Overview:
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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.
History:
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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)
What it Does:
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PREFAR Implementing Agencies
Department of State (DoS)
U.S. Agency for International Development (USAID)
Department of Defense (DoD)
Department of Commerce (DoC)
Department of Labor (DoL)
Department of Health and Human Services (HHS)
Peace Corps
U.S. Agency for International Development (USAID)
Department of Defense (DoD)
Department of Commerce (DoC)
Department of Labor (DoL)
Department of Health and Human Services (HHS)
Peace Corps
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
- Ethiopia
- Guyana
- Haiti
- Kenya
- Namibia
- Nigeria
- Rwanda
- 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.
More foreign aid for AIDS - A $50-billion bill to fight AIDS and other diseases in Africa and elsewhere gives us reason to cheer. (Los Angeles Times)
House Votes to Continue and Expand President's Global Effort Against AIDS (by David Brown, Washington Post)
House Approves $50 Billion Extension of US HIV/AIDS Program (by Dan Robinson, Voice of America)
Bush AIDS initiative gets bipartisan renewal - Concessions are made as both sides authorize $50 billion through 2013 to greatly expand the president’s initiative. (by James Hohmann, Los Angeles Times)
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)
2008 AIDS Relief Budget Request Tops Original Commitment: United States remains global leader in fight against AIDS, official says (by Cheryl Pellerin, America.gov)
Criticism/Oversight/Watchdog/Additional Information and Analysis
The Institute of Medicine's report on PEPFAR (PEPFAR Watch)
New GAO Report Shows Restrictions in President’s Global AIDS Strategy Undermine Effective HIV Prevention Efforts (PEPFAR Watch) (PDF)
Health GAP Report - Between the Lines GAO Report on PEPFAR Prevention Programs: U.S. Abstinence/Being Faithful-Only Programs Produce Stigma and Death (PEPFAR Watch) (PDF)
GAO's Conclusions on PEPFAR Prevention Funding (PEPFAR Watch) (DOC)
News Coverage of U.S. Global AIDS Efforts (PEPFAR Watch)
Smith Defends President Bush's AIDS Prevention Program (by Chris Smith, House of Representatives)
Congressman Waxman's Letter to Secretary Rice concerning GAO Report "Spending Requirement Presents Challenges for Allocating Prevention Funding Under the President's Emergency Plan for AIDS Relief" (by Henry A. Waxman, House of Representatives) (PDF)
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.
What is PEPFAR? (Avert)
The Power of Partnerships: Fourth Annual Report to Congress on PEPFAR
Where Does the Money Go:
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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)
Risk and Reality - U.S. Funding of HIV Prevention Programs in Ethiopia (PEPFAR Watch) (PDF)
Controversies:
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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.
AIDS Funding Binds Longevity of Millions to U.S.: Open-Ended Commitment of Money Is Implied (by David Brown, Washington Post)
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.
Drug Prices
PEPFAR Paying More Than Twice as Much for Many AIDS Drugs as Other Aid Organizations, Draft GAO Report Says (Kaiser Network)
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.
(Avert)
Suggested Reforms:
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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.
House Approves PEPFAR Reauthorization Bill (Medical News Today)
Did Congress Forget About Women and Girls? (by Jamila Taylor, RH Reality Check)
PEPFAR and the Global AIDS Pandemic: The Reauthorization of PEPFAR - the President's Emergency Plan for AIDS Relief: Legislation to Combat Global AIDS Pandemic compromised by ideological constraints (Religious Coalition for Reproductive Choice)
AHF to Congress: Keep PEPFAR Funding Priority on AIDS Treatment (Business Wire)
Bush AIDS initiative gets bipartisan renewal: Concessions are made as both sides authorize $50 billion through 2013 to greatly expand the president's initiative (by James Hohmann, Los Angeles Times)
Indiana Activists to Senator Lugar: You Hold the Keys to Stop HIV and AIDS: Local Indiana AIDS and Health Advocates Deliver Giant Keys to Senator Lugar’s Office, Demand Critical Reforms to U.S. Global AIDS Programs (PEPFAR Reauthorization Action Team)
A Remedy for PEPFAR's Flaws: Comprehensive HIV Prevention (Population Action International)
Global HIV/AIDS: A More Country-Based Approach Could Improve Allocation of PEPFAR Funding
(GAO Report) (PDF)
Debate:
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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
George Bush's Aids relief plan is undermined by morality clauses (by Nina O'Farrell, The Guardian)
From the Right
PEPFAR ‘Compromise’ Abandons Successful Approaches to International AIDS Relief
(by Daniel P Moloney, Heritage Foundation)
Former Directors:
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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
- Table of Contents
- Overview
- History
- What it Does
- Where Does the Money Go
- Controversies
- Suggested Reforms
- Comments
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President’s Emergency Plan for AIDS Relief (PEPFAR)
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