Global AIDS programs (U.S.)

President's Emergency Plan For AIDS Relief
The President's Emergency Plan For AIDS Relief was a commitment of $15 billion over five years (2003–2008) from President George W. Bush to fight the global HIV/AIDS pandemic. As the largest international health initiative ever initiated by one nation to address a single disease, the program sought to provide antiretroviral treatment (ART) to 2 million HIV-infected people in resource-limited settings; to prevent 7 million new infections; and to support care for 10 million people (the "2-7-10 goals"). As of September 2007, the program estimates that it has supported the provision of ART to approximately 1,445,500 people. Ambassador Mark R. Dybul has been the U.S. Global AIDS Coordinator since July 2006.

Authorizing legislation
The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (or the Global AIDS Act) established the State Department Office of the Global AIDS Coordinator to oversee all international AIDS funding and programming.

Program details
PEPFAR prioritizes resource-limited countries with high HIV/AIDS prevalence rates. The 15 current "focus countries" include Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. While most of the $15 billion for this program will be spent on these focus countries, $4 billion is allocated for programs elsewhere, and for HIV/AIDS research. (The other $1 billion is contributed to the Global Fund, see below). See the PEPFAR World Wide Activities Map

Prevention
To slow the spread of the epidemic, PEPFAR supports a variety of prevention programs: the ABC approach (Abstain, Be faithful, and correct and consistent use of Condoms); prevention of mother to child transmission (PMTCT) interventions; and programs focusing on blood safety, injection safety, secondary prevention ("prevention with positives"), counseling and education.

20% of the PEPFAR budget is spent on prevention, with the remaining 80% going to care and treatment, laboratory support, antiretroviral drugs, TB/HIV services, support for orphans and vulnerable children (OVC), infrastructure, training, and other related services. Of the 20% spent on prevention, one third of the budget must be spent on abstinence-only campaigns, a controversial requirement (see below). The other two thirds is alloted for the widespread array of prevention interventions described above, including counseling, education, injection safety, blood safety and condoms.

Treatment
In addition to providing antiretroviral therapy (ART), PEPFAR supports prevention and treatment of opportunistic infections, as well as services to prevent and treat malaria, tuberculosis, waterborne illness, and other acute infections. PEPFAR supports training and salaries for personnel (including clinicians, laboratorians, pharmacists, counselors, medical records staff, outreach workers, peer educators, etc), renovation and refurbishment of health care facilities, updated laboratory equipment and distribution systems, logistics and management for drugs and other commodities. This is intended to ensure the sustainability of PEPFAR services in host countries, enabling long-term management of HIV/AIDS.

PEPFAR-supported care and treatment services are implemented by a wide array of US-based and international groups and agencies. Among the largest "Track 1.0" (treatment) partners are Harvard University, Columbia University's International Center for AIDS Care & Treatment Programs (ICAP), the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), and the  Relief consortium of Catholic Relief Services.

Care
For those who have already been infected with HIV/AIDS, PEPFAR provides HIV counseling, resources for maintaining financial stability, etc. Special care is given to orphans and vulnerable children (OVCs) and services are provided that meet the unique needs of women and girls, including victims of sex trafficking, rape, abuse, and exploitation. Fact sheet on Gender and HIV/AIDS Finally, the Emergency Plan works closely with country leaders, military groups, faith-based organizations, etc. in an attempt to eliminate stigma.

Programs
PEPFAR establishes bilateral programs in host countries and also works closely with multilateral partners, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the United Nations program on AIDS (UNAIDS), as well as local Faith-Based Organizations. PEPFAR also endorses the international principles of the "Three Ones": — one national plan, one national coordinating authority, and one national monitoring and evaluation system in each of the host countries in which organizations work.

Accountability
PEPFAR reports to Congress on an annual basis, providing programmatic and financial data as required by law. The Second Annual Report to Congress on the President's Emergency Plan for AIDS Relief is available on the official PEPFAR website, as are more specific reports, financial information and other information.

PEPFAR is exempt from the Mexico City Policy, also known as the "global gag rule." 

Criticism
Public health experts and nonprofit organizations have questioned the tactics and effectiveness of PEPFAR programs, including requirements mandating that one-third of prevention spending be directed towards abstinence-only programs.

According to its critics, PEPFAR is influenced too heavily by American political and social groups with "moral" rather than public health agendas. PEPFAR Watch, a website run by the Center for Health and Gender Equity and Health GAP, notes that the legislation behind PEPFAR “contains several restrictions, including those on funding for prevention activities and on organizations working with commercial sex workers.” PEPFAR has also refused to fund effective yet “taboo” safe needle exchange programs to prevent HIV transmission among drug users.

