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President’s Emergency Plan for AIDS Relief (PEPFAR)

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Overview:

The President’s Emergency Plan for Aids Relief (PEPFAR) is a pledge of $15 billion over five years (2003-2008) to fight the global HIV/AIDS pandemic. The legislation that authorized PEPFAR also established the State Department Office of the U.S. Global Aids Coordinator (OGAC), which oversees all international AIDS funding and programming. The Department of State and OGAC - along with the U.S. Agency for International Development (USAID), the Departments of Defense, Commerce, Labor, and Health and Human Services, and the Peace Corps - are responsible for administering PEPFAR. Through three strategic program areas (prevention, care and treatment), the initiative was intended to prevent 7 million new infections, treat 2 million people living with AID-related illnesses, and provide care and support for 10 million persons affected by AIDS. In its first two years, PEPFAR reportedly provided support for 471,000 people in 114 countries. Most of these were in 15 “focus countries,” - a list that currently includes Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.

 
Although considered a much-needed surge in the global fight against HIV/AIDS, PEPFAR is widely criticized for slow bureaucracy and restrictive policies. Most notably, recipient countries are required to spend the majority of funding for prevention of sexually-transmitted HIV/AIDS on abstinence-until-marriage programs - to the exclusion (and more often, prohibition) of condom-related education; organizations working with commercial sex workers are bound by morally based restrictions; funding is prohibited from being used by organizations that provide abortion services; and the U.S. will not fund safe needle exchange programs for IV drug users, despite the proven efficacy of such programs. Generally, the U.S. is accused of flagrantly ignoring scientific and statistical evidence, and instead imposing an ideological agenda on countries, organizations and individuals in need. The U.S. has also been criticized for pushing expensive brand-name pharmaceuticals in the programs instead of affordable generics, thereby greatly decreasing the number of individuals who receive treatment.
 
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The Global Fund to Fight AIDS, Tuberculosis and Malaria was created in 2001 as a multilateral funding body. In President Bush’s January 2003 State of the Union address, he announced the Emergency Plan for AIDS Relief (PEPFAR), outlining a five-year, $15 billion initiative, of which $10 billion would be new money. Congress authorized PEPFAR in May of the same year with P.L. 108-25 (PDF), the United States Leadership Against Global HIV/AIDS, Tuberculosis, and Malaria Act of 2003. The first PREPFAR ambassador was sworn in on October 6, 2003, and Ambassador Mark R. Dybul has been the U.S. Global AIDS Coordinator since 2006.
 
The PEPFAR budget must be reauthorized each year, and the program was renewed for another five-year term in 2008.

 

PEPFAR Important Dates and Information (PEPFAR Watch)

 

 

 

more
What it Does:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREFAR Implementing Agencies
 
Countries
Of the total 123 countries that receive assistance from PEPFAR, there are 15 focus countries that receive about two-thirds ($10 billion) of the funding:
-       Botswana
-       Cote d'Ivoire
-       Ethiopia
-       Guyana
-       Haiti
-       Kenya
-       Mozambique
-       Namibia
-       Nigeria
-       Rwanda
-       South Africa
-       Tanzania
-       Uganda
-       Vietnam
-       Zambia
 
About $4 billion goes to other PEPFAR countries and for additional activities including HIV/AIDS research; and $1 billion is allocated to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.  
 
Budget/Funding
PEPFAR was enacted as a five-year plan, from 2003 to 2008. (In addition to the $15 billion allocated to PEPFAR over a five-year period, the domestic AIDS/HIV expenditure for FY 2006 was $21 billion).
 
In May 2007 President Bush announced his intention to double the budget to $30 billion to cover the next five years - from 2008-2013, outlining a shift from emergency planning to a “sustainable response.” The Administration requested $5.4 billion for FY 2008, bringing total spending over the initial five-year period to more than $18 billion - which is 20% more than originally planned. However, with current budget levels around $6 billion per year, critics lamented the new $30 billion, five-year plan will amount to flat funding - and not be sufficient.
 
However, in April 2008, lawmakers raised the five-year budget proposal to $50 billion. See below.
House Approves Global AIDS Program (by Jim Abrams, Political Base).
Ignoring Facts, Biden, Lugar Proceed on PEPFAR (by Scott Swenson, RH Reality Check)
Senate Panel Acts on AIDS Bill (by Jim Abrams, Associated Press)
Both Sides See Benefit in AIDS Deal (by Adam Graham-Silverman, CQ Politics)
 
Criticism/Oversight/Watchdog/Additional Information and Analysis
Smith Defends President Bush's AIDS Prevention Program (by Chris Smith, House of Representatives)
 
PEPFAR Purchases and Drugs
In addition to the billions of dollars of PEPFAR money spent on the purchase of HIV antiretroviral drugs, there is a wide range of other purchases authorized by the initiative, which specifies that all products must be “of the highest quality” and ensure “safety and efficacy.” According to avert.org, this means that drugs have to be approved by the U.S. Food and Drug Administration (FDA) or a regulatory agency in Canada, Japan, or Western Europe. Products pre-qualified by the World Health Organization (WHO) are excluded, “even though their system is trusted by most other donors and national governments.”
 
