The President’s Emergency Plan for AIDS Relief (PEPFAR), set up by the Bush administration in 2003, has been touted as the most ambitious public health programme to tackle HIV & AIDS in the world. Since the Obama administration took over in 2008, the administration has been reworking the mechanics of the project to include bilateral country partnership agreements and linkages with the Global Fund and other large multilateral health organisations. These changes have been described as more pragmatic and efficient than the original PEPFAR. While some have welcomed such collaborative efforts, others have expressed concern that since PEPFAR is now part of a broader Global Health Initiative (GHI), its efforts have been co-opted and the potential for its effectiveness, reduced. More specifically, it has moved from being defined by the ‘E’ for emergency in its name to a post-emergency programme focused on strengthening health systems and prevention efforts.

This paper briefly explores two key changes in the PEPFAR programme since Obama took office and explores some of the alleged effects the programme is having on HIV & AIDS programming in Africa. It specifically focuses on the shift from US-driven to bilateral country relationships as well as the move to multilateral cooperation and the implications of these reallocations. The move to a sustainability focus and country-lead approach presents some pressing challenges for both donors and African countries in their pursuit to provide treatment, care and prevention options.

Changes since 2008: PEPFAR & the Global Health Initiative

Shortly after Obama took office he proposed the Global Health Initiative (GHI) which came with a US$ 63 billion promise (over 6 years) to help partner countries improve health outcomes through strengthened health systems. PEPFAR became the flagship programme of the GHI. Since Obama’s unveiling of the GHI, PEPFAR funding levels have been ‘flat-lined’, meaning they are no longer increasing at the rate that they were increasing in the first 5 years of the programme between 2003-2008.⁽²⁾ This flat-line carries implications for how far a PEPFAR dollar can go towards treatment, care and prevention. This is PEPFAR’s biggest change since 2008 - moving from the initial vision of providing direct ‘emergency’ relief to countries struggling to put people onto anti-retroviral treatment by bypassing local governments as quickly as possible, to a sustainable, integrated response for the delivery of health care as a whole.⁽³⁾ Although the programme has had high levels of success in terms of treatment, the number of new infections is drastically outnumbering the number of people receiving treatment, which has called into question its effectiveness on prevention efforts.⁽⁴⁾

The shift from U.S. driven to bilateral country ownership

The 2008 reauthorisation of PEPFAR and its inclusion in the GHI created new dimensions to the implementation of the programme. PEPFAR shifted away from the “15 focus country” approach to the development of a Partnership Framework model for regions and countries, which significantly broadened its reach. This was done with the aim of ensuring long-term sustainability and country ownership. PEPFAR now aims to work in partnership with host nations to support treatment, prevention and care for millions of people in more than 85 countries through bilaterally funded programming.⁽⁵⁾

Although country ownership is not a new idea, it is a popular one in light of PEPFAR’s new mission of strengthening health systems, cutting costs and ensuring sustainability. Country ownership means that partner countries contribute a greater share of financing and take over implementation, supported with technical assistance by PEPFAR and other multilateral partners.⁽⁶⁾ In an event on country ownership held by the Center for Global Development (CGD) in June 2010, it was highlighted that there are multiple challenges in achieving country ownership and maintaining success over the long term (beyond 2014).⁽⁷⁾ During the event, the U.S. government was criticised for failing to communicate and establish definitions or concrete guidelines for the implementation of country ownership within partnership agreements.⁽⁸⁾

Since this particular event, a comprehensive document entitled “Efforts to Align Programmes with Partner Countries’ HIV & AIDS Strategies and Promote Partner Country Ownership” was released in September 2010 that includes a set of definitions and guidelines relating to partnership agreements.⁽⁹⁾ The key recommendation stated that, “The Secretary of State directs the Office of the Global AIDS Coordinator to develop and disseminate a methodology for establishing indicators needed for baseline measurements of country ownership prior to implementation of partnership frameworks”. Given that partnership frameworks were established during the reauthorisation in 2008 and the implementation methodologies and guidelines have not taken full shape yet, this could point to some logistical setbacks for bilateral efficiency and clarity which may pose problems for PEPFAR’s new approach.

