by Justin Coile                                                                                                                                                         April 23, 2012

Abstract

    In the last decade the United States has led a foreign aid mission in Africa to confront the HIV/AIDS pandemic that has been wreaking havoc on the continent. President Bush announced the Presidents Emergency Plan for AIDS Relief during the State of the Union Address in 2003. Since then tens of billions of dollars have been spent to curb the pandemic. This money has been funneled into mostly indigenous programs on the ground in Africa. The strategy of partnering with stakeholders in Africa is a departure from previous foreign aid attempts where the United States has sent our own people to administer the aid. PEPFAR aims to treat millions with antiretroviral medicine, prevent future infections and provide care for those affected by the disease. The cost of treatment with antiretroviral medication has drastically fallen. Millions of infections have been prevented, many through the use of treatment in preventing mother to child transmission of the disease. The people are becoming more educated about the disease, and care is being provided to patients who were previously told to go home and die. Our actions of mercy are sure to improve foreign relations in the region. The political goodwill established now should prove to be beneficial in the future as Africa develops, creating much needed allies in this volatile region.

Introduction

    HIV/AIDS has reached pandemic status in many parts of Africa, particularly sub-Saharan Africa. This part of the world has faced so many setbacks and has had so much working against the hope for prosperity. HIV has taken a firm hold on the people of this land and has had a devastating impact. This infection is sure to keep these nations from developing into successful and prosperous nations if something drastic is not done to stem its spread.

    President George W. Bush first announced his idea for the Presidents Emergency Plan for AIDS Relief (PEPFAR) during the State of the Union Address in January 2003. Appropriations for the plan were made in September 2004 and implementation began shortly thereafter. PEPFAR has since become the largest effort by any nation in history to combat one disease.

    The appropriations for the bill in 2004 authorized fifteen billion dollars to fund this plan for its next five years; when PEPFAR was re-authorized in 2009, forty-eight billion dollars in total funding was authorized for fiscal years 2009-2014.  Some of the funds appropriated included money earmarked for existing programs such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. There were fourteen countries initially identified as focus countries to receive aid from PEPFAR. These countries include; Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia. Vietnam was later added as a focus country for a total of fifteen. (U.S. State Department, 2004)

    This emergency response by the United States is meant to be an act of mercy to help those suffering in Africa. America has a longstanding tradition of generosity in helping less fortunate countries. Our country has been blessed with success and great wealth. President Bush believed that with that wealth comes a responsibility to help others in times of need.

    America’s generosity is not without political benefit. Africa is a continent that mostly has yet to develop. The United States’ involvement and support in curbing the AIDS pandemic is an opportunity for excellent foreign relations. It is a unique opportunity we have to gain allies at this stage of their development. While most of Africa is still in the third world that means there is huge potential for growth. African countries have often had unstable governments that have oppressed their people and held them back from prosperity. With the political uprisings and regime changes of late we have the opportunity to get in on the ground floor in influencing the development of new governments. Our presence in Africa puts us in a better position for capitalizing on this opportunity.

Objectives

    During the 2003 state of the union address, President George W. Bush announced some specific objectives that he had for the plan. He called for the plan to “prevent seven million new AIDS infections...treat at least two million people with life-extending drugs...and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS” (Bush, 2003). Some of the specifics not mentioned in this quote were to provide ten million people with care and support and spend fifteen billion dollars over five years toward the cause (US Department of State, 2004).

    When PEPFAR was reauthorized in 2009 the goals were updated and boosted. The new goals called for the treatment of more than four million people with antiretroviral medication. The plan aimed to prevent twelve million new cases of HIV and provide care for twelve million, including five million orphans and vulnerable children. PEPFAR also planned to double the amount of at risk babies born HIV free, which were 240,000 in the first five years. A new goal in the reauthorization was to train and retain 140,000 new health care workers. Spending over the next five years would be forty-eight billion dollars, more than doubling the commitment of the first five years. (US Department of State, 2009)

Methodology/Tactics

    PEPFAR is a large undertaking with a broad scope. There is not one simple solution to restraining the AIDS pandemic. Because of this, the plan calls for a multifaceted approach to provide relief in the target countries. This includes treating the diseased with antiretroviral medicines to control the advancement of the infection and suppress its effects. Preventing the spread of HIV is key to the long-term goal of bringing the number of infected individuals in check. Because of the many different ways in which HIV is spread there must also be many different approaches to prevention. All of the modes of transmission need to be addressed to have a substantial impact. PEPFAR also seeks to provide care and support for people infected and affected by HIV.