This clause is particularly important for the issue of generic antiretroviral drugs - which, at significantly lower costs, could cover much more ground within the budget constraints. While the PEPFAR strategy document states that drugs can be “bioequivalent versions of branded ARV and other medications,” the requirement that they be FDA-approved precludes the use of most generic ARVs, which are normally only pre-qualified by the WHO. Furthermore, reports advert.org, the U.S. government’s policy “totally excluded the purchase of Fixed Dose Combinations (FDCs), none of which were approved by the FDA.” 
 
After several bureaucratic and logistical impediments, PEPFAR use of generics went from 27% of all ARVs in FY 2006 to about 73% in FY 2007 - with critics blaming unnecessary bureaucracy for the slow start.

The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR

 

 

more
Where Does the Money Go:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Division of Funding
According to advert.org, PEPFAR has “a very strong emphasis” on treatment and care, with only about a fifth of funding allocated to prevention. Congress mandated that 55% of funding go to treatment, and in FY 2006–FY 2008 75% of this sum (or 41% of the total money) was allocated for the purchase and distribution of antiretroviral drugs;15% for “palliative” or “comfort” care (for individuals with HIV/AIDS and their loved ones); 20% for prevention - of which at least 33% must be spent on abstinence-until-marriage campaigns (the actual percentage is higher; see below) and 10% to help orphans and vulnerable children (in FY 2006- FY 2008, at least half of this is mandated for NGOS - including faith-based organizations).
 What is PEPFAR (Avert)
 
More on Funding and Spending
Divine Intervention (by Helena Bengtsson and Alejandra Fernández Morera, Center for Public Integrity)

Engendering Bold Leadership: First Annual Report to Congress on the President's Emergency Plan for AIDS Relief

 

 

more
Controversies:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Implications of Long-Term Funding
President Bush’s plan for the long-term provision of life-prolonging drugs means that millions of people in other countries will be dependent on the U.S. to extend their lives.
 
Tobias Prostitution Scandal
Bush’s inaugural OGAC appointee and “hammer” in pushing the U.S.’s abstinence and anti-prostitution agendas gets caught in a call-girl ring.
Morality Gets a Massage (by The Editors, The Nation)
 
Many Problems
Since its implementation, PEPFAR has come under a great deal of criticism. Although this is the largest international health initiative ever initiated by one nation to address a single disease, more than 90% of people who need treatment still don't have access to it. PEPFAR Watch, a website run by the Center for Health and Gender Equity and Health, has drawn attention to many of the program's flaws including:
-       Refusal to fund effective yet “taboo” safe needle exchange programs to prevent HIV transmission among drug users
-       The mandate that 1/3 of prevention spending be directed towards abstinence-only programs
-       The use of only a few generic drugs as part of PEPFAR, meaning that it is much more expensive to treat people under PEPFAR than it has to be
-       The creation of a market for name-brand AIDS drugs that didn't previously exist in much of the global south by purchasing patented drugs. This undermines efforts to get pharmaceutical companies to issue manufacturing licenses to generic companies or to lower the costs on their drugs in the global south.
-       The requirement of numerous doctors, nurses, and other health care workers, meaning that these physicians are drawn from an already overburdened health system and are no longer able to meet the health needs they were previously meeting.
 
More Issues
The issues surrounding PEPFAR policy and implementation are numerous, complex - and deeply interconnected. Comprehensive information, analysis and related documents are available through the PEPFAR Watch website, and are organized as follows:
-       Women & Girls - The U.S. government forces organizations to push its ideological messages about sex, sexuality and reproduction - at the expense of internationally recognized human rights (See Cairo and Beijing Conventions on Sexual and Reproductive Health and Rights).
 
As some of the most vulnerable members of society and the most susceptible to HIV infection (according to a 2006 UNAIDS report, 74% of young people living with HIV and AIDS sub-Saharan Africa are female), women, girls and youth should be the centerpiece of prevention strategies - which must be based on the realities of gender disparity.
 
Among the myths propagated through PEPFAR policy strictures is the one that marriage protects women and girls from infection. Abstinence and “be faithful” doctrines that discourage or prohibit contraception and condom information and distribution (and deny women their sexual and reproductive health rights) are based on cultural biases and the assumption that women will contract HIV/AIDS primarily through “promiscuous” sexual behavior. (In fact, according to a 2005 UNFPA report, more than four-fifths of new HIV infections in women result from sex with their husbands or primary partners).
-       Youth - According to PEPFAR Watch, “approximately 50% of all new HIV infections worldwide occur in youth ages 15-24. In some parts of sub-Saharan Africa, young women in this age group are four to seven times more likely to be infected than their male peers.
-       Sex Workers - There is increasing evidence that the anti-prostitution policies the U.S. imposes on organizations prevent them from reaching marginalized and at-risk groups - and undermine needed interventions in “high-risk” communities.
-       Faith-Based Organizations - Under the Bush Administration, faith-based organizations are given increasing funding and special priority.
-       Injecting Drug Users - U.S. opposition to needle-exchange impedes global efforts to combat HIV/AIDS
-       LGBTQ - Critics highlight a lack of sensitivity in policy decisions regarding marginalized populations, including Lesbian, Gay, Bisexual, Transgender and Queer individuals.
-       Treatment Access - Although PEPFAR has been instrumental in increasing global access to treatment, critics outline several impediments that prevent a current 90% of people in need from receiving treatment.
-       VCT - Voluntary Counseling and Testing
-       Trade Agreements - many governments receiving PEPFAR aid risk compromising their sovereignty under pressure from multilateral international trade agreements (e.g., with the WHO) that pressure them to introduce reforms favoring multinational business and investment - notably in pharmaceuticals and ARVs.
-       Health Care Systems - Global shortage in healthcare practitioners is particularly acute in sub-Saharan Africa and the Global South, exacerbated by the HIV/AIDS pandemic.
-       Children & Orphans
-       Reproductive Health
 
