./AIDS, TB, and malaria.

PEPFAR also has the advantage of bipartisan support in Congress. The original legislation remains a model of legislative bipartisanship. There is no evidence that the program will lose bipartisan support during the reauthorization process.

Important Considerations for PEPFAR Reauthorization

As the reauthorization process moves forward, there are critical issues that merit serious attention.

First, the dynamics of AIDS remedial efforts in 2002-03 is dramatically different in 2007 and will most likely be different in 2012 or 2013. As noted by Representative Tom Lantos, the chairman of the House of Representatives International Affairs Committee in a September 2007 hearing on PEPFAR, the program became operational in 2003 to address an "emergency" situation of limited resources, hopelessness, and despair around the world, especially for millions of individuals living with H.I.V./AIDS. In 2007, more individuals living with AIDS are on antiretroviral therapy. Today, more stakeholders are engaged in H.I.V. preventive programs, and more communities are benefiting from TB and malaria programs. By 2010, UNAIDS in one scenario anticipates that up to 14 million individuals may be on antiretroviral therapy. Availability of lifesaving AIDS drugs will effectively replicate the situation in the West, where AIDS is now largely a chronic condition. By 2013, cost of care will increase substantially, and millions of AIDS orphans will strain community and public resources in Africa. Although significant challenges remain, the desperation of 2002-03 is now replaced with better clarity regarding needs, responsibilities, and next steps. Lantos believes that PEPFAR 2 should focus more on "sustainable" remedial efforts.

Second, despite the huge financial outlays available to PEPFAR and the Global Fund, a significant shortfall remains regarding financial resources available for H.I.V./AIDS, TB, and malaria programs. UNAIDS estimates that to achieve the universal access to H.I.V. prevention, treatment, care, and support in 2010 as adopted by the United Nations and Group of 8 nations, the cost will be $32-51 billion per annum, with 14 million people on antiretroviral therapy. If the current pace of treatment, prevention, support, and care is maintained until 2015, UNAIDS estimates that 8 million individuals will be on antiretroviral therapy with an annual price tag of $14-18 billion. The Global Fund estimates that it is facing a shortfall for its operations in 2008 and 2009. The proposed $30 billion for PEPFAR over five years, while commendable, will not close the looming funding gap.

Third, health care systems in countries hit hardest by AIDS continue to struggle and are unable to meet the needs of target populations. A hallmark of the country-level program strategy of PEPFAR is the utilization of existing health systems and facilities. However, these health systems lack organizational capacity, operate with dilapidated infrastructure, have significant health work force shortages, and struggle to meet personnel and staff training costs. It is difficult for externally funded programs to meet their objectives when the health systems of focus countries are reeling. PEPFAR, according to published reports, had addressed infrastructure issues in some of the focus countries. PEPFAR reportedly supported more than 90 percent of the expenditure utilized to revamp the H.I.V. treatment and supportive care infrastructure in Nigeria, Ethiopia, Uganda, and Vietnam.

Functional health systems are critical to future PEPFAR operational effectiveness. Luckily, two independent but related strategies are unfolding regarding improvements in health systems capacity. African heads of state recently approved a sweeping new health strategy for the continent anchored on effective and robust health systems in all African countries. The new health strategy for the period 2007 through 2015 articulates the envisaged role of African countries, regional institutions, and international development partners. The African Union, the continental organization, is now charged with the responsibility of monitoring the implementation of the new health strategy in African countries. In addition, African heads of state also approved a new continental plan on achieving universal access to H.I.V./AIDS, TB, and malaria by 2010. This universal access plan seeks significantly to enhance the capacity of African countries to respond to H.I.V./AIDS, TB, and malaria and to use lessons learned to accelerate improvement in overall health system capacities.

In Congress, new legislation known as the African Health Capacity Investment Act of 2007 is now moving its way through the Senate. The new legislation introduced by Senators Richard Durbin, Norm Coleman, Russell Feingold, Christopher Dodd, John Kerry, and Jeff Bingaman seeks to amend the Foreign Assistance Act of 1961 to allow the government to significantly assist African governments to improve human capacity in the health sector and to help participating countries better retain medical and other health professionals. The legislation will also enhance the capacity of African countries to improve rural-based health services.

The PEPFAR reauthorization process should benefit from the new Africa health strategy as well as the proposed legislation on increased human capacity in health. The African Union's permanent representative to the United States, Amina Salum Ali, recently introduced the new Africa health strategy in Washington, D.C. PEPFAR 2 should reflect health priorities identified in the new Africa health strategy.

