PEPFAR and the Global AIDS Response

In 2001, only 100,000 people with AIDS in the developing world had access to antiretroviral drugs (ARVs). According to Dr. Peter Piot, the executive director of UNAIDS, today more than 2.5 million people in the developing world are on ARVs. "All these lives saved are the direct result of the significant increase in the world's commitment to fighting AIDS," he said. At a September 20, 2007, Director's Forum co-sponsored by the Woodrow Wilson Center's Global Health Initiative and Environmental Change and Security Program, Piot said U.S. leadership in particular "has truly transformed the global response to AIDS and the course of the epidemic."

U.S. efforts have been predominantly channeled through the President's Emergency Plan for AIDS Relief (PEPFAR), which is set to expire at the end of fiscal year 2008. On May 30, 2007, President George W. Bush called for a reauthorization of PEPFAR that would double the initial 2003 commitment of $15 billion to a total of $30 billion over the next five years. Piot applauded the proposed increase, warning, "We cannot become complacent in our early success…We cannot rest until the last person living with HIV has access to treatment and we are reaching everybody with prevention activities, and transmission is stopped." U.S. Representative Nita Lowey (D-NY), chairwoman of the Subcommittee on State, Foreign Operations, and Related Programs, emphasized the need to increase global efforts on HIV/AIDS prevention. Kent Hill, assistant administrator of the Bureau for Global Health at the U.S. Agency for International Development (USAID), called for increased coordination within the health sector and between the health sector and other sectors integral to fighting HIV/AIDS.

A Pivotal Point

Piot highlighted several current trends in the HIV/AIDS epidemic, which indicate that the disease is expanding and globalizing. According to Piot, HIV/AIDS, a disease that was unknown 26 years ago, is now the fourth-highest cause of mortality in the world. "We are starting to see the feminization of the epidemic," he reminded the audience, urging the world to respond with new strategies that focus on prevention and treatment for women. Most unfortunately, continued Piot, HIV/AIDS's devastating impact on the worst-affected countries has become clear. Particularly in certain parts of Africa, HIV/AIDS has reversed progress in development. According to Piot, by 2010, the five most severely affected countries in Africa will have lost one in five potential workers to AIDS.

In other parts of the world, such as China and the former Soviet Union, where the epidemic has yet to establish a strong hold, rapid economic growth can be expected to spread the disease quickly. "AIDS is not a disease of poverty, but of marginalization and inequality," he said. Those living on the margins of society are often at the highest risk of contracting and spreading the disease—not just the poor, but women in general, orphaned and vulnerable children, injecting drug users, prisoners, and victims of human trafficking and prostitution.

According to Piot, these trends mean there is still a place for AIDS "exceptionalism"—the prioritization of the AIDS pandemic. Piot compared AIDS' power to bring catastrophe to populations to the devastating effects of unchecked climate change and nuclear threats. In addition, he said, "Investments in the fight against AIDS are having an impact beyond AIDS." As examples, he highlighted long-ignored yet significant issues—such as violence against women and gender inequality—that are now the focus of new interest and resources.

Goals for PEPFAR Reauthorization

Piot emphasized that "we are at a turning point in our response to the epidemic." According to Piot, increased funding, cooperation, and prevention are necessary to improve the effectiveness and sustainability of the global AIDS response. Outlining his objectives for PEPFAR reauthorization, Piot called on Congress and the Bush administration to "continue on the same upward trajectory" in terms of funding. He did not place all responsibility for combating HIV/AIDS on PEPFAR, but he argued that the U.S. government's actions set a powerful example. "Putting more money into PEPFAR will compel the rest of the world to do the same," he said. "If we delay increased investments now, five years from now the bill will be even greater. A lot of energy and time has been invested in setting up systems—supply chain management, procurement, and community activities," Piot said. "These early investments will be lost if we are not going to continue on the upward trajectory. If we are not moving forward, then we are slipping back."

Furthermore, said Piot, "we must make the money work, which means maximizing our effectiveness by coordinating with donors, government implementers, and so on." In addition to increasing overall funding and coordination, AIDS prevention measures must be consistently evaluated and expanded. Responses to the spread of HIV/AIDS should be "country-driven and flexible," allowing for the development of prevention plans that suit each situation. Piot continued, "Anything that has the word 'only' in it doesn't work for AIDS, whether it's treatment-only, prevention-only, condoms-only, abstinence-only, male circumcision-only—we need it all."

Prioritizing Prevention

Lowey commended the achievements of PEPFAR over the last five years, particularly in increasing access to treatment. "The first PEPFAR program changed the world forever by initiating [ARV] treatment. Our next program must reflect a true commitment to prevention," she said. "In 2006, for every one person who received treatment, another six people became infected. This statistic translates into an additional 60 million infections by 2015 if the world has not dramatically shifted its prevention paradigm," she continued. "Some argue that we're heading backwards in our efforts to slow the pandemic."