Drug Prices
 
Spending on Abstinence and “Be Faithful”
About 20% of PEPFAR spending is allocated to prevention - at least a third of which Congress earmarked for abstinence-only-until-marriage programs. In late 2005 PEPFAR tightened the rope with a new requirement that at least two-thirds of all funding for prevention of sexual transmission of HIV go to “AB” (abstinence and “be faithful”) strategies. Under this scheme, countries with a “generalized” epidemic (most of Africa) must produce a “very strong justification to not meet the 66 percent requirement,” and all fifteen focus countries are expected to comply. While the remaining funds may be spent on “condoms and related activities,” including media campaigns and community initiatives, policy requires any condom programs to include abstinence - and any program not focused solely on abstinence-until-marriage does not count as part of the AB earmarked funds. Thus, argue critics, AB activities actually receive far more than twice the resources committed to encouraging condom use.

What is PEPFAR

(Avert)

 

 

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Suggested Reforms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practical suggestions for reforming the many contentious issues at stake in PEPFAR policy include: removing the prohibitions and “morality clauses” that complicate and impede funding disbursement to some of the most needy and vulnerable sectors of society -  including Congressional earmarks for abstinence-only-until-marriage programs (recently reformed, see below) and the suppression of contraceptive and condom education and distribution; the anti-prostitution oath and prohibition of safe needle exchange initiatives. Although President Bush specifically exempted PEPFAR funding from the global gag rule (which prohibits US aid from funding family planning services that provide abortion information or services), there is still confusion about administering family planning services and the rule prevents successful implementation of dual family-planning/reproductive health and HIV/AIDS instruction and services.
 
2008 Reauthorization Bill
The House approved the President’s Reauthorization Bill in early April 2008. The legislation was considered a compromise, evidencing a response to critical feedback - albeit one critics find incomplete and counterproductive. The one-third “abstinence only” requirement for prevention funds replaced with “balanced funding” for ABC programs based on country-specific evidence - however, the bill imposes a requirement that countries report to Congress if AB programs constitute less than half of spending on programs aimed at preventing sexual transmission, which critics label “confusing.” The 55% floor for treatment provisions was also eliminated. The Bill retains the anti-prostitution pledge requirement, and permits groups to use PEPFAR funding for HIV testing and education in family planning clinics - but not for contraception or abortion services. (That is, the programs that are allowed to integrate HIV testing, counseling and education services with family planning must already receive U.S. funding - and therefore abide to the global gag rule). The result is a failure to truly integrate family planning and HIV/AIDS initiatives.
 
Did Congress Forget About Women and Girls? (by Jamila Taylor, RH Reality Check)

Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding

(GAO Report) (PDF)

 

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Debate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abstinence Only
The issue of whether and how mandatory PEPFAR funds should be allocated to abstinence-only-until-marriage programs is a highly contested issue, including among lawmakers. Generally, Bush Administration policies on sexual and reproductive health and rights (SRHR) and HIV/AIDS - including the global gag rule on abortion, the anti-prostitution oath recipient organizations are compelled to take, increasing faith-based organization (FBO) support, and the stubborn adherence to mandatory funding for AB programming at the expense of condom education - have been widely maligned by human rights groups and HIV/AIDS advocates. 
See Suggested Reforms
 
From the Right

PEPFAR ‘Compromise’ Abandons Successful Approaches to International AIDS Relief

(by Daniel P Moloney, Heritage Foundation)

 

 

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Former Directors:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Randall Tobias
Senior Official Linked to Escort Service Resigns (by Brian Ross and Justin Rood, ABC News)
Morality Gets a Massage(by The Editors, The Nation)

Overseas Private Investment Corporation Bio

 

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Founded: 2003
Annual Budget: $5.4 billion
Employees:
Official Website: http://www.pepfar.gov/
President’s Emergency Plan for AIDS Relief (PEPFAR)
Birx, Deborah
U.S. Global AIDS Coordinator

Deborah L. Birx, who started studying the HIV virus in the early 1980s, was confirmed on April 4, 2014, to be head of the President’s Emergency Plan For AIDS Relief (PEPFAR) and an ambassador-at-large.

 

Birx comes from a scientifically-oriented family. Her father, Donald, was a mathematician and electrical engineer and her mother, Adele, was a nursing instructor. One brother was a mathematician and the other a nuclear physicist. Birx earned her B.S. in chemistry at New York state’s Houghton College in 1976 and went on to Penn State’s Hershey School of Medicine, earning her M.D. in 1980. She also went into the Army at that time and did her residency at Walter Reed Army Medical Center.

