policy paper outline: PEPFAR

Policy issue and background
• Since the first cases of AIDS in the 1980s, more than 25 million people have died from related symptoms.
• Estimates put worldwide infection today at approximately 35 million. Every year, 2-3 million people lose their lives to AIDS; one third of those people are in sub-Saharan Africa.
• The most common methods of transmission of HIV are sexual contact, exposure to bodily fluids, and mother-to-child transmission.

Current U.S. policy
• President Bush announced the PEPFAR (President's Emergency Plan for AIDS Relief) in 2003. It is a five-year, $15 billion initiative to combat the AIDS pandemic.
• Fifteen focus countries will receive $10 billion in aid; dozens of smaller nations will receive a total of $4 billion dollars.
• The three main goals are prevention, treatment, and care. Most of the funding is spent on treatment.
• One-third of the prevention budget is for abstinence-only programs; emphasis is on the ABC approach (Abstain, Be faithful, or use a Condom).
• The goal is to support prevention of 7 million infections, antiretroviral treatment for 2 million HIV-infected individuals, and care of 10 million people infected and affected by HIV/AIDS, including orphans and vulnerable children, by October 2008.

Strengths and weaknesses of current U.S. policy
• According to the official PEPFAR website, through 2006 the U.S. is well on its way to meeting the set goals.
• PEPFAR is well-intentioned, and is the self-proclaimed largest initiative by a single country for a single disease. However, in FY 2006 alone, the U.S. budget included $21 billion for treating and preventing domestic HIV/AIDS.
• There is a good deal of controversy over the ABC approach—it is seen as the U.S. trying to push its conservative religious values on victims of a disease. The ABC approach often focuses more on ideology than what is most effective for the patients, and stigmatizes condom use.
• For the first several years of PEPFAR, the U.S. refused to use generic ARV drugs because they were not FDA-approved. Twice as many patients could have been treated by not limiting prescriptions to name-brand pharmaceuticals; generic drugs cost as little as 10% of the name-brand drug price. The FDA was slow in approving drugs even though they had been approved by the WHO. Generic drugs have been, from early-on, 3-in-1 pills that need only be taken once a day, whereas name-brand drugs required taking several pills several times a day. Missing doses decreased the efficacy of the prescription.
• U.S. pharmaceutical companies are working on developing second-line regimens for AIDS victims who are resistant to first-line prescriptions.
• Despite the “Three Ones”—one national plan, one national coordinating authority, and one national monitoring evaluation system—PEPFAR is often considered a unilateral approach to the AIDS problem, pushing its own agenda on the focus countries and has sometimes disregarded the programs each nation has developed that were in some cases more effective than PEPFAR has proven.
• Teaching women to abstain until marriage and be faithful to their partner does little good if men continue to seek out prostitutes, particularly without using condoms. Additionally, cultural degradation of women means that for many girls and young women, their first sexual encounter is forced, and they have little power to negotiate condom use or whether they wish to have intercourse at all. Without changing societal views of women, there is little point in teaching women about being faithful.

Policy recommendations
• The PEPFAR website gives very ambiguous numbers when citing the current progress. For example, it states the U.S. has “supported community outreach activities to nearly 61.5 million people to prevent sexual transmission,” “supported prevention of mother-to-child HIV transmission services for women during more than 6 million pregnancies,” and “supported antiretroviral prophylaxis for HIV-positive women during 533,700 pregnancies, averting an estimated 101,500 infant HIV infections.” When looking at the goal of preventing 7 million infections by 2010, how does the U.S. determine how close it is to reaching that goal?
• Although $15 billion is indeed a substantial sum of money to be spending outside the U.S., it is very little compared to what the U.S. budget includes for domestic HIV/AIDS research and treatment. Since Americans are concerned very little with the AIDS problem in comparison to how much most Africans are concerned with the AIDS problem, the U.S. should reexamine its funding policies. At the very least, the American public should be made more aware of the PEPFAR program. Regardless of how small a percentage of the yearly budget $3 billion is ($15 billion over three years), it is so much more than many Americans will ever see that they deserve to know what the government is spending money on.
• The ABC approach has medical evidence to support its effectiveness, but it carries a lot of Western-centric ideology and conservative moral values that may not be in line with the cultures the U.S. is trying to aid. We should avoid making condom use a last resort, or refusing to make them available on the grounds that they will be used in “immoral” situations. Funding stipulations that require 1/3 of the prevention budget to be directed to programs which advocate abstinence-until-marriage should be removed. Numerous organizations are helping to reduce the number of HIV infections around the globe; funding should not be denied them simply because they are willing to distribute condoms, which have proven to be a very effective prevention method.
• The U.S. should continue to develop cheap, 3-in-1 ART drugs that will reduce the cost of treating individuals, allow more individuals to receive treatment, and make life easier for those who live with AIDS. The FDA should work with the WHO in expediting the drug approval process. Pharmaceuticals need to find effective second-line prescriptions for patients who are resistant to first-line prescriptions, and find inexpensive ways of producing those second-line drugs.
• Deference should be given to national governments and organizations that already have programs in place for combating AIDS, if those programs have proven effective. PEPFAR should work alongside existing systems rather than creating extra levels of bureaucracy.
• Part of the prevention section of PEPFAR should be a goal to increase respect for women through classes, workshops, and activities. Until the social status of women is raised in many of the focus countries, little progress can be made. It has been proven that there is a negative correlation between a woman’s level of education and her likelihood of contracting HIV. Therefore, it would be in the best interest of both the U.S. and the focus countries to provide more opportunities for girls and young women to complete at least a basic elementary school education.