Multilateral cooperation and AIDS ‘entitlement’

The ‘revamped’ PEPFAR, under the GHI, points to multilateral efforts as essential in achieving long-lasting success. The redirection and reallocations certainly impact direct HIV & AIDS care but PEPFAR is attempting to find efficiencies in their programmes to get more for less, without sacrificing quality. So far, this has included strategies like switching to generic drugs where possible.⁽¹⁰⁾ It also involves a transition to partnering with organisations like the Global Fund to Fight AIDS, Tuberculosis, and Malaria to “expand collaboration and ensure consistency and efficiency of programming.”⁽¹¹⁾

Multilateral funding tends to be more stable over the long term, and the Global Fund model, which relies on recipient country leaders to plan and implement its programmes, is particularly suited to facilitate a more sustainable trajectory. This dimension has received both criticism and praise. On the one hand, some believe that since the introduction of multilateral cooperation the global health battle against HIV & AIDS has been diluted and progress on ARV dispensation, drastically altered. On the other hand, other global health circles maintain that the HIV & AIDS emergency occurred a decade ago and see now as a time to employ a broader, more sustainable approach that would see patients and donor countries moving away from their reliance on the United States.⁽¹²⁾

Many factors have caused this shift. Firstly, budget restraints in the U.S mean that congress is under mounting pressure to stop steady financial increases and to do more, with less. Secondly and thirdly, as the gap expands between the number of people who need treatment and the number getting it is combined with a mounting call to move away from "AIDS exceptionalism"— greater funding for AIDS programmes at the expense of overall health resources - a shift to a ‘pragmatic’ approach is inevitable.⁽¹³⁾ Still, there are tangible signs of reduced funding having effects on treatment rollout. Reportedly, a memo sent by the US Centre for Disease Control and Prevention advised PEPFAR partners on flat-lined anti-retroviral budgets for 2010 and 2011. It advised that, given the predicted increase in ARVs needed, “new patients should not be enrolled unless their treatment could be paid for, despite no increased funding from PEPFAR.”⁽¹⁴⁾ While many convincingly argue that there is still an ‘emergency’ in terms of AIDS treatment needs, it seems that ‘pragmatism’ is coming up against this sense of urgency. This tension continues to surface between AIDS treatment advocates and PEPFAR programming objectives.

The urgency of prevention efforts in light of treatment costs

In order to heed these concerns relating to increasing treatment costs, the obvious focus falls on scaling up prevention efforts to mitigate increasing treatment expenditures in the future. As PEPFAR initially focussed on treatment, it does not carry a good reputation with regard to preventing the transmission of HIV. According to PEPFAR’s published reports, “for every two patients put on antiretroviral drugs today, five others contract HIV.”⁽¹⁵⁾ Therefore, multilateral linkages with the Global Fund, the World Health Organisation and other non-governmental organisation partners are as important as ever in preventing the transmission of the virus so that treatment funding does not escalate to a point of no return.

Furthermore, Mead Over, a senior fellow at the CGD, argues that the United States has unwittingly created a global “AIDS entitlement” to U.S.-funded AIDS treatment, which could grow to as much as US$ 12 billion a year by 2016.⁽¹⁶⁾ He suggests that AIDS treatment financing should be conditional based on country-level success in both treatment adherence and prevention outreach.⁽¹⁷⁾ Mead Over states that magnifying the outcomes of prevention interventions by locating high-risk communities and targeting them with context specific prevention programmes is the only way to do this.⁽¹⁸⁾

Implications & concerns for African partner countries

There is no doubt that PEPFAR provides an unprecedented amount of support to AIDS affected countries in Africa. In many sub-Saharan African countries, PEPFAR provided between 40% and 95% of the AIDS treatment response between 2003 and 2008.⁽¹⁹⁾ Pragmatists argue that given the variety of health challenges in many sub-Saharan countries, it is wise to move to a broader health systems approach. This way, resources are directed towards childhood diseases and reducing maternal mortality because these are more cost-effective than fighting HIV & AIDS. However, opponents to this point out that children will be saved only to die later of AIDS.⁽²⁰⁾ This highlights both the challenges facing African countries in terms of prevention efforts and incidence rates. While it could be safe to say that AIDS treatment advocates do not necessarily see the health systems approach as a negative thing in and of itself, the problem arises when that approach overrides increases in treatment funding and ARV rollout. Given the nature of the virus, it is impossible to ”treat ourselves out of this epidemic”⁽²¹⁾, which puts treatment advocates and funding managers in an adversarial position as ARV funding must increase to keep people living with the virus alive.