 

Birx’s specialty was immunology, concentrating on allergies at first. She found herself as a victim of an allergy in the 1980s when she ate kiwi fruit on an airplane and had an anaphylactic reaction severe enough that the plane had to land to get her emergency treatment. Ironically, Birx was on her way to a convention of allergists when the incident occurred.

 

But in the early 1980s while participating in a fellowship sponsored by Walter Reed and the National Institutes of Health, Birx began to be consulted on patients with what became known as HIV. Her early knowledge of the disease may have saved her life. While giving birth to her eldest daughter in 1983, Birx had complications, but told her husband not to let the doctors give her blood. They didn’t, and the blood that Birx would have received was later found to contain HIV.

 

Thus, she began a long career of searching for a cure for that disease. From 1985 to 1989, Birx was assistant chief of hospital immunology services at Walter Reed. She moved to the Department of Retroviral Research, first as assistant and in 1994 as head of the department. Beginning 1n 1996, as director of the U.S. Military HIV Research Program, Birx helped lead the RV144 vaccine trial, which took place in Thailand between 2003 and 2006, considered to be the first vaccine trial that showed a lowering of the HIV infection rate.

 

Birx has spent much of her career working in Africa, beginning in 1998 to set up trials there. In 2005, Birx moved to the Centers for Disease Control and Prevention as director of its Division of Global HIV/AIDS in the Center for Global Health. She held that post until being appointed to lead PEPFAR. She retired from the Army in 2008 as a colonel.

 

Birx has two adult daughters, Devynn Birx-Raybuck and Danielle Birx-Raybuck.

-Steve Straehley

 

To Learn More

Remarks at Swearing-in Ceremony for Ambassador-at-Large and Coordinator of the USG Activities to Combat HIV/AIDS Deborah Birx

Six Prominent Women Scientists Making a Difference in the AIDS Fight (by Mary Rushton, IAVI Report)

Official Biography

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Goosby, Eric
Previous Ambassador

A pioneer in the fight against AIDS, Eric P. Goosby has, since June 23, 2009, overseen the President’s Emergency Plan for AIDS Relief (PEPFAR) as part of his role as U.S. Global AIDS Coordinator, leading all of the federal government’s international HIV/AIDS efforts.

 
Goosby’s father, Dr. Zuretti Goosby, was a dentist and one-time elected member of the San Francisco Board of Education. Born in San Francisco in 1952, Goosby received his Bachelor of Arts in biology from Princeton University (1974) and his MD from the University of California, San Francisco, where he also completed his residency (1981). He then completed a two-year Kaiser Fellowship at UCSF in general internal medicine with a subspecialty in infectious diseases.
 
Goosby has more than 30 years of experience with HIV/AIDS, beginning with his early years treating patients at San Francisco General Hospital, where, as an intern, he encountered his first AIDS patient in 1979. Before long, 80% of the hospital’s patients were those infected with AIDS.
 
In 1986, he served as AIDS activity division attending physician, and in 1987 was appointed associate medical director of San Francisco General Hospital’s AIDS Clinic.
 
In 1991, Goosby began his government career as director of HIV services at the Health Resources and Services Administration in the U.S. Department of Health and Human Services. In this position, he administered the newly authorized Ryan White CARE Act, overseeing the distribution of federal funds and the planning of services in 25 AIDS epicenters around the U.S.
 
Three years later, Goosby became director of the Office of HIV/AIDS Policy in the Department of Health and Human Services, where he advised on the federal HIV/AIDS budget and worked with Congress on AIDS-related issues.
 
In 1995, Goosby created and convened the department’s Panel on Clinical Practices for the Treatment of HIV Infections. This panel defined how to use protease inhibitors in conjunction with already existing antiretrovirals, later expanding its work to address standards of care for antiretroviral use for pediatric patients and pregnant women.
 
Goosby also served as interim director of the National AIDS Policy Office at the White House, reporting directly to President Bill Clinton as his senior advisor on HIV-related issues. In 1998, he helped to foster and orchestrate the dialogue on racial disparities in HIV/AIDS that led to the Minority AIDS Initiative. Goosby’s office also coordinated scientific reviews of needle exchange programs.
 
In 2000, Goosby served as acting deputy director of the National AIDS Policy Office in the White House, while continuing to work as director of HIV/AIDS policy at the Department of Health and Human Services.
 
After leaving government service when George W. Bush took over the presidency, he served as CEO and chief medical officer of the Pangaea Global AIDS Foundation. In this role Goosby helped in the development and implementation of HIV/AIDS national treatment plans in South Africa, Rwanda, China, and Ukraine. He continued in this position for eight years until President Obama asked him to return to government service in June 2009.
 
Goosby was also a professor of clinical medicine at the University of California, San Francisco, before joining the Obama administration.
 
Goosby and his wife, Nancy Truelove, have a son, Eric, and a daughter, Zoe.
 
