PEPFAR "Compromise" Abandons Successful Approaches to InternationalAIDS Relief

Report Public Health

PEPFAR "Compromise" Abandons Successful Approaches to InternationalAIDS Relief

March 11, 2008 11 min read
Daniel Moloney
McKenna Senior Fellow in Political Economy
Daniel Patrick Moloney is a Senior Policy Analyst at the DeVos Center...

On February 27, 2008, by voice vote, the House Foreign Affairs Committee passed H.R. 5501, a bill to reauthorize the President's Emergency Plan for AIDS Relief (PEPFAR). First proposed by President Bush in 2003, the initiative aims to fight HIV and AIDS in countries with generalized epidemics, primarily in Africa. The Senate Foreign Relations Committee is scheduled to consider its own reauthorization bill (S. 2731), the early drafts of which have been substantially similar to the House version.

These attempts at reauthorization represent significant departures from the current law, are hugely expensive, and would take U.S. policy off-course as it seeks to combat HIV/AIDS in countries with generalized epidemics.

As it considers reauthorization, Congress should seek to build on the successful foundation laid by the original PEPFAR by preserving its emphases on (1) treating those who have HIV; (2) preventing new HIV infections; and (3) ensuring, through bilateral programs, that the assistance is in accord with U.S. policy priorities.

Losing Focus on HIV/AIDS

The President describes the current initiative as "the largest commitment by any nation to combat a single disease in human history," namely HIV/AIDS.[1] The "compromise" bill, however, tries to deal with numerous social ills of the developing world: violence against women,[2] inadequate economic opportunities,[3] malnutrition,[4] and poorly functioning legal frameworks,[5] to name a few.

Further mission creep is evident in the bill's call for spending on teachers in public schools;[6] "life-skills training;"[7] research at U.S. agricultural colleges on food security;[8] and, through the International Monetary Fund, increased government spending worldwide on health care generally.[9] Finally, it requires U.S. policy to promote Western-style feminism and to require "changes in male attitudes and behavior...that support and foster gender equality."[10]

The bill could be characterized as a multi-purpose foreign aid bill that tries to address the root causes of a variety of problems loosely related to human sexuality. This detracts from the law's stated goals and makes it a less effective instrument for combating HIV/AIDS.

Losing Focus on the Generalized Epidemic in Africa

PEPFAR has been directed primarily at sub-Saharan Africa, both in the President's rhetoric[11] and in the design of the law.[12] Africa was the original focus because of its generalized HIV/AIDS epidemic. Generalized means that the epidemic (defined as when the average infected person is likely to infect more than one other person[13]) reaches the general population. Many countries have a concentrated HIV/AIDS epidemic; i.e., one that is concentrated among those in particular subpopulations who engage in high-risk behaviors--intravenous drug users who share needles, prostitutes, and men who have sex with men--but does not reach the population at large.[14] Other than a few small countries around the Caribbean such as Haiti, the Bahamas, and perhaps Guyana, the only countries to have experienced generalized epidemics are in sub-Saharan Africa.[15]

The original law was an emergency commitment to help those countries with generalized epidemics. As President Bush explained, there was "a severe and urgent crisis" in "whole countries in Africa." The goal of the President's "Emergency Plan for AIDS Relief" was "to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean."[16] The program was not intended as a generic program to fight AIDS wherever it might be found, but as a targeted program to "turn the tide" against a particular humanitarian crisis.

In another example of mission creep, the House bill expands the scope of the initiative to include Europe, Asia, and any country in which HIV infection rates are high among the subpopulations of prostitutes, drug users, and men having sex with men.[17] These regions do not have the same battle with a generalized AIDS epidemic as do the original focus countries in sub-Saharan Africa and the Caribbean.

Losing Focus on Medical Treatment

In announcing PEPFAR during his 2003 State of the Union Address, President Bush emphasized the importance of treating those already infected with HIV/AIDS. The Administration argued that the drop in the price of medicines, especially anti-retroviral (ARV) treatment, had made it financially possible for the developed world to make an important difference in the humanitarian crisis in sub-Saharan Africa. The President pledged U.S. assistance to help close the gap between the millions of people who needed ARV medicines and the mere thousands who could obtain it.[18]

Current law requires that 55 percent of the $3 billion annual PEPFAR budget be spent on the medical treatment of 2 million HIV patients so as to extend their lives, prevent their children from becoming orphans, and reduce their infectivity.[19] In H.R. 5501, this provision is stripped out; there is no requirement that money be spent on medicine rather than on the bill's other priorities (e.g., legal services for victims of violence, advocating better laws regarding inheritance, research into vaccines unrelated to AIDS, etc.).

Some claim that this requirement is no longer necessary because lower prices for ARV drugs have freed money for other projects. If that were true, one would expect the bill to have ambitious goals to treat more people with each dollar spent. Yet the contrary is the case: The bill more than triples the PEPFAR budget but increases its treatment goals by only one-half.[20] Meanwhile, as more people become infected with HIV, the demand for such life-saving treatment continues to grow.

