On Wednesday, May 30th, President Bush called on the United States Congress to double current funding for the President’s Emergency Plan for AIDS Relief (PEPFAR).¹  PEPFAR, a 5-year, $15 billion initiative to combat global AIDS, Malaria and Tuberculosis is set to expire in 2008.  Although the current program funds activities in over 100 countries, the majority of PEPFAR’s $15 billion dollars has been spent on HIV programs in the 15 focus countries of Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.  The President’s request would extend PEPFAR for an additional five years at $30 billion.

In his request to Congress, the President asked for a continuation and expansion of PEPFAR programs, with a notable shift that increases emphasis on prevention.  PEPFAR’s current goals—often referred to as 2-7-10—are to support treatment for two million people, prevent seven million new infections, and care for 10 million people.  For the next five year authorization, the President proposed that funding should be used to avert an additional five million infections through prevention, support the two million currently on treatment, and provide treatment to an additional 500,000 individuals.  The President also included a specific request to support four million orphans and children through the care component of the program.²

Notably, the President proposed that PEPFAR begin to utilize a system of “Partnership Compacts” with funded countries. The Partnership Compact system is a method currently used by the U.S. Millennium Challenge Corporation (MCC).  The MCC oversees the Millennium Challenge Account, a development fund that provides assistance to countries that are selected on a competitive basis through a set of 16 indicators that assess a country’s effectiveness at ruling justly, investing in people, and fostering economic growth.³  The President did not mention in his announcement what type of indicators would be used under PEPFAR.  However, while speaking at the Global Health Council’s 34th International Conference on Global Health, Ambassador Mark Dybul, U.S. Global AIDS Coordinator, suggested that country laws related to gender equality and the protection of orphans and vulnerable children may be two of the indicators used to award Partnership Compacts.

President Bush failed to address several of the program areas that have caused concern among public health experts and advocates of sexual and reproductive health and rights, including PEPFAR’s abstinence-until-marriage funding earmark, the anti-prostitution pledge, and the provision allowing grantees to opt-out from providing HIV-prevention information they find morally objectionable.  The abstinence earmark, which requires that 33% of all prevention funds be spent on promoting abstinence-until-marriage as the primary means of preventing HIV transmission, has been cited by both the U.S. General Accounting Office and the Institute of Medicine as greatly hindering the ability of country teams to implement comprehensive prevention programs that address the epidemiological, social, and cultural needs of PEPFAR countries.⁴  Likewise, the anti-prostitution pledge requirement, which mandates that all grantees sign an oath promising not to do anything to promote prostitution or empower sex-workers, has limited implementers’ abilities and willingness to work with this high-risk population.

“Although we welcome the President’s commitment to expanding funding and continuing PEPFAR, his announcement raises several questions about the administration’s willingness to listen to the mounting scientific evidence about the ineffectiveness of the current program structure, particularly as it relates to the abstinence earmark,” said William Smith, vice president for public policy at SIECUS.  “Reauthorization of PEPFAR provides a tremendous opportunity for the United States not only to be the global leader in funding for HIV prevention but to also become the leader in providing comprehensive, evidence-based prevention programs that truly address the realities of those facing this devastating epidemic.”

For more information about PEPFAR and to see SIECUS’ recommendations for improving the program, see our PEPFAR Country Profiles at http://www.siecus.local/inter/pepfar/.

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