Eric Goosby Biography (State Department)
Eric Goosby (Wikipedia)
Eric Goosby (WhoRunsGov, Washington Post)
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Table of Contents
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Overview:

The President’s Emergency Plan for Aids Relief (PEPFAR) is a pledge of $15 billion over five years (2003-2008) to fight the global HIV/AIDS pandemic. The legislation that authorized PEPFAR also established the State Department Office of the U.S. Global Aids Coordinator (OGAC), which oversees all international AIDS funding and programming. The Department of State and OGAC - along with the U.S. Agency for International Development (USAID), the Departments of Defense, Commerce, Labor, and Health and Human Services, and the Peace Corps - are responsible for administering PEPFAR. Through three strategic program areas (prevention, care and treatment), the initiative was intended to prevent 7 million new infections, treat 2 million people living with AID-related illnesses, and provide care and support for 10 million persons affected by AIDS. In its first two years, PEPFAR reportedly provided support for 471,000 people in 114 countries. Most of these were in 15 “focus countries,” - a list that currently includes Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.

 
Although considered a much-needed surge in the global fight against HIV/AIDS, PEPFAR is widely criticized for slow bureaucracy and restrictive policies. Most notably, recipient countries are required to spend the majority of funding for prevention of sexually-transmitted HIV/AIDS on abstinence-until-marriage programs - to the exclusion (and more often, prohibition) of condom-related education; organizations working with commercial sex workers are bound by morally based restrictions; funding is prohibited from being used by organizations that provide abortion services; and the U.S. will not fund safe needle exchange programs for IV drug users, despite the proven efficacy of such programs. Generally, the U.S. is accused of flagrantly ignoring scientific and statistical evidence, and instead imposing an ideological agenda on countries, organizations and individuals in need. The U.S. has also been criticized for pushing expensive brand-name pharmaceuticals in the programs instead of affordable generics, thereby greatly decreasing the number of individuals who receive treatment.
 
more
History:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Global Fund to Fight AIDS, Tuberculosis and Malaria was created in 2001 as a multilateral funding body. In President Bush’s January 2003 State of the Union address, he announced the Emergency Plan for AIDS Relief (PEPFAR), outlining a five-year, $15 billion initiative, of which $10 billion would be new money. Congress authorized PEPFAR in May of the same year with P.L. 108-25 (PDF), the United States Leadership Against Global HIV/AIDS, Tuberculosis, and Malaria Act of 2003. The first PREPFAR ambassador was sworn in on October 6, 2003, and Ambassador Mark R. Dybul has been the U.S. Global AIDS Coordinator since 2006.
 
The PEPFAR budget must be reauthorized each year, and the program was renewed for another five-year term in 2008.

 

PEPFAR Important Dates and Information (PEPFAR Watch)

 

 

 

more
What it Does:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREFAR Implementing Agencies
 
Countries
Of the total 123 countries that receive assistance from PEPFAR, there are 15 focus countries that receive about two-thirds ($10 billion) of the funding:
-       Botswana
-       Cote d'Ivoire
-       Ethiopia
-       Guyana
-       Haiti
-       Kenya
-       Mozambique
-       Namibia
-       Nigeria
-       Rwanda
-       South Africa
-       Tanzania
-       Uganda
-       Vietnam
-       Zambia
 
About $4 billion goes to other PEPFAR countries and for additional activities including HIV/AIDS research; and $1 billion is allocated to the Global Fund to Fight AIDS, Tuberculosis, and Malaria.  
 
Budget/Funding
PEPFAR was enacted as a five-year plan, from 2003 to 2008. (In addition to the $15 billion allocated to PEPFAR over a five-year period, the domestic AIDS/HIV expenditure for FY 2006 was $21 billion).
 
In May 2007 President Bush announced his intention to double the budget to $30 billion to cover the next five years - from 2008-2013, outlining a shift from emergency planning to a “sustainable response.” The Administration requested $5.4 billion for FY 2008, bringing total spending over the initial five-year period to more than $18 billion - which is 20% more than originally planned. However, with current budget levels around $6 billion per year, critics lamented the new $30 billion, five-year plan will amount to flat funding - and not be sufficient.
 
However, in April 2008, lawmakers raised the five-year budget proposal to $50 billion. See below.
House Approves Global AIDS Program (by Jim Abrams, Political Base).
Ignoring Facts, Biden, Lugar Proceed on PEPFAR (by Scott Swenson, RH Reality Check)
Senate Panel Acts on AIDS Bill (by Jim Abrams, Associated Press)
Both Sides See Benefit in AIDS Deal (by Adam Graham-Silverman, CQ Politics)
 
Criticism/Oversight/Watchdog/Additional Information and Analysis
Smith Defends President Bush's AIDS Prevention Program (by Chris Smith, House of Representatives)
 
PEPFAR Purchases and Drugs
In addition to the billions of dollars of PEPFAR money spent on the purchase of HIV antiretroviral drugs, there is a wide range of other purchases authorized by the initiative, which specifies that all products must be “of the highest quality” and ensure “safety and efficacy.” According to avert.org, this means that drugs have to be approved by the U.S. Food and Drug Administration (FDA) or a regulatory agency in Canada, Japan, or Western Europe. Products pre-qualified by the World Health Organization (WHO) are excluded, “even though their system is trusted by most other donors and national governments.”
 