In contrast to the disease-specific funding of PEPFAR pre-2008 which was criticised for being fragmented and inefficient, it would be tough to deny the value of PEPFAR’s new approach since the GHI’s primary focus and funding allocation is towards AIDS efforts while promoting a more integrated government-wide strategy.⁽²²⁾ While these developments look promising, the CGD notes that a ‘key ingredient’ in bilateral partnerships is responsibility and trust. Given that the Global Fund has seen funding delays and interruptions in 2010 due to corruption charges and allegations in countries such as Zambia, Kenya and others, it is crucial for both donors and countries to have a sense of mutual trust. Both sides must fulfil their commitments, pointing to the fact that while donors have a role to play in being straightforward and upfront about information and allow host countries more logistical control, host countries also need to demonstrate responsible and effective use of resources to both minimise corruption and produce results.⁽²³⁾

Concluding remarks

As bilateral and multilateral relationships between XYZ progress and a more efficient methodology for implementation is introduced for partnership agreements, the proposed effectiveness of the move from ‘emergency’ to post-emergency funding holds weight. However, it appears that this perceived effectiveness has yet to produce tangible results. The danger in moving past an ‘emergency’ approach by highlighting the need to maintain universal treatment goals as well as concerns about the timeliness of country ownership implementation strategies are just a few of the challenges the ‘new’ PEPFAR faces.

The urgency of the rapidly escalating incidence of HIV and opportunistic infections and the subsequent treatment and funding demands, make the need for the new integrated, sustainable approach imperative now more than ever. Perhaps most notably, however, is the urgency of delivering scaled-up, effective, context driven prevention programmes. The statistic presented by Mead Over points to the fact that as a global community we are in the difficult (some might say impossible) position of dramatically increasing funding for treatment in the years to come if integrated models combing treatment, prevention and a health systems approach are not successful.

NOTES:

(1) Contact Katherine Austin-Evelyn through Consultancy Africa Intelligence’s HIV & AIDS unit (hiv.aids@consultanyafrica.com).
(2) Zwilich, Todd. 2009. Obama Administration May Flat-Line Funding for PEPFAR. The Lancet, 373(9672), p.1325.
(3) Katie Paul, ’The Pefar Paradox’, Newsweek, November 2009, http://www.newsweek.com.
(4) Ibid.
(5) ’Pepfar’s Past: 2003-2008’, Pepfar Watch, http://www.pepfarwatch.org.
(6) Nandini Oomman &; Christina Droggitis, ’Country Ownership and rethinking Global Health Partnerships: From dependence to symbiosis’, Global Health Policy Blog: Center for Global Development, 25 June 2010, http://blogs.cgdev.org.
(7) Ibid.
(8) Ibid.
(9) ’Efforts to Align Programmes with Partner Countries’ HIV/AIDS Strategies and Promote Partner Country Ownership’, United States Accountability Office: Report to Congressional Committes, September 2010, http://www.pepfarwatch.org.
(10) “PEPFAR Five-year Strategy” President’s Emergency Plan for AIDS Relief website, 2009, http://www.pepfar.gov.
(11) “PEPFAR’s Role in the GHI”, President’s Emergency Plan for AIDS Relief website, http://www.pepfar.gov.
(12) ’Foreign Policy Examines GHI, PEPFAR’, Kaiser Daily Health Report: Kaiser Global Health, 28 June 2010, http://globalhealth.kff.org.
(13) Katie Paul, ’The Pefar Paradox’, Newsweek, November 2009, http://www.newsweek.com.
(14) Voelker, R. 2010. One Casualty of Global Economic Crisis: Uncertain Finances for HIV/AIDS Programmes. The Journal of the American Medical Association. 304(3), pp. 259-261.
(15) “PEPFAR Five-year Strategy” President’s Emergency Plan for AIDS Relief, 2009, http://www.pepfar.gov.
(16) Mead Over, Prevention Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It. Center for Global Development Working Paper 144 , April 2008, http://www.cgdev.org.
(17) Ibid.
(18) Ibid.
(19) Laura Stemple, ’The AIDS Funding Crisis: International Commitments, Global Donors and the Role of NGOs’, The American Society of International Law Insights Bulletin, 14 December 2010, http://www.asil.org.
(20) Katie Paul, “The Pefar Paradox”, Newsweek, November 2009, http://www.newsweek.com.
(21) Ibid.
(22) Ibid.
(23) Nandini Oomman & Christina Droggitis, 'Country Ownership and rethinking Global Health Partnerships: From dependence to symbiosis', Global Health Policy Blog: Center for Global Development, 25 June 2010, http://blogs.cgdev.org.

Written by Katherine Austin-Evelyn ⁽¹⁾