President Bush asks for doubling of PEPFAR funds

President George Bush has asked the US Congress to double US support for HV treatment and prevention overseas through the PEPFAR programme to $6 billion a year until 2013, with the aim of providing HIV treatment for 2.5 million people.

Launched in 2003, the President’s Emergency Plan for AIDS Relief is designed to scale up HIV treatment, prevention and care in southern and eastern Africa plus Nigeria, Haiti, Guyana and Vietnam.

As of last September the programme was paying for antiretroviral treatment for 822,000 people in the 15 target countries plus 165,000 people in other countries.

“We believe strongly that to whom much is given, much is required. Much has been given to the United States of America. Therefore, I believe strongly that much is required of us in helping solve this problem,” said President Bush yesterday, announcing his request in the White House Rose Garden.

“This investment has yielded the best possible return: saved lives,” he said.

The US is the world's largest bilateral donor of financial support for HIV treatment, prevention and care.

Religious leaders, who had provided a strong impetus for the Bush administration to launch PEPFAR in 2003, welcomed the increase in funds.

It also found support in Congress. “The call to double the budget for this vital effort is music to my ears, and I will do all I can to ensure harmonious support for it,” said Rep. Tom Lantos (D-California), chairman of the House Foreign Affairs Committee.

The increase was also welcomed by Ileana Ros-Lehtinen, the highest ranking Republican member on the committee, indicating bipartisan support for the measure.

However the scale of increase was criticised by the activist group Health GAP. “$30 billion over five years would actually result in an overall decrease in the percentage of people with HIV on treatment because of U.S. investments. This announcement, while an increase in funding for an historic programme, is not on the scale that is so desperately needed from the U.S,” said Paul Davis of Health GAP.

Paul Zeitz of the Global AIDS Alliance questioned whether the sums requested represented a doubling, or merely the maintenance of a steady level of funding.

“For fiscal year 2007 Congress approved $4.5 billion for AIDS, TB and malaria programmes (excepting the new bilateral malaria initiative). For fiscal year 2008 the President requested $5.4 billion, which Congress seems likely to approve. If the next phase of the US global AIDS response simply held to this 2008 level over a five year period it would cost $27 billion, or nearly what the President proposed today.”

In practice, Congress’s vote of $4.5 billion for fiscal year 2007 allocated only $3.2 billion to the PEPFAR programme, with the rest of the money distributed between the Global Fund to Fight AIDS, TB and Malaria, the US Centers for Disease Control, and USAID’s Child Survival and Health Program.

He argued that the US appeared to be scaling back its commitment to funding treatment; at present one-third of those in need of treatment receive it because of US funds, but at the current projected rate of growth in PEPFAR funds and numbers on treatment, only 20% of the 12 million people expected to need treatment in 2013 will receive it due to US aid.

The US government says that the increase in funding is required in order to continue existing programmes while at the same time expanding those efforts.

Global AIDS Coordinator Dr Mark Dybul told the San Francisco Chronicle: "The most common question we get from Africa is “What happens next? We won't save as many lives in 2008 unless people know that the commitment beyond that date is moving forward."

Money will also be invested in expanding health care worker capacity, and in accompanying information, the US State Department said: “PEPFAR will further expand efforts to strengthen health systems, and to leverage programs that address malaria, tuberculosis, child and maternal health, clean water, food and nutrition, education and other needs,” evidently a recognition that a vertical approach to HIV programmes will not be sustainable, and that massive investment in health systems will be necessary.

"There is a catastrophic shortage of health workers in Africa, and unless PEPFAR commits to spending new money to address this crisis, the U.S. will not be able to meet its treatment and prevention goals - or sustain its progress over the next phase of this program," said Asia Russell of Health GAP. At least $5.5 billion in additional spending by the U.S. is needed to invest in training and retaining health professionals during the next four years of PEPFAR, according to Health GAP.

PEPFAR is looking to unleash money from new sources to fund health sector expansion, saying that the US will pursue Partnership Compacts by which US resources and other commitments will increase in partnership with countries dedicated to fighting their HIV epidemics through:

• Increasing their own resources, according to economic ability, for HIV/AIDS and health systems.
• Implementing policies and practices to optimise effectiveness of resources in key areas, e.g. health workforce expansion, gender equality, protection of the rights of orphans, effective HIV counselling and testing

PEPFAR has been criticised in the past for restrictions on how money can be spent, some inserted into legislation by the US Congress and some implemented by order of the executive branch of government.

Rep. Tom Lantos said that he proposed to look in particular during reauthorisation at the requirement that 33% of HIV prevention funds channelled through PEPFAR be spent on abstinence-based education.

Other prominent Democratic party legislators, who now form the majority in Congress for the first time since PEPFAR was established, have also expressed concerns about the restriction. Powerful members of the Senate and House Appropriations committees, Sen. Dianne Feinstein (D – California) and Rep. Barbara Lee (D – California) have said they want to see the restriction lifted.