Lowey stressed the need for flexibility and individual country leadership in the development of prevention strategies. "In many countries, we have implemented a uniform prevention strategy that is often called ‘ABC': ‘A' for abstinence, ‘B'—be faithful, ‘C'—use condoms…Unfortunately, the cookie cutter approach has not worked universally," she said. "Of course, donors should continue to support efforts that utilize effective medical innovations, but in the end, the decision-making process and program implementation must be country- and community-driven."

Lowey cited early successes in reducing infection rates in Uganda as an example of the importance and value of community-led prevention efforts. On a recent trip to Africa, Lowey had the opportunity to meet with individuals who had been fighting the AIDS epidemic since the mid-1980s. According to Lowey, these leaders believe the Uganda epidemic was halted due to grassroots efforts that promoted education and community support. "What worked in Uganda in the late 1980s and early 1990s was a homegrown solution, one that was very specific to Uganda's culture and needs," she said. "Unfortunately, recent evidence from Uganda suggests that the HIV incidence is rising again."

Lowey explained that many of those working against AIDS in Uganda believe this is a side effect of the success of treatment programs. "Some working at TASO [The AIDS Support Organization] shared with us their belief that the introduction and availability of treatment was leading many Ugandans to see HIV/AIDS as a chronic disease rather than a death sentence," she said. Lowey emphasized that in expanding PEPFAR, it is necessary to acknowledge how global efforts to stop the epidemic have altered the dynamics and perception of HIV/AIDS in many communities. Prevention efforts must be scaled up and targeted to address these changes.

Lowey argued that success in fighting HIV/AIDS will depend on the health sector's coordination with other areas, particularly education and nutrition. "As we consider the next phase of the global AIDS initiative and our response to this unyielding pandemic, we must broaden our thinking and ensure that comprehensive community-based approaches with a development perspective are incorporated into our strategic plan," she said.

Cross-Sectoral Cooperation and Collaboration

Hill built upon Piot and Lowey's comments on cross-sectoral collaboration, emphasizing that HIV/AIDS is not an isolated health issue and that multi-sectoral coordination has been, and will continue to be, vital to success. "People think that the work on HIV/AIDS has to do with just those categories [directly related to treatment and prevention of the disease]…and that when Congress gives money to [U.S. Global AIDS Coordinator] Ambassador Dybul and PEPFAR, that is all it goes for; there isn't anything for the so-called 'wraparound' programs. That could not be further from the case," he said.

Hill argued that gender equality, family planning, human rights, programs for orphaned and vulnerable children, education, nutrition, economic development, and health system infrastructure are all vital sectors in the fight against AIDS. According to Hill, divorcing HIV/AIDS programs from these sectors will lead to less-than-optimal outcomes. For example, Hill said, "Take the issue of nutrition. People say, ‘That is humanitarian. That is not HIV/AIDS.' Nonsense. You can't do treatment for people who are on ARVs if you don't recognize that the impact of that treatment is going to be impacted by whether or not people have enough to eat. So you had better be cooperating with—or if possible, even finding some funds for—nutrition programs to address that." He continued, "My main message here is that you cannot think of HIV as simply an isolated, particular part of the health agenda. It's connected to lots of other development matters that you have to address at the same time if you are really going to succeed."

Hill praised the spirit of cooperation that exists between international bodies on HIV/AIDS efforts. He recommended that international aid groups, as well as PEPFAR and the U.S. government, continue to ask, "How does what we are proposing to do fit with what the other international donors are doing?" According to Hill, it is this focus on cooperation that will prevent overlapping efforts and lead to future successes. "I think if we redouble our efforts—and not just our money, but if we work smarter and we cooperate better and we focus on prevention and deal with some of these prevention drivers that we haven't spent enough time on—we can make a difference, but it's going to require all of that for us to succeed," he said. A collaborative effort is particularly important at this time, when there is an opportunity to halt emerging epidemics of HIV/AIDS, continued Hill. "I think we ought to get ahead of the curve in places like Russia and the Ukraine and invest in strategies even for the general population, because there are all sorts of signs that there isn't the check on sexual behavior that would stop [epidemic HIV] if it starts there," said Hill.

Hill spoke specifically to the need for further emphasis on behavioral research, as behavior change is key to prevention. He highlighted the issue of concurrent multiple sexual partners—a significant driver of the epidemic in many areas of the world—as one that has not received sufficient attention in prevention efforts. Piot agreed that renewed efforts are needed in this area, but also acknowledged that developing effective behavior change programs is extremely difficult. Hill and Piot concurred that behaviors that put people at higher risk for contracting HIV do not happen in a void. There are significant societal and cultural factors associated with these—and all—behaviors that must be accounted for in prevention efforts, lest new problems be created.

Creating the Future

Piot concluded by extending a formidable challenge to the audience: "We cannot predict the future, but we can create it. The mark that AIDS makes on history from this day is not out of control; it is largely in our hands…Today, as we prepare for the years to come, and as we make our budgets and formalize our plans, we must commit ourselves to not simply continuing our efforts, but intensifying them."

Drafted by Michaela Hoffman.