-Prevention

    Preventing the spread of HIV is key to the long-term success of reducing the impact of AIDS. The number of people with AIDS will forever be sustained and grow if effective preventative measures are not taken. The five-year strategy of PEPFAR mentioned that for every person put on antiretroviral treatment two and a half people are infected with HIV. This has to change if we are to turn the tide of HIV prevalence, until then it will become a bigger, more difficult and expensive problem to fight.

    PEPFAR, like any other program, has limited funds with which to work. For that reason the plan has adopted the strategy of identifying the people and areas with the greatest need to focus its preventative efforts. The plan has largely limited its scope to the countries identified as focus countries, although some funding makes it to other countries. These focus countries stand to benefit the greatest from PEPFAR efforts. Within these countries the administration has identified vulnerable populations on which to focus preventative efforts. This population includes; men who have sex with men, vulnerable women and girls, people in prostitution, injection drug users, mobile populations, youth, incarcerated people and health care workers.

    Preventing HIV infection needs to be approached from many different angles. There are many reasons that people contract HIV and each of these reasons must be dealt with to have effective change. PEPFAR is seeking to prevent infection using behavioral, structural and biomedical interventions. One way the program is preventing spread of the disease is creating Health, Dignity and Prevention Programs for people living with HIV and AIDS. This intervention goes right to the source of infection to educate them and hopefully keep them from spreading the disease to others. Some interventions can be as simple as circumcising African men, which has been shown by the World Health Organization and UNAIDS to be somewhat effective in reducing the rate of transmission to men in heterosexual relationships. Behavior change is being attempted, but implementing change is a challenge. This would be extremely effective if it wasn’t so difficult to change people’s behavior. Blood and injection safety is being used to prevent transmission of the disease by these routes. (U.S. State Department, 2009)

    One of the most successful preventative measures in PEPFAR has been the prevention of mother to child transmission. Antiretroviral drug prophylaxis and treatment has been shown to be effective in preventing a child born of an HIV infected mother from being infected with the virus. In fiscal year 2011 alone about 660,000 women received this treatment and the result has been about 200,000 babies born free of the HIV virus (PEPFAR, 2012). This preventive measure has been responsible for providing the opportunity of a full life to hundreds of thousands of children who would have otherwise been destined to illness, suffering, stigma and an early death.

    Testing and counseling has been an effective way to identify those with the disease and educate at risk populations. There is also research being conducted to find new and innovative preventive measures including microbicides, pre-exposure prophylaxis and vaccines. Any small gain from this research has the potential to have a tremendous impact on preventing the spread of HIV in the future. (U.S. State Department, 2009)

-Treatment

    The treatment of AIDS has come a very long way in recent years. In his 2003 state of the union address, President Bush pointed out that the cost for a year worth of antiretroviral treatment has fallen from $12,000 to less than $300. The AIDS cocktail of years past has been replaced with a simpler regimen. This simplified treatment helps not only with cost, but it also has a great impact on compliance with treatment and it’s ability to be administered within a resource-poor health care delivery system.

    Before PEPFAR, only about 50,000 Africans with HIV/AIDS were receiving treatment. AIDS was a death sentence and if someone presented with it they would often be turned away because the treatment was unavailable and the hospitals did not have the resources to provide it. Eight years after its proposal, more than 3.9 million people are receiving antiretroviral treatment as a direct result of PEPFAR. (U.S. State Department, 2011). This number far exceeds the original goal of treating two million made by President Bush and is near the goal of four million established during PEPFAR’s reauthorization in 2009. During the first five years, mortality from AIDS in the target countries fell by 10.5 percent. This would imply that in the first five years about 1.2 million people have averted death thanks to the treatments made available by PEPFAR (Bendavid & Bhattacharya, 2009).

    Much of the success in treating patients has been the result of beefing up the health care delivery infrastructure in these resource-poor countries. The health systems in the focus countries are poorly developed and lack the capacity to treat all of those who are at the point where treatment would be beneficial.

    One of the objectives in the strategic plan for the second five years is to target treatment to those who would receive the greatest benefit. There is a push to reach the sickest people first. One way to identify the sickest people objectively is by using metrics like the CD4 cell count. Another group that would receive much benefit are pregnant women. Providing treatment for pregnant women can prevent infecting her child with the HIV virus. Treatment of pregnant women also prevents orphan children; it is extremely important for a mother to be alive and healthy during the first years of her child’s life so she can provide the care required of a young child. People with the comorbidities of HIV and Tuberculosis are also a target group to receive treatment because this combination has proven to be the leading cause of death in HIV infected people. (U.S. State Department, 2009)

-Care and Support

    PEPFAR was designed to be an act of mercy from the United States to those less fortunate. It is not feasible for the US to provide treatment to every person suffering from AIDS, but this act aimed to provide care and support for millions of people affected by the disease directly or indirectly. PEPFAR provides for different types of care to people living with AIDS as well as orphans and other vulnerable children who have been impacted by the pandemic. Antiretroviral treatment is only one part of caring for people with HIV/AIDS.

