On July 24, 2008, the House of Representatives voted to accept a Senate bill reauthorizing the President’s Emergency Plan for AIDS Relief (PEPFAR). The President is expected to sign it as soon as possible, to much fanfare, because of the popular program’s effectiveness in its first five years. Even though PEPFAR was working according to plan, Congress nonetheless decided to “fix” the program. The subsequent changes in policy suggest that the results from PEPFAR’s second five years are likely to be more mixed.
The program’s successes were the result of sound design. The program focused on countries in which HIV/AIDS had reached the general population, mostly in sub-Saharan Africa and in the Caribbean. The aid consisted primarily in three things:
- Treatment: Providing life-saving medicine and associated medical care;
- Prevention: Supporting efforts to prevent new infections; and
- Palliative Care: Helping those suffering from AIDS in a variety of ways, with a special focus on children orphaned or otherwise affected by the epidemic.
The program included several features to ensure that the program stayed on mission:
- It set ambitious targets for each of the three categories above;
- It worked primarily through direct country partnerships, which guaranteed that assistance would be provided according to the successful U.S. strategic plan, rather than through multilateral AIDS organizations with different priorities;
- It included hard spending requirements and other spending guidelines to make sure that the program’s funds were spent in accord with its priorities. In particular, it required that 55% of all funds were spent on medical treatment, and that 33% of all prevention funds be spent on programs to promote abstinence before marriage and fidelity within marriage.
All of these features worked as intended in PEPFAR’s first five years, and should have been preserved. Going into this year’s negotiations, the objective should have been to reauthorize the program with only minimal changes. Instead, early legislative drafts dropped the prevention and treatment spending requirements, and diffused funding among many new activities, while tripling funding to $50 billion.
After hard-fought negotiations, the reauthorization bill now upholds the priority that PEPFAR has given to life-saving medical treatment. The reauthorization preserves the rule that over half of the money go to treatment, and it sets new ambitious targets for the number of people the program will treat.
In several other areas, however, the reauthorization breaks with the successful policies of its predecessor. The reauthorization scales back PEPFAR’s original commitment to the successful fidelity and abstinence programs, the only programs shown to be effective at preventing new HIV infections in sub-Saharan Africa’s generalized epidemic. The money that had been set aside for such programs has been freed up for other purposes–including programs to help prostitutes, drug users, and “men who have sex with men” manage their high-risk lifestyles through the “effective use” of condoms. The new bill also includes dozens of new items not directly related to HIV/AIDS and which duplicate other foreign aid programs, such as fighting hunger, promoting microfinancing, and supporting public school education.
One area in which the reauthorization improves on the original PEPFAR is in oversight of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, a UN-inspired multilateral program that pre-existed PEPFAR. The Global Fund lacked transparency and oversight, it had been racked by scandal and corruption, and it tended to work at cross-purposes to U.S. policy, even though the U.S. was its biggest contributor. The reauthorization requires significantly greater oversight over the Global Fund, marking a major improvement over the original law.
Since the reauthorization gives a lot of power to the bureaucrats running the program, the direction of the program is going to be determined largely by the Global AIDS Coordinator. A strong hand at PEPFAR’s helm would be able to preserve its focus on fighting AIDS in the world’s hardest-hit countries. The future of the program, then, depends heavily on whom the next administration chooses to head it, and on the vigilance with which Congress and interested parties monitor its operations.