The President's Emergency Plan for AIDS Relief (PEPFAR) has
received praise from across the political spectrum, both for its
principles and for its successes in fighting HIV/AIDS in some of
the world's poorest countries. Announced by President George W.
Bush in the 2003 State of the Union Address, PEPFAR fights HIV/AIDS
primarily in countries with generalized epidemics. These countries are
mostly, though not exclusively, in Africa.
PEPFAR's successful track record is a result of its focus on
- Treating those infected with HIV,
- Preventing new HIV infections, and
- Ensuring, through bilateral programs, that assistance is in
accord with U.S. policy.
Bills under consideration in the U.S. House and Senate (H.R.
5501 and S. 2731) represent significant departures from the current
law. These bills are hugely expensive, and would take existing U.S.
policy off its present, successful course.
Rather than simply reauthorizing PEPFAR, Congress seeks to
rewrite it, vastly expanding funding while removing structural
guidance that stipulates how it is apportioned. The structure of
the original PEPFAR law was essential for keeping it focused on its
prevention and treatment objectives. The congressional bills fail
to do this. Both more than triple the $15 billion cost of the
original program, yet neither adjusts the targets of the program to
reflect this increase. Instead, both propose to spend tens of
billions of dollars on projects not directly related to the fight
against HIV/AIDS. This proposed spending duplicates existing
programs, and diverts resources into social engineering projects at
odds with the values of many Americans.
To achieve PEPFAR's goal, policy must continue to be guided by
strong requirements that will direct funding toward effective
prevention and treatment strategies, rather than a diffuse set of
general development goals.
From Good Intentions to Good Policy: The Original Design
As proposed by President Bush in 2003, PEPFAR was built around
- Providing medicine to treat those who have HIV/AIDS in those
countries where the disease affects the general population,
- Funding local programs that aim to prevent new HIV infections,
- Providing palliative care to those suffering from HIV/AIDS,
including children orphaned as a result of HIV-infected
To justify its ambitious agenda and $15 billion price tag, the
original law used three structural features to keep the
program focused on its priorities: ambitious targets, spending
requirements, and an emphasis on bilateral agreements.
The law set ambitious targets for the number of people in its
treatment, prevention, and care programs. These goals were so
ambitious that they could not be met were the money lost to waste
or corruption, or simply diverted to other development activities
not directly providing treatment, care, or prevention of
The law also provided strong guidance so that the money would be
spent in proportion to the law's priorities. It did this in two
distinct but related sections of the law. The first, a "Sense of
Congress" resolution, declared that 55 percent of the funds should
be spent on medicine and treatment, 10 percent on orphans and
children affected by HIV, 20 percent on prevention programs, and 15
percent on palliative care. This gave the Global AIDS Coordinator
some idea how to balance the competing ends of the bill. The next
section, which actually allocated the funds, made the first two
elements of this nonbinding resolution into binding spending
requirements. Though it did not make binding that 20 percent be
spent on prevention, it did require that one-third of funds spent
on prevention be spent on programs that promote abstinence outside
of marriage and fidelity within it. By requiring that the money be
spent according to these specific percentages, rather than
authorizing particular dollar amounts, the law ensured that its
priorities would always be implemented in the same proportions,
even were Congress later to appropriate funds at amounts different
than the law had authorized.
The law required that PEPFAR deliver aid through bilateral
arrangements with each of the partner countries, rather than
through multilateral organizations. This procedural safeguard gave
the U.S. its best opportunity to make sure the funds were spent on
its priorities. It was consistent with the President's belief that
welfare and aid programs work best when they support civil society,
rather than supplant it with an international bureaucracy.
The bills in the House and the Senate undermine these
principles. They set goals too low for their budgets, remove most
of the spending mandates under the guise of "flexibility," and add
radical new agendas on which the unstructured and abundant funds
are to be spent.
Funding Should Fit Program Goals
In asking Congress to reauthorize PEPFAR for the next five
years, the Bush Administration sought to increase the budget by 100
percent to $30 billion over five years. However, the President
sought to increase its goals by a mere 20 percent to 70 percent
(depending on the criterion) over that period. Some Members of
Congress have complained that the Administration's goals are too
low to justify doubling the funding. They note that the program is
on track to meet its original goals of 2 million treated, 7 million
infections prevented, and 10 million people in care, while staying
close to its original budget of $15 billion-$18 billion. Given such
a history, the Administration's moderately increased goals should
require only moderately increased funding, particularly now that so
much early infrastructure has been laid in the focus countries and
some efficiencies of scale may be expected.
The Administration defends its lower goals on the grounds that
they are realistic given local infrastructure. It also notes that
its proposed goals represent a U.S. commitment to treat a number of
people equal to the commitment of all other aid-donor nations
combined. For the U.S. to treat more would not demand enough of the
world community. It also expresses doubts that in 2013 there will
be as many people to be treated in the focus countries as some of
its critics predict.