    Medical needs of HIV positive patients begin long before the patient is ready for antiretroviral treatment. Care ideally begins shortly after the infection is discovered. This care, if effectively administered, will reduce HIV related morbidity and mortality as well as prevent further infection.

    One aspect of caring for people with HIV is dealing with the opportunistic infections that arise as a result of the person’s compromised immune system. This treatment includes screening, prophylaxis and treatment for these diseases. Particular attention is paid to tuberculosis in the focus countries. PEPFAR also seeks to provide safer drinking water and improved sanitation and hygiene to protect these people from potential infection. Improved nutrition has been shown to improve outcomes in both people receiving treatment and those who are not. Insecticide treated bed nets are provided to reduce exposure to mosquito borne illnesses. Testing, counseling and Health, Dignity and Prevention Programming are provided for people living with AIDS as well as their families.

    Pain management and palliative care programs were severely lacking in PEPFAR focus countries. Many of these countries have restrictive policies regarding pain management practices. This limits the efforts of providing care and some of the attention of the administration has been focused on reforming these practices. The palliative care programs administered through PEPFAR have improved the end of life care of many people who have suffered from AIDS. These programs have also lessened the burden on families of the ill, preventing children from dropping out of school to take care of their sick parent. These palliative care programs also help the families cope with the situations they are facing. PEPFAR has set forth a strategy of providing home-based care and has trained a slew of community health workers to help provide this care.

    One troubling effect of the AIDS pandemic is the increase in orphans and vulnerable children. PEPFAR has earmarked ten percent of its funding to mitigate the effect of AIDS on the children living in affected communities. This is a complex problem and has been approached in a variety of ways. The plan calls for building up of the national systems of care in these communities. It involves strengthening the capacity of families and communities to care for these children in ways that are sensitive to the diverse populations of orphans and vulnerable children. PEPFAR is taking a cooperative approach and working with countries affected by the pandemic. This cooperation is essential to deal with the problem of orphaned and vulnerable children that has been created by this horrible disease. (U.S. Department of State, 2009)

Partners

    PEPFAR is broad in scope and provides funding to many different partners that operate programs consistent with the mission of the plan. Part of the strategy of PEPFAR is to utilize indigenous partners to provide the care to those affected by HIV/AIDS. This strategy increases local ownership and pride in the mission. This sense of ownership increases participation in the programs. It also provides the infrastructure for long-term success even after the emergency is past and foreign aid becomes less available. Partners in implementing PEPFAR have included existing and newly created non-government organizations (NGO’s), governments and faith based organizations. An example of a partnering organization is the Elizabeth Glaser Pediatric AIDS Foundation, which is detailed below.

-Elizabeth Glaser Pediatric AIDS Foundation

    The Elizabeth Glazer Pediatric AIDS Foundation is an example of one of the many organizations that have been able to respond to the African AIDS pandemic as a result of PEPFAR and the funding it has provided. Organizations like this are evidence of PEPFAR’s strategy of partnering with non-governmental organizations (NGOs) to provide the intended services. In the first annual report to congress Ambassador Randall Tobias proudly states that eighty percent of PEPFAR’s partners are indigenous organizations. Local ownership of the plan is a key component to ensure a sustained impact. The plan has successfully intertwined itself with the existing infrastructure and partnered with the stakeholders in the affected countries to deliver education, treatment and support to vulnerable individuals. This strategy is a departure from previous foreign aid where the United States was very centralized and independent in distributing the aid.

    The Elizabeth Glaser Foundation was created in 1988, well before PEPFAR was ever envisioned. Elizabeth was infected with HIV through a blood transfusion during her daughter’s birth. She unknowingly infected her daughter via breast milk and later infected her son in utero. The foundation originally focused on pediatric AIDS research, as very little was known about it at that point.