This clause is particularly important for the issue of generic antiretroviral drugs - which, at significantly lower costs, could cover much more ground within the budget constraints. While the PEPFAR strategy document states that drugs can be “bioequivalent versions of branded ARV and other medications,” the requirement that they be FDA-approved precludes the use of most generic ARVs, which are normally only pre-qualified by the WHO. Furthermore, reports advert.org, the U.S. government’s policy “totally excluded the purchase of Fixed Dose Combinations (FDCs), none of which were approved by the FDA.” 
 
After several bureaucratic and logistical impediments, PEPFAR use of generics went from 27% of all ARVs in FY 2006 to about 73% in FY 2007 - with critics blaming unnecessary bureaucracy for the slow start.

The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR

 

 

more
Where Does the Money Go:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Division of Funding
According to advert.org, PEPFAR has “a very strong emphasis” on treatment and care, with only about a fifth of funding allocated to prevention. Congress mandated that 55% of funding go to treatment, and in FY 2006–FY 2008 75% of this sum (or 41% of the total money) was allocated for the purchase and distribution of antiretroviral drugs;15% for “palliative” or “comfort” care (for individuals with HIV/AIDS and their loved ones); 20% for prevention - of which at least 33% must be spent on abstinence-until-marriage campaigns (the actual percentage is higher; see below) and 10% to help orphans and vulnerable children (in FY 2006- FY 2008, at least half of this is mandated for NGOS - including faith-based organizations).
 What is PEPFAR (Avert)
 
More on Funding and Spending
Divine Intervention (by Helena Bengtsson and Alejandra Fernández Morera, Center for Public Integrity)

Engendering Bold Leadership: First Annual Report to Congress on the President's Emergency Plan for AIDS Relief

 

 

more
Controversies:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Implications of Long-Term Funding
President Bush’s plan for the long-term provision of life-prolonging drugs means that millions of people in other countries will be dependent on the U.S. to extend their lives.
 
Tobias Prostitution Scandal
Bush’s inaugural OGAC appointee and “hammer” in pushing the U.S.’s abstinence and anti-prostitution agendas gets caught in a call-girl ring.
Morality Gets a Massage (by The Editors, The Nation)
 
Many Problems
Since its implementation, PEPFAR has come under a great deal of criticism. Although this is the largest international health initiative ever initiated by one nation to address a single disease, more than 90% of people who need treatment still don't have access to it. PEPFAR Watch, a website run by the Center for Health and Gender Equity and Health, has drawn attention to many of the program's flaws including:
-       Refusal to fund effective yet “taboo” safe needle exchange programs to prevent HIV transmission among drug users
-       The mandate that 1/3 of prevention spending be directed towards abstinence-only programs
-       The use of only a few generic drugs as part of PEPFAR, meaning that it is much more expensive to treat people under PEPFAR than it has to be
-       The creation of a market for name-brand AIDS drugs that didn't previously exist in much of the global south by purchasing patented drugs. This undermines efforts to get pharmaceutical companies to issue manufacturing licenses to generic companies or to lower the costs on their drugs in the global south.
-       The requirement of numerous doctors, nurses, and other health care workers, meaning that these physicians are drawn from an already overburdened health system and are no longer able to meet the health needs they were previously meeting.
 
More Issues
The issues surrounding PEPFAR policy and implementation are numerous, complex - and deeply interconnected. Comprehensive information, analysis and related documents are available through the PEPFAR Watch website, and are organized as follows:
-       Women & Girls - The U.S. government forces organizations to push its ideological messages about sex, sexuality and reproduction - at the expense of internationally recognized human rights (See Cairo and Beijing Conventions on Sexual and Reproductive Health and Rights).
 
As some of the most vulnerable members of society and the most susceptible to HIV infection (according to a 2006 UNAIDS report, 74% of young people living with HIV and AIDS sub-Saharan Africa are female), women, girls and youth should be the centerpiece of prevention strategies - which must be based on the realities of gender disparity.
 
Among the myths propagated through PEPFAR policy strictures is the one that marriage protects women and girls from infection. Abstinence and “be faithful” doctrines that discourage or prohibit contraception and condom information and distribution (and deny women their sexual and reproductive health rights) are based on cultural biases and the assumption that women will contract HIV/AIDS primarily through “promiscuous” sexual behavior. (In fact, according to a 2005 UNFPA report, more than four-fifths of new HIV infections in women result from sex with their husbands or primary partners).
-       Youth - According to PEPFAR Watch, “approximately 50% of all new HIV infections worldwide occur in youth ages 15-24. In some parts of sub-Saharan Africa, young women in this age group are four to seven times more likely to be infected than their male peers.
-       Sex Workers - There is increasing evidence that the anti-prostitution policies the U.S. imposes on organizations prevent them from reaching marginalized and at-risk groups - and undermine needed interventions in “high-risk” communities.
-       Faith-Based Organizations - Under the Bush Administration, faith-based organizations are given increasing funding and special priority.
-       Injecting Drug Users - U.S. opposition to needle-exchange impedes global efforts to combat HIV/AIDS
-       LGBTQ - Critics highlight a lack of sensitivity in policy decisions regarding marginalized populations, including Lesbian, Gay, Bisexual, Transgender and Queer individuals.
-       Treatment Access - Although PEPFAR has been instrumental in increasing global access to treatment, critics outline several impediments that prevent a current 90% of people in need from receiving treatment.
-       VCT - Voluntary Counseling and Testing
-       Trade Agreements - many governments receiving PEPFAR aid risk compromising their sovereignty under pressure from multilateral international trade agreements (e.g., with the WHO) that pressure them to introduce reforms favoring multinational business and investment - notably in pharmaceuticals and ARVs.
-       Health Care Systems - Global shortage in healthcare practitioners is particularly acute in sub-Saharan Africa and the Global South, exacerbated by the HIV/AIDS pandemic.
-       Children & Orphans
-       Reproductive Health
 