Losing Focus on Effective Prevention

Current law directs 20 percent of all PEPFAR spending to programs that are designed to prevent people from getting AIDS in the first place.[21] One-third of that 20 percent must be spent on programs that promote abstinence until marriage and fidelity within marriage. Such programs have been shown to reduce the rate of HIV infection among the general population in sub-Saharan Africa.[22]

The generalized HIV/AIDS epidemics in sub-Saharan Africa are primarily the result of high-risk sexual behaviors among the general population. James Chin, one of the world's leading AIDS epidemiologists, states that "extensive epidemic sexual HIV transmission can occur only in those populations where there are large numbers of persons who have unprotected sex with multiple and concurrent sex partners (traditionally defined as sexual promiscuity)."[23] Estimates indicate that 20 percent-40 percent of sexually active adults in some sub-Saharan countries are promiscuous in this way.[24] Programs that discourage such behavior and promote fidelity within marriage have been shown to be the most effective in preventing the spread of HIV in that region.[25]

The House bill makes sweeping negative claims about marriage[26] and strips out the requirement that one-third of prevention funds be spent on programs that promote abstinence before marriage and fidelity within it. The phrase "abstinence-until-marriage" has been eliminated from the bill, and there is no money set aside specifically for this type of program. The bill would replace this requirement with a vague promise to fund undefined "behavioral change programs" in a "meaningful and equitable way."[27] Abstinence-until-marriage programs could fall under this strategy, but there is no requirement that they be funded.


Even as it increases PEPFAR funding to $50 billion, the House reauthorization bill loses its focus on delivering emergency assistance to "turn the tide" on a specific humanitarian crisis in specific countries. Rather than building on the strategies that have been shown to control and even roll back the HIV/AIDS epidemic, the bill has become a $50 billion slush fund promoting a variety of causes that are not directly relevant to that goal. The bill removes the provisions in current law that guarantee funding for programs that deliver life-saving medicines and that slow the growth of generalized AIDS epidemics. The early drafts of the legislation, which the Senate Foreign Relations Committee appears set to consider, preserve these troublesome features of the House bill.

"A tremendous possibility [is] within our grasp," said President Bush in proposing the original PEPFAR. "Seldom has history offered a greater opportunity to do so much for so many."[28]Millions of HIV patients lack access to treatment. U.S. policy has helped millions already, and, in the President's words, "[W]e can bring healing and hope to many more." For the U.S. to continue to "lead the world in sparing innocent people from a plague of nature,"[29] Congress must heed the President's call to "maintain the principles that have changed behavior and made this program a success."[30]

Daniel P. Moloney is Senior Policy Analyst in the DeVos Center for Religion and Civil Society at The Heritage Foundation.



[1]"President Bush Announces Five-Year, $30 Billion HIV/AIDS Plan," Office of the White House Press Secretary, May 30, 2007, at (March 4, 2008).

[3]Sec. 301(a) of H.R. 5501, p. 66.

[4]Sec. 301(c) of H.R. 5501, pp. 76-86.

[5]Sec. 313(a) of H.R. 5501, p. 112.

[6]Sec. 301(a) of H.R. 5501, pp. 65-66.

[7]Sec. 101(b)(2)(A) of H.R. 5501, p. 23.

[8]Sec. 301(c) of H.R. 5501, p. 83.

[9]Sec. 501 of H.R. 5501, p. 127.

[10]Sec. 313(a) of H.R. 5501, p. 111.

[11]President George W. Bush, State of the Union Address, January 28, 2003, at (March 4, 2008).

[12]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 focus country without a generalized HIV/AIDS epidemic.

[13]For the technical epidemiological definition of "epidemic," see James Chin, The AIDS Pandemic (Oxford: Radcliffe Publishing, 2007), p. 60.

[14]Ibid., p. 2. See also James Chin, "Myths and Misconceptions of the AIDS Pandemic," San Francisco Chronicle, March 11, 2007, at (March 4, 2008).

[15] Chin, The AIDS Pandemic.

[16]President Bush, State of the Union Address, January 28, 2003.

[17]Sec. 102(2)(D)(iii) of H.R. 5501, p. 35.

[18]President George W. Bush, State of the Union Address, January 28, 2003.

[19]Public Law 108-25, Sec. 403(a).

[20]Where the original PEPFAR set out to treat 2 million people with ARV drugs on an overall budget of $15 billion, the compromise bill asks for an additional $35 billion but seeks to treat only an additional 1 million people over five years. Compare Sec. 301(a)(2) of H.R. 5501, pp. 51-52, with Sec. 402 (a)(3) of Public Law 108-25.

[21]Sec. 402 (b)(3) of Public Law 108-25.

[22]Public Law 108-25, Sec. 403(a): "For fiscal years 2006 through 2008, not less than 33 percent of the amounts appropriated...for each such fiscal year shall be expended for abstinence-until-marriage programs."

[23]Chin, The AIDS Pandemic, p. 1. Emphasis in original.

[24]Ibid., pp. 64, 78-79. See also Stèphane Helleringer and Hans-Peter Kohler, "Sexual Network Structure and the Spread of HIV in Africa: Evidence from Likoma Island, Malawi," AIDS 2007, Vol. 21, No. 17 (2007).

[25]Rand L. Stoneburner and Daniel Low-Beer, "Population-Level HIV Declines and Behavioral Risk Avoidance in Uganda," Science, Vol. 304, No. 5671 (April 30, 2004), pp. 714-718. See also "The ABCs of HIV Prevention," USAID fact sheet, at (March 6, 2008); Theo Smart, "PEPFAR: Epidemiologist Presents a Scientific Rationale for Focusing on Abstinence & Being Faithful in Sub-Saharan Africa," AIDSMAP, July 25, 2006 at (March 6, 2008).

[26]Sec. 2 of H.R. 5501, pp. 6-10.

[27]Sec. 403(a) of H.R. 5501, pp. 117-118.

[28]President Bush, State of the Union Address, January 28, 2003.






Daniel Moloney

McKenna Senior Fellow in Political Economy