Fourth, despite the evident impact of PEPFAR, United States global health programs remain fragmented. PEPFAR today remains largely focused on H.I.V./AIDS, with limited coordination with other United States global health programs. However, as noted by Nils Daulaire, the head of the Global Health Council in Washington, D.C., and a veteran expert on international health programs, single-focused programs are best suited for emergency or short-term interventions. Since AIDS has multisectoral impact, in addition to its well-known health consequences, PEPFAR 2 should focus on coordinated and leveraged linkages with other global health programs. PEPFAR 2 should establish operational linkages with other United States global health programs, especially in the areas of maternal and child health services, communicable diseases, poverty alleviation, food and nutritional support, health workforce development, health systems improvement, and program management support.

Fifth, the operational relationship between PEPFAR and the Global Fund will gradually become intertwined. Today, PEPFAR and the Global Fund are the dominant players in the financing of AIDS remedial effort. The United Nations system remains the intellectual and technical leader in the fight against AIDS. With the possible exception of the Gates Foundation or perhaps a significant commitment from the Google foundation, PEPFAR and the Global Fund will remain the dominant financing mechanism.

However, their dominance will leave with no alternative than to collaborate and coordinate their activities, at least in the PEPFAR-focused countries. As the treatment needs of AIDS, TB, and malaria patients grow, stakeholders in donor and recipient countries will increasingly demand streamlined and better-coordinated programs at target population levels. The elimination of duplicative services will be a major issue in the years ahead as survival rates of individuals living with AIDS increases in Africa and additional resources to finance their care becomes uncertain. It is likely that PEPFAR and the Global Fund, and other future financing players, will reach agreement on areas of comparative advantages and realign their operations accordingly. These organizations will collaborate closely, including sharing operational activities while maintaining separate fiduciary responsibilities.

Sixth, AIDS, TB, and malaria are complex health conditions that require flexibility in program operations. PEPFAR began operations more than three years ago with multiple funding "directives" or "authorities." Directives are an important legislative tool to "direct" executive branch implementation activities. The AIDS orphan and vulnerable children directives had immediate impact on the ground in Africa.

However, directives may sometimes have unintended operational consequences. A case in point is the ABC prevention concept incorporated in the original PEPFAR legislation. As noted by Senator Lugar while introducing the PEPFAR reauthorization bill, the current directive to spend at least 33 percent of all PEPFAR resources on prevention activities led to a situation whereby the implementation of the concurrent directive on abstinence programs "had the effect of squeezing funding for prevention activities that had nothing to do with sexual prevention." According to Lugar, programs such as prevention of mother-to-child transmission and strategies to ensure blood transfusion safety suffered squeezed funding. Lugar is proposing restriction of the abstinence directive to programs that deal with prevention of sexual transmission of diseases.

PEPFAR 2 requires operational flexibility as interventions move from short-term, "emergency" response to long-term "sustainability" strategies. Flexibility in program operations is also important as interventions shift from enhancing health system capacity to long-term strategies for deploying community-based preventive, treatment, and supportive care. Operational flexibility is also critical as the focus or recipient countries move from dependence on external support to the control of interventions in their countries.

Finally, the community-based system of care remains a fundamental weakness of internationally directed programs. The Congress is right continuously to ask tough questions regarding the impact of multibillion dollar funded programs in target communities around the world. The usual approach to international health programming is to focus on aggregate national data. However, it is known that huge geographical, social, economic, and cultural variation exist in many countries regarding risk status to specific communicable diseases.

As a bilateral program, PEPAR is focused on national data. However, H.I.V./AIDS is a deeply personal health issue. TB and malaria are also personal. It is important for PEPFAR to demonstrate sustained impact at personal levels, especially among individuals or families infected or affected by H.I.V./AIDS, TB, and malaria. PEPFAR 2 should include support for community-based health services. This support should include health system improvements at primary health care and health clinic levels, including infrastructure support; community-based information, education, and communication campaigns; community-based monitoring and evaluation programs, including the use of independent monitors; and a valid documentation of the baseline and trend indicators regarding the knowledge, attitude, and perception (KAP) of at-risk populations on the effectiveness of intervention programs. The community-based strategy should also include collaboration with other ongoing focus country initiatives on poverty alleviation, gender equity, and boy/girl education.

The global fight against H.I.V./AIDS, TB, and malaria will be won one person, one family at a time. The reauthorization of the PEPFAR program creates opportunities to realign the strategic focus from an "emergency" response to a long-term intervention program with a major emphasis on community-based services.

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