If the Administration's request is disproportionate to its
goals, the bills in the House and the Senate are even more so. Both
bills add an additional $20 billion to the President's request-more
than the entire first five years of the program-while barely
changing the Administration's underwhelming new goals. The
bills authorize up to $9 billion to fight other diseases common in
Africa (i.e., tuberculosis and malaria), and they authorize
billions more in contributions to the Global Fund to Fight AIDS,
Tuberculosis, and Malaria. After taking all these into account and
after assuming full funding of the bills' priorities, the
Congressional Budget Office concluded that the bills would still
have at least $15 billion left over. To date, no one in either
chamber has adequately explained what will be done with the "extra"
Congress could improve the fit between PEPFAR's funding and its
goals by making the latter more ambitious. For example, Senators
Tom Coburn (R-OK), Jon Kyl (R-AZ), Saxby Chambliss (R-GA), and
Richard Burr (R-NC) have introduced S. 2749, the Save Lives First
Act of 2008. This bill would set PEPFAR's treatment goal at
providing HIV/AIDS treatment and pre-treatment medical monitoring
to 7 million people, about one-half of them in sub-Saharan
Africa-an increase from 3 million in the House and Senate bills. It
would also reinstitute the provision in current law allocating at
least 55 percent of all PEPFAR funds to treatment. To treat that
many people is estimated to cost between $8.4 billion and $11.5
Higher goals require more money, but the draft bills' proposed
goals for treatment, prevention, and care are not by themselves
high enough to justify even the Administration's $30 billion price
tag. Activities extraneous to the original program are likely to
make up the difference. Whether Congress decides to increase
PEPFAR's treatment goals along the lines of the Save Lives First
Act, or whether it sticks with its current goals, a $50 billion
budget would still include extra billions likely to be spent on
purposes irrelevant to PEPFAR.
"Flexibility" Means Blank Check Worth
The original PEPFAR law contained binding requirements that 55
percent of all funds be spent on medical treatment, and 10 percent
on orphans and vulnerable children. It further required that 33
percent of the prevention funds be spent on abstinence and fidelity
programs. The spending restrictions (except for that
regarding orphans) have been criticized, both by NGOs that disagree
with U.S. priorities, and by bureaucrats who implement the
Both the House and the Senate strip out these funding
requirements for prevention and treatment. (The Senate bill even
strips out most of the nonbinding "Sense of Congress" resolutions
of the original law.) The House bill gives the Global AIDS
Coordinator complete control over 55 percent of the funding, and
the Senate bill writes a blank check for 90 percent of the funds.
Beyond this, the bills provide some vague guidance, but not hard
requirements, on how money will be spent. The Global AIDS
Coordinator is left to prioritize the multiple goals and agendas of
New Funds and Radical New Agendas
The proposed legislation expands the activities eligible for
PEPFAR funding well beyond the scope of the original program,
offering some clues about how its "extra billions" could be spent.
Some of these new agendas are duplicative of other foreign aid
programs and are irrelevant to fighting HIV/AIDS. For example, the
legislation promotes micro-finance, education, general health care,
and food security, among other new programs.
The bills also add a number of radical new agendas that change
the focus of PEPFAR, are at odds with the values of many Americans,
and trample on the cultural values of the partner countries. For
example, the bills before Congress make it U.S. policy to teach
safer drug-use techniques to injection drug users, and safer sex
techniques to prostitutes, injection drug users, and men who have
sex with men (MSM). The original law made no special provisions
for outreach to these populations, reflecting the fact that
infections among these risk groups are marginal to the generalized
epidemic in sub-Saharan Africa, as opposed to the
epidemics concentrated among these groups in countries such as
Russia and Thailand. Where it did mention them, the original law
sought to eradicate prostitution and to encourage injection drug
users to stop, recognizing that public health policy
should not enable such high-risk behavior but seek to end it. In a
clear policy reversal, the proposed legislation strips out the
original commitment to eradicate prostitution, and makes PEPFAR
dollars available to activities intended to make illicit drug use
"safer." Not coincidentally, it also allows PEPFAR to expand to
include more focus countries in Europe and Asia where the epidemics
are concentrated among prostitutes and drug users.
The bills would also commit the U.S. to altering the relations
between men and women in developing countries to reflect the values
of Western gender activists. The bills encourage U.S.
intervention on sensitive cultural topics that are not
scientifically demonstrated to have direct impacts on rates of
HIV/AIDS morbidity or mortality, but very well might offend those
whom U.S. policy is designed to help. Whatever merits these
provisions might have as aspirations, they were not in the original
bill, they would do nothing to stop the AIDS emergency in
sub-Saharan Africa, and they would commit the U.S. to agendas that
are likely to be unpopular in partner countries.
Conclusion: Compassionate Aid Is Effective
The three structural features of the original law-ambitious
targets, spending restraints, and an emphasis on bilateral
agreements-have helped PEPFAR stay on target. In the process, the
U.S. has created a strong precedent for combating HIV/AIDS in poor
countries with generalized epidemics. PEPFAR's commitment to
abstinence and fidelity programs, which was and is still ridiculed
by many activists and others, is now recognized to have a
measurable impact on HIV infection rates.