On July 2, 2003, President George W. Bush selected former Eli Lilly and Company chief executive Randall L. Tobias as the Global AIDS Coordinator in charge of PEPFAR.

"This decision is another deeply disturbing sign that the president may not be prepared to fulfill his pledge to take emergency action on AIDS," noted Paul Zeitz, executive director of the Global AIDS Alliance. "It raises serious questions of conflict of interest and the priorities of the White House." Several said they feared that Tobias would be "the fox in charge of the henhouse," as Kate Krauss of the AIDS Policy Project put it. |Ambassador Mark Dybul replaced Tobias as U.S. Global AIDS Coordinator on August 11, 2006.

Bush's AIDS project under Tobias has been called "extremely flawed" by critics. Tobias later become the Administrator of the United States Agency for International Development (USAID), where he held the rank of Ambassador. Tobias, a proponent of abstinence as Global AIDS Coordinator, ironically resigned from the United States Department of State over a pay for sex scandal in April 2007.

Another early criticism was that PEPFAR initially supported only branded antiretroviral drugs instead of cheaper generic versions; this has become less of an issue since distribution of generic drugs began in late 2005.

2008 funding reauthorization
The Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 is a continuation and expansion of the original PEPFAR funding mechanism. Under the proposal, additional funding would be providing to fight the spread of diseases and help rehabilitate affected communities.

House version


On April 2, 2008, the House approved a $50 billion reauthorization for the program. The bill contained $20 billion more in funding than originally proposed by President Bush. In addition to $9 billion for tuberculosis and malaria treatment and prevention, the legislation would also provide aid for:


 * Improving access to drinking water
 * Training for health care workers
 * Food assistance for those impacted AIDS

The reauthorization does not retain the original limitations on funding that required some prevention spending be used to promote abstinence.

The House voted 308 - 116 to approve the reauthorization.



Senate version


Work on the Senate version of the expanded Global AIDS package was delayed by a group of seven Republican Senators, including Sens. Tom Coburn (Okla.), Jeff Sessions (R-Ala.) a Minority Whip Jon Kyl (R-Ariz.). The Senators were upset they had been kept out of negotiations between the Senate Foreign Relations Committee leadership and the White House over the funding.

Following the delaying tactics, a deal was struck to allow the legislation to move forward. At face value, the Senate legislation appears identical to the bill passed earlier by the House. However, an amendment attached to the Senate version earmarks $48 billion for the global AIDS fight. The $2 million difference would be spent on domestic initiatives, including "American Indian health care, law enforcement and clean water programs."

Other notable differences include:
 * A provision lifting the congressional ban on immigrants and visitors who are infected with HIV/AIDS from entering the country.
 * Requiring more than half of the funding go toward treatment and care.
 * Tying the use of some funding to abstinence education.

Senate amendments rejected
The Senate took up its version of the bill in July 2008.

Among the amendments considered were:


 * An amendment sponsored by Sen. Jim DeMint (R-SC) to "limit the countries to which Federal financial assistance may be targeted under this Act." It was tabled by a vote of 70-24.




 * An amendment sponsored by Sen. John Cornyn (R-Texas) to "establish a bipartisan commission for the purpose of improving oversight and eliminating wasteful government spending under the President's Emergency Plan for AIDS Relief." It was rejected by a margin of 63-32.




 * An amendment sponsored by Sen. Judd Gregg (R-NH) to "strike the provision requiring the development of coordinated oversight plans and to establish an independent Inspector General at the Office of the Global AIDS Coordinator." It was rejected by a margin of 51-44.




 * An amendment sponsored by Sen. Jim DeMint (R-SC) to "reduce to $35,000,000,000 the amount authorized to be appropriated to combat HIV/AIDS, tuberculosis, and malaria in developing countries during the next 5 years." It was rejected by a margin of 64-31.



Senate passage
On July 17, the Senate incorporated S. 2731 into the House's H.R. 5501 as an amendment. It then passed the amended version of H.R. 5501 by a vote of 80-16.



House gives final passage to bill
On July 24, the House passed Senate's version of H.R. 5501.



The bill was signed into law on July 30, 2008.

External sites

 * Official PEPFAR website
 * Office of the Global AIDS Coordinator
 * AIDS.gov - The U.S. Federal Domestic HIV/AIDS Resource

External articles

 * Five Year Strategy Fact Sheet
 * Funding Fact Sheet
 * Funding Information for FY2006
 * A USA government fact sheet on the project