Drug Prices
 
Spending on Abstinence and “Be Faithful”
About 20% of PEPFAR spending is allocated to prevention - at least a third of which Congress earmarked for abstinence-only-until-marriage programs. In late 2005 PEPFAR tightened the rope with a new requirement that at least two-thirds of all funding for prevention of sexual transmission of HIV go to “AB” (abstinence and “be faithful”) strategies. Under this scheme, countries with a “generalized” epidemic (most of Africa) must produce a “very strong justification to not meet the 66 percent requirement,” and all fifteen focus countries are expected to comply. While the remaining funds may be spent on “condoms and related activities,” including media campaigns and community initiatives, policy requires any condom programs to include abstinence - and any program not focused solely on abstinence-until-marriage does not count as part of the AB earmarked funds. Thus, argue critics, AB activities actually receive far more than twice the resources committed to encouraging condom use.

What is PEPFAR

(Avert)

 

 

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Suggested Reforms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Practical suggestions for reforming the many contentious issues at stake in PEPFAR policy include: removing the prohibitions and “morality clauses” that complicate and impede funding disbursement to some of the most needy and vulnerable sectors of society -  including Congressional earmarks for abstinence-only-until-marriage programs (recently reformed, see below) and the suppression of contraceptive and condom education and distribution; the anti-prostitution oath and prohibition of safe needle exchange initiatives. Although President Bush specifically exempted PEPFAR funding from the global gag rule (which prohibits US aid from funding family planning services that provide abortion information or services), there is still confusion about administering family planning services and the rule prevents successful implementation of dual family-planning/reproductive health and HIV/AIDS instruction and services.
 
2008 Reauthorization Bill
The House approved the President’s Reauthorization Bill in early April 2008. The legislation was considered a compromise, evidencing a response to critical feedback - albeit one critics find incomplete and counterproductive. The one-third “abstinence only” requirement for prevention funds replaced with “balanced funding” for ABC programs based on country-specific evidence - however, the bill imposes a requirement that countries report to Congress if AB programs constitute less than half of spending on programs aimed at preventing sexual transmission, which critics label “confusing.” The 55% floor for treatment provisions was also eliminated. The Bill retains the anti-prostitution pledge requirement, and permits groups to use PEPFAR funding for HIV testing and education in family planning clinics - but not for contraception or abortion services. (That is, the programs that are allowed to integrate HIV testing, counseling and education services with family planning must already receive U.S. funding - and therefore abide to the global gag rule). The result is a failure to truly integrate family planning and HIV/AIDS initiatives.
 
Did Congress Forget About Women and Girls? (by Jamila Taylor, RH Reality Check)

Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding

(GAO Report) (PDF)

 

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Debate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abstinence Only
The issue of whether and how mandatory PEPFAR funds should be allocated to abstinence-only-until-marriage programs is a highly contested issue, including among lawmakers. Generally, Bush Administration policies on sexual and reproductive health and rights (SRHR) and HIV/AIDS - including the global gag rule on abortion, the anti-prostitution oath recipient organizations are compelled to take, increasing faith-based organization (FBO) support, and the stubborn adherence to mandatory funding for AB programming at the expense of condom education - have been widely maligned by human rights groups and HIV/AIDS advocates. 
See Suggested Reforms
 
From the Right

PEPFAR ‘Compromise’ Abandons Successful Approaches to International AIDS Relief

(by Daniel P Moloney, Heritage Foundation)

 

 

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Former Directors:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Randall Tobias
Senior Official Linked to Escort Service Resigns (by Brian Ross and Justin Rood, ABC News)
Morality Gets a Massage(by The Editors, The Nation)

Overseas Private Investment Corporation Bio

 

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Founded: 2003
Annual Budget: $5.4 billion
Employees:
Official Website: http://www.pepfar.gov/
President’s Emergency Plan for AIDS Relief (PEPFAR)
Birx, Deborah
U.S. Global AIDS Coordinator

Deborah L. Birx, who started studying the HIV virus in the early 1980s, was confirmed on April 4, 2014, to be head of the President’s Emergency Plan For AIDS Relief (PEPFAR) and an ambassador-at-large.

 

Birx comes from a scientifically-oriented family. Her father, Donald, was a mathematician and electrical engineer and her mother, Adele, was a nursing instructor. One brother was a mathematician and the other a nuclear physicist. Birx earned her B.S. in chemistry at New York state’s Houghton College in 1976 and went on to Penn State’s Hershey School of Medicine, earning her M.D. in 1980. She also went into the Army at that time and did her residency at Walter Reed Army Medical Center.

