President's Emergency Plan for AIDS Relief making significant contributions to the fight against HIV/AIDS pandemic

The President's Emergency Plan for AIDS Relief is making significant contributions to the fight against the HIV/AIDS pandemic, but it needs to strengthen its prevention efforts and develop programs that ensure long-term sustainability in focus countries, according to a report released Friday by the Institute of Medicine and the National Research Council, the Washington Post reports (Brown, Washington Post, 3/31).

PEPFAR directs an authorized $15 billion over five years for HIV/AIDS and tuberculosis primarily to 15 focus countries and provides funding to the Global Fund To Fight AIDS, Tuberculosis and Malaria. President Bush in February signed a $463.5 billion spending resolution (HJ Res 20) for fiscal year 2007 that includes a $1.3 billion increase for international HIV/AIDS and TB programs. The resolution brings the total for PEPFAR in FY 2007 to $4.5 billion (Kaiser Daily HIV/AIDS Report, 2/16). For the report, the IOM panel interviewed hundreds of people and sent delegations to 13 of the 15 PEPFAR focus countries. The panel did not address how the PEPFAR model of foreign aid compared with other models. In addition, because the audit was conducted soon after many PEPFAR programs were launched, the review focused on implementation rather than long-term results. According to the IOM report, PEPFAR through September 2006 purchased antiretroviral drugs for 822,000 people in the program's focus countries. Of those receiving treatment access during that time period, 61% were women and 9% were children, the report found. PEPFAR also pays for 165,000 people's antiretroviral drugs in other developing countries, according to the report. PEPFAR money has been used to provide 500,000 pregnant women with access to short courses of treatment to help prevent vertical HIV transmission. According to program officials, this strategy has prevented about 100,000 new HIV cases. In addition, PEPFAR is helping support 4.7 million people from families affected by HIV/AIDS, including two million orphans, the Post reports (Washington Post, 3/31).

Restrictions, Recommendations
According to the IOM, PEPFAR should shift its "primary focus" from providing emergency relief to "building the capacity of affected nations to sustain their fight against HIV/AIDS over future decades." The report said that a shift in programming should include "expansion and better integration of prevention, treatment, and care services for all at-risk populations; increased attention to factors that raise the vulnerability of women and girls; and greater emphasis on ensuring that U.S.-sponsored activities are in tune with other anti-HIV initiatives in each country" (National Academy of Sciences release, 3/30). The panel highlighted PEPFAR regulations it said were "hindering" to the program, including the need for separate FDA approval of antiretroviral drugs that already have received prequalification from the World Health Organization, as well as PEPFAR's budget allocation requirements, including for abstinence-until-marriage programs (McNeil, New York Times, 3/31). By law, at least one-third of HIV prevention funds that focus countries receive through PEPFAR must be used for abstinence-until-marriage programs (Kaiser Daily HIV/AIDS Report, 9/8/06). According to the Post, the report found that the abstinence-funding requirement has "greatly limited" the ability of countries receiving PEPFAR funding to design their own programs. Although the panel said that no public health workers in the field support dropping PEPFAR's abstinence component, the "committee has been unable to find evidence ... that 33% is the appropriate allocation for such activities." The panel added that the debate over the ABC prevention strategy -- which stands for abstinence, be faithful and use condoms -- has taken focus away from other risky behaviors, including alcohol use and violence against women, according to the Post.

Reaction
"In its first two years, PEPFAR has demonstrated what many doubted could be done, namely that HIV/AIDS services can be scaled up rapidly in countries with severe resource constraints and other daunting obstacles," IOM Committee Chair Jaime Sepulveda, presidential chair and visiting professor at the University of California-San Francisco, said, adding, "These accomplishments are just a start, however. For continued progress toward PEPFAR's five-year targets and ultimate goals, U.S. efforts should transition from focusing on emergency relief to long-term strategic planning and capacity building. And they should ensure that countries can direct resources where they are needed most" (NAS release, 3/30). Ambassador Mark Dybul, who serves as the U.S. global AIDS coordinator and administers PEPFAR, said PEPFAR "very much welcome[s] the report. No one's got all the right answers." He said that report's emphasis on increasing prevention, building up the supply of health care workers and creating more sustainable systems support the Bush administration's goals for the program (Reichard, CQ HealthBeat, 3/30). Paul Zeitz, executive director of the Global AIDS Alliance, said the abstinence-only spending requirement "really created confusion on how to do effective prevention," adding that he supports eliminating the requirement and allowing countries to decide how to spend money on prevention (Donnelly, Boston Globe, 3/31). Dybul said that the abstinence-spending requirement applies only to PEPFAR's overall prevention budget and that countries are not required to spend funds on abstinence messages if they have low levels of sexual HIV transmission. He added that in countries with high rates of heterosexual transmission of the virus, evidence has shown that ABC is the most effective strategy. In addition, Dybul said that PEPFAR's drug review process effectively provides focus countries with access to the least expensive antiretrovirals available worldwide (Washington Post, 3/31). Ruth Macklin, a panel member and bioethicist at the Albert Einstein College of Medicine, called the restrictions "hamstrings or shackles," adding, "There's a feeling that when reporting to Congress you have to pussyfoot around a bit and show respect for the legislation" (New York Times, 3/31).

The report is available online.