As far as storylines go, PEPFAR has had it pretty good so far. Since George W. Bush first introduced the President's Emergency Plan for AIDS Relief in 2003, the program has been able to swing around impressive credentials: more than 2 million people in 15 focus countries have started on antiretroviral treatment and more than 10 million have been supported with overall care. Thanks to the program's promising results, Congress raised the budget of PEPFAR by $4 billion over the course of its existence. With $6.7 billion to its name, PEPFAR is now the biggest public-health initiative in the world.
But after years of steady gains in funding, health experts say PEPFAR's funding will likely flatline under the Obama administration. At the same time, they expect the gap between the number of people who need treatment and the number getting it to widen. With budgets squeezed by the financial crisis, and a growing call in global health circles to move away from "AIDS exceptionalism"—defined as greater funding for AIDS programs at the expense of overall health resources—the jewel of Bush's foreign-policy portfolio is poised to start looking much less shiny.
But even though its results may not look as impressive, the program is as strong and smart as ever. Up until now, PEPFAR was defined by the "E" in its name: emergency. The emphasis was on starting up strong and making a big impact, which often meant bypassing local governments to get as many people on treatment as possible, as quickly as possible. But while that has produced impressive results, the approach is far from sustainable. The program's record on preventing transmission of HIV has been lackluster, and worldwide the number of new infections is drastically outpacing the number of people receiving treatment, according to PEPFAR's published reports. For every two patients put on antiretroviral drugs today, five others contract HIV—a rate that has remained steady even as PEPFAR money made enormous strides in bringing down the death rate.
If that doesn't change—and there is little indication it will—PEPFAR risks becoming a black hole of an entitlement program, committed to funding treatment indefinitely as more and more patients live longer and longer. "The problem is, there's no way you can treat ourselves out of this epidemic," said Dr. Stefano Bertozzi, who directs HIV work at the Bill & Melinda Gates Foundation. "As you newly start people on treatment, you need to maintain those people you started on treatment in previous years. The number of people you're sustaining next year is always going to be greater than the number of people you're sustaining this year." According to a cost analysis from the Center for Global Development, an independent research organization, maintaining present successes for the ever-increasing number of patients would cause U.S. AIDS spending to swell to $12 billion by 2016, consuming half the foreign-assistance budget and squeezing out U.S. spending on other programs, including other health initiatives.
The way out of this conundrum, according to policy experts? Shift more resources over to prevention efforts. Transfer programs to local ownership and put national governments on the hook for delivering services. Monitor and evaluate which programs are working, then report the results.
According to Eric Goosby, the U.S. global AIDS coordinator in charge of PEPFAR, those items are all on the agenda. On the prevention front, PEPFAR is pouring resources into peer-education programs and mother-to-child transmission interceptors. The program is also doubling the funding for monitoring and effectiveness studies, from $23 million this year to $40 million to $50 million in 2010. And in line with the administration's push to broaden global health and development plans beyond one disease—epitomized by a new $63 billion, six-year initiative—Goosby is looking to move away from both reliance on NGO contractors and commitment to a narrow AIDS focus. "Patients are going to need these drugs 20 to 30 years in the future, so we need to focus on sustainability. To do that, we need to work off PEPFAR platforms to expand into a broader constellation of services for each patient," he says.
That position has the support of AIDS advocates, who have had to fight off accusations that AIDS gets too much attention in the public-health realm. "It doesn't make sense for a counselor to have a discussion about contraception with a woman in one building, then have a different program in a different building about HIV prevention. People co-infected with HIV and TB shouldn't have to go to clinics across town to have those problems dealt with," says Bertozzi of the Gates Foundation. In other words: public health isn't a zero-sum game.
Of course, making the change is easier said than done. Politically, the strategy is risky. Improvements on the prevention side, which may produce the best results in the long term, are difficult to measure (you can show how someone caught a bug, but it's tougher to prove a negative and track why he didn't catch it). And while increased partnership with national governments is a worthy goal, it also carries the risk of slow transitions, less impressive results, and a loss of congressional enthusiasm when funding time comes around again. Handing off programs to local control can be a messy process, cautions Peter Navario, a global health fellow at the Council on Foreign Relations who specializes in HIV/AIDS systems in developing countries. In one case he cites, an international NGO that tried to turn over a program to doctors and administrators in South Africa ended up having to resume leadership of the program—twice.
But lower expectations and untidy transitions may be a necessary price to pay. Expensive quick fixes can't work forever; eventually, local doctors are going to need to be trained to take over from their expat counterparts. If, as the experts say, the Obama administration is putting all the right pieces into place to mold PEPFAR into a post-emergency program, then the challenge at home is to make sure congressional support doesn't wane if critics spin the numbers as evidence of ineffective leadership. The new monitoring and evaluation studies should help. They would have helped even more if they had been implemented at the start, say AIDS fund administrators. But so the proverb goes: if the best time to plant a tree is 200 years ago, the second best time is today.