 

Birx’s specialty was immunology, concentrating on allergies at first. She found herself as a victim of an allergy in the 1980s when she ate kiwi fruit on an airplane and had an anaphylactic reaction severe enough that the plane had to land to get her emergency treatment. Ironically, Birx was on her way to a convention of allergists when the incident occurred.

 

But in the early 1980s while participating in a fellowship sponsored by Walter Reed and the National Institutes of Health, Birx began to be consulted on patients with what became known as HIV. Her early knowledge of the disease may have saved her life. While giving birth to her eldest daughter in 1983, Birx had complications, but told her husband not to let the doctors give her blood. They didn’t, and the blood that Birx would have received was later found to contain HIV.

 

Thus, she began a long career of searching for a cure for that disease. From 1985 to 1989, Birx was assistant chief of hospital immunology services at Walter Reed. She moved to the Department of Retroviral Research, first as assistant and in 1994 as head of the department. Beginning 1n 1996, as director of the U.S. Military HIV Research Program, Birx helped lead the RV144 vaccine trial, which took place in Thailand between 2003 and 2006, considered to be the first vaccine trial that showed a lowering of the HIV infection rate.

 

Birx has spent much of her career working in Africa, beginning in 1998 to set up trials there. In 2005, Birx moved to the Centers for Disease Control and Prevention as director of its Division of Global HIV/AIDS in the Center for Global Health. She held that post until being appointed to lead PEPFAR. She retired from the Army in 2008 as a colonel.

 

Birx has two adult daughters, Devynn Birx-Raybuck and Danielle Birx-Raybuck.

-Steve Straehley

 

To Learn More

Remarks at Swearing-in Ceremony for Ambassador-at-Large and Coordinator of the USG Activities to Combat HIV/AIDS Deborah Birx

Six Prominent Women Scientists Making a Difference in the AIDS Fight (by Mary Rushton, IAVI Report)

Official Biography

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Goosby, Eric
Previous Ambassador

A pioneer in the fight against AIDS, Eric P. Goosby has, since June 23, 2009, overseen the President’s Emergency Plan for AIDS Relief (PEPFAR) as part of his role as U.S. Global AIDS Coordinator, leading all of the federal government’s international HIV/AIDS efforts.

 
Goosby’s father, Dr. Zuretti Goosby, was a dentist and one-time elected member of the San Francisco Board of Education. Born in San Francisco in 1952, Goosby received his Bachelor of Arts in biology from Princeton University (1974) and his MD from the University of California, San Francisco, where he also completed his residency (1981). He then completed a two-year Kaiser Fellowship at UCSF in general internal medicine with a subspecialty in infectious diseases.
 
Goosby has more than 30 years of experience with HIV/AIDS, beginning with his early years treating patients at San Francisco General Hospital, where, as an intern, he encountered his first AIDS patient in 1979. Before long, 80% of the hospital’s patients were those infected with AIDS.
 
In 1986, he served as AIDS activity division attending physician, and in 1987 was appointed associate medical director of San Francisco General Hospital’s AIDS Clinic.
 
In 1991, Goosby began his government career as director of HIV services at the Health Resources and Services Administration in the U.S. Department of Health and Human Services. In this position, he administered the newly authorized Ryan White CARE Act, overseeing the distribution of federal funds and the planning of services in 25 AIDS epicenters around the U.S.
 
Three years later, Goosby became director of the Office of HIV/AIDS Policy in the Department of Health and Human Services, where he advised on the federal HIV/AIDS budget and worked with Congress on AIDS-related issues.
 
In 1995, Goosby created and convened the department’s Panel on Clinical Practices for the Treatment of HIV Infections. This panel defined how to use protease inhibitors in conjunction with already existing antiretrovirals, later expanding its work to address standards of care for antiretroviral use for pediatric patients and pregnant women.
 
Goosby also served as interim director of the National AIDS Policy Office at the White House, reporting directly to President Bill Clinton as his senior advisor on HIV-related issues. In 1998, he helped to foster and orchestrate the dialogue on racial disparities in HIV/AIDS that led to the Minority AIDS Initiative. Goosby’s office also coordinated scientific reviews of needle exchange programs.
 
In 2000, Goosby served as acting deputy director of the National AIDS Policy Office in the White House, while continuing to work as director of HIV/AIDS policy at the Department of Health and Human Services.
 
After leaving government service when George W. Bush took over the presidency, he served as CEO and chief medical officer of the Pangaea Global AIDS Foundation. In this role Goosby helped in the development and implementation of HIV/AIDS national treatment plans in South Africa, Rwanda, China, and Ukraine. He continued in this position for eight years until President Obama asked him to return to government service in June 2009.
 
Goosby was also a professor of clinical medicine at the University of California, San Francisco, before joining the Obama administration.
 
Goosby and his wife, Nancy Truelove, have a son, Eric, and a daughter, Zoe.
 
Eric Goosby Biography (State Department)
Eric Goosby (Wikipedia)
Eric Goosby (WhoRunsGov, Washington Post)
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