PEPFAR's Shortcomings: What is to Be Done?

The Bush legacy will not be a bright one. Its failed regulatory practices have placed the country and much of the world in economic turmoil, and its main foreign policy effort leaves the incoming administration with two unfinished wars. Taken objectively, the Bush record speaks of little positive.

However, one aspect of the Bush Administration's foreign policy portfolio is lauded by critical observers: the President's Emergency Plan for AIDS Relief (PEPFAR). As an American who works in Rwanda on reforming health care policies, practices and infrastructure, I'm among those who've recognized that PEPFAR has been a mainly progressive and productive program and provides an excellent base of experience on which the Obama administration can build.

In 2003, when President Bush launched PEPFAR, it became the largest commitment by any nation to combat a single disease in human history. At that time, only about 50,000 people in all of Sub-Saharan Africa were receiving anti-retroviral treatment. Today, PEPFAR, in partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria, supports treatment for nearly 1.7 million people in the region -- and tens of thousands more around the world, from Asia to Eastern Europe. Here in Rwanda, there are over 50,000 people on drug treatment today.

Despite this improvement, PEPFAR is clearly just a first step. As we confront the current state of the global AIDS crisis, PEPFAR is beginning to look old and creaky and in desperate need of a serious effort aimed at strengthening its positive points, while jettisoning the parts of the program that have either been inefficient or ineffective. The central questions the Obama administration must ask are: is our taxpayer money being deployed as effectively as possible and do the previous policies all make public health sense?

The answer to the first question depends on the country where programming is placed. Generally speaking, PEPFAR, which relies on international partners for implementation, works best where governments are the worst. By bypassing the bureaucracy and corruption of many governments in southern Africa, PEPFAR has achieved tremendous results. But in countries where leadership and transparency are good, money might best go through the Global Fund to Fight AIDS, Tuberculosis and Malaria, which provides direct support to established, effective national efforts.

To the second question, there's plenty of data showing that much of PEPFAR policy was flawed by the administration's decision to allow ideology to trump science. PEPFAR allocated 1/3 of all it's funding to abstinence and fidelity programs. Those programs may have done more harm than good.

Fidelity programs implied that women with few decision rights over sex simply had to remain faithful to avoid AIDS. Meanwhile, their husbands were out contracting the virus and passing it to them. It was supremely disempowering, misogynistic and, ultimately, deadly. Lifting the gag rule and bundling family planning, contraception, HIV prevention, and maternal and early childhood health together is essential to fighting this disease and restoring womens reproductive rights to the program.

While programs discouraging premarital sex have delayed the age of first sex (called sexual debut), they may have increased the risk of AIDS. How's that? Students taught to abstain appeared more likely to practice unsafe sex when they did start. Thus, the administration may have managed to generate more, not fewer, AIDS cases by pushing this largely religiously-driven policy into practice. In a sexually-transmitted disease epidemic, people need to be able to talk about sex. By restricting passage of information about safe sex, PEPFAR utterly failed the "real world" test. Unprotected sex is responsible for approximately 80 percent of new Sub-Saharan HIV cases. This figure is not unknown to those who've guided PEPFAR programs and funding. Imposing a gag-rule on recipients of PEPFAR funding has made them less effective. More critically, it has needlessly wasted lives.

In spite of PEPFAR's achievements, its programs (and those of other governments and multilateral organizations), are unfortunately not extensive enough. Last June, a joint WHO/UN Aids report showed that while nearly three million are now receiving anti-retroviral drugs in the developing world, this is less than a third of the estimated 9.7 million people who need them. The gap between those in need and those receiving drugs is currently the number who will die from AIDS this year - approximately 5 million people. We must reach more people and we must do it quickly.

If there's one piece of core learning from PEPFAR, it's that the world needs a more holistic approach to public health matters. AIDS cannot be treated in a vacuum. And yet, PEPFAR has encouraged this. At one health center where I work, there is no international support for maternal health, child health, or other primary health care. Yet, $75,000 has been provided to build a new facility to serve the roughly 300 people in a community of 25,000 who are HIV positive. For too long, funds that have been disbursed as part of PEPFAR's programs have been used only for AIDS. This has led to a situation of tragic disparity in treatment priorities. It is nothing short of tragic and unsustainable to deny patients with easily treatable diseases because a health center's staff and resources are earmarked for AIDS. In many centers across Africa, it's easier (and cheaper) for patients to receive expensive AIDS treatment than generic antibiotics, family planning, and other basic services.

Soon, President Obama will decide in which direction to take PEPFAR. He can't fail to see that the program is inadequately funded. He must also know that PEPFAR can be made much more effective with the resources it currently employs. The Obama transition team is already reviewing PEPFAR's strengths and shortcomings. They can see that reallocating the nearly 1/3 of program funds currently earmarked for ineffective abstinence programs is essential to making the program more effective. A comprehensive women's health initiative; restoring funds to partners conducting abortion counseling; and treating more patients -- not just AIDS patients; those elements can be paid for with these funds. They will go a long way to preventing future cases.