Rather than write a blank check to an unelected bureaucracy,
Congress should retain firm control over PEPFAR, which touches on
such delicate issues as sex, marriage, and the relations between
men and women. Congress should insist that PEPFAR retain its focus
on preventing new HIV infections and treating those infected with
HIV/AIDS. PEPFAR should not duplicate the efforts of America's
other aid programs. Lawmakers should insist that the funds
authorized and appropriated for PEPFAR will not support activities
irrelevant to fighting HIV/AIDS in countries with generalized
epidemics. Congress should authorize funds for PEPFAR at a level
appropriate to its central goals. If Congress wishes to fund other
activities, it should do so by increasing the budget for other
assistance programs rather than diffusing PEPFAR's focus.
America's PEPFAR partners are waiting on congressional
reauthorization before setting their own budgets, putting pressure
on Congress to move quickly. Hasty passage of the existing House
and Senate bills, however, would not allow them to make their plans
either, since so many funding decisions would still be left to the
discretion of the Global AIDS Coordinator in the next
administration, and subject to the annual appropriations process
and the lobbying of NGOs. With lives at stake, strategic efficiency
and effectiveness are paramount. Ambitious goals, clear spending
directives, and a reassertion of successful U.S. policies will
maintain the structure and proportion that have leveraged America's
generous intentions into a highly effective policy.
Daniel Patrick Moloney,
Ph.D., is Senior Policy Analyst in the Richard and
Helen DeVos Center for Religion and Civil Society at The Heritage
Generalized epidemics affect the general population,
including married women, children and others without unique risk
behaviors, as opposed to a concentrated epidemic, which is
narrowly concentrated in certain risk groups, such as drug users or
prostitutes. Public Law 108-25, Sec. 102 (a)(2) names 14 "focus
countries," 12 in sub-Saharan Africa and two in the Caribbean. In
July 2004, Vietnam became the 15th focus country, and it remains
the only one without a generalized epidemic.
Public Law 108-25, enacted May 27, 2003.
Statement of Ambassador Mark Dybul, U.S. Global AIDS Coordinator,
before the Senate Committee on Foreign Relations, October 24, 2007,
p. 10, at
2007/DybulTestimony071024pp.pdf (April 21, 2008).
Increases were from $15 billion to $30 billion; from 2 million
people treated to 2.5 million; from 7 million new infections
prevented to 12 million; and from 10 million people receiving care
to 12 million, including 5 million orphans and vulnerable
Both bills increase the Administration's treatment target from 2.5
million to 3 million people on anti-retroviral (ARV)
Heritage calculation assuming constant scaling up from 2 million
treated in 2008 to 7 million in 2013. Costs derived from two
estimates on total costs per patient year in sub-Saharan African
clinics. Estimates assume that cost of ARV medications are 2008
prices based upon the official Supply Chain Management System
catalog. For the higher of the two figures ($460 per patient year),
the labor and lab cost estimates come from Lori Bollinger and John
Stover, "Financial resources required to achieve universal access
to HIV prevention, treatment, care and support: Methodology for
Care and Treatment Interventions Methodological Annex - III,"
UNAIDS Report, August 20, 2007.
annex_iii_treatment_care_methodology_en.pdf (May 7,
2008). For the lower figure ($336 per patient year), see Julia E.
Aledort et al., "Primary Estimates of the Costs of ART Care
at 5 AHF Clinics in Sub-Saharan Africa" Rand Corporation/AIDS
Healthcare Foundation study (2006) at
Aledort%20costs%20of%20ART.pdf (May 7, 2008).
Surprisingly, there are no published official numbers from the U.
S. government on the total costs to treat patients with ARV
medicine in PEPFAR focus countries.
majority of the PEPFAR funds were directed towards ARV medicine, as
the largest fixed expense of PEPFAR. This is because prices for
anti-retroviral medicine are set by costs in the developed world,
and do not reflect the very low labor costs in sub-Saharan Africa.
Prevention and care programs are labor dependent and so are less
expensive in lower-income countries.
Statement of Ambassador Mark Dybul, U.S. Global AIDS Coordinator,
Prostitutes: H.R. 5501 § 102(2)(F), p. 36; S. 2731
§ 101(a), p. 17, and § 102(2)(F), p. 42.
Injection drug users: H.R. 5501 101 (a)(2), p.
20, § 102(2)(F), p. 36, and § 301 (a)(5)(b)(2), pp.
74-75; S. 2731 § 102(2)(F), p. 42, and § 301 (e)(2)(B),
p. 85; Men who have sex with men: H.R. 5501 § 101
(a)(2), p. 21, § 102(2)(H), p. 37, and § 301 (a)(4)(A),
p. 59; S. 2731 § 301(c)(1)(H), p. 66, and § 301(c)(3)(C),
James D. Shelton, "Ten myths and one truth about generalised HIV
epidemics," The Lancet, Vol. 370, pp. 1809-1811, December
Public Law 108-25, §101 (a)(4).
H.R. 5501 §102(2)(D)(iii), p. 35; S. 2731
§102(2)(E)(iii), p. 41 and §102(2)(F), pp. 41-42. See
Moloney, "PEPFAR 'Compromise' Abandons Successful Approaches to
International AIDS Relief."
H.R. 5501 §313(a) p. 111.