    In 1999 The Elizabeth Glaser Foundation began international work to prevent the spread of HIV from mothers to their babies in six countries. With the enactment of PEPFAR they have been able to expand the scope and intensity of their international work. The number of countries where this organization now serves has risen from the six original countries before PEPFAR to fourteen. As of September 30, 2011 the Glaser foundation has reached more than 13.6 million women with services to prevent the spread of HIV to their children. (Elizabeth Glaser Pediatric AIDS Foundation, 2012)

Complementary Programs

    PEPFAR is not the first and is certainly not the only program with the intent of providing relief for the global AIDS pandemic. It is also not the only program to receive support from the United States government. Several of these complementary programs are integrated in the overall strategy of PEPFAR and the United States was involved with many of them before our emergency plan was ever envisioned.

    UNAIDS was established in 1994 by a United Nations resolution, it was launched two years later in 1996. It has similar goals to PEPFAR and has been effective in bringing attention to the AIDS pandemic. UNAIDS has ten cosponsors; the United States is not one of them.

    The Global Fund to Fight AIDS, Tuberculosis and Malaria is a public-private partnership established in 2002 to distribute resources to fight HIV/AIDS as well as malaria and tuberculosis. The US has an obligation under PEPFAR to donate a certain amount of money to the Global Fund. The US has established itself as the first and largest donor to the Fund, and it has provided about six billion dollars so far.  The Global Fund has similar goals to treat, provide care and prevent new infections of HIV. (Larson, Bertozzi & Piot, 2011)

The Politics of PEPFAR

    While PEPFAR was billed as essentially an act of mercy, which it was, the politics of the act prove to be much more involved than that. The continent of Africa has been in a continual state of turmoil, and the AIDS problem prior to PEPFAR had been viewed as a security issue. The AIDS epidemic was put on the security agenda during the later part of the Clinton presidency. HIV/AIDS greatly affected the United States’ security interests through our foreign policy and relations. The disease also affects international security as it has the potential to create and foster regional destabilization. President Clinton announced in 2000 that AIDS would officially be treated as a threat to US national security (Dietrich, 2007). George Bush did not use the issue of security to garner support for PEPFAR. This was a shift from the previous stance on AIDS relief and had several implications. The humanitarian and mercy causes for enacting PEPFAR will likely not hold up as well long term as if the problem was viewed as a security interest. Acts of compassion and mercy are some of the first things to be cut in lean times, while national security threats are something that will not be messed around with. People tend to snub being compassionate to others when they are struggling themselves.

    Another new political development resulting from PEPFAR is the shift from multilateral efforts to a more unilateral response from the United States. The existing programs such as the UN Global Fund would have been more than happy to receive the extra funding from the US, but we decided to take up the task ourselves. Backlash from these other organizations was minimized because PEPFAR was seen as a complementary rather than competitive program. The US would have lost much of its the ability to impose its own agenda into the response if the money was surrendered to UN or other programs. The decision to direct the program itself allowed the US to protect its own interests and support stakeholders that were politically favorable. (Alan, 2010)

    There were considerable economic implications to the passage of PEPFAR. Fifteen billion dollars was destined to be spent on AIDS relief, and many stakeholders had an economic interest in where and on what this money was to be spent. A consortium of major pharmaceutical companies created at least two lobbying groups to lobby congress for PEPFAR funding. Condom producers were poised to capitalize on the increased spending on prevention. Countries highly affected by the AIDS pandemic also had an economic interest in being chosen as one of the focus countries of the program.

    One issue that was the subject of significant criticism was the policy to only support the distribution of name brand antiretroviral medications. There was concern that the pharmaceutical industry’s lobbying efforts had influenced this policy. The result of their efforts was that a large percentage of those affected by AIDS were not receiving treatment. This concern was sustained by the appointment of former Eli Lilly chairman Randall Tobias, who had little experience with AIDS or African politics, as the US Global AIDS Coordinator. The administration held that this policy was to assure quality as well as protect patent rights. After much pressure, the decision was made to allow funding for the distribution of generic antiretroviral treatments that had received FDA approval. Some generics were approved under the expedited FDA review process in 2005 and were being purchased with PEPFAR funding by the end of that year. This was a rare example of an administration reversing its policy to put humanitarian issues ahead of US economic interests, although it took significant pressure to do so. (Dietrich, 2007)

    Another policy that has created some political backlash has been the requirement that some of the funding be spent on teaching abstinence until marriage and faithfulness after marriage. This teaching is part of the ABC approach that began in Uganda and has achieved some success. The ABC’s represent teaching abstinence until marriage, faithfulness to one partner and the use of condoms if the other approaches fail. The ABC teaching is widely used under PEPFAR but some organizations have taken out the C. This points to the larger issue of Christian values being engrained in the plan. President Bush is known to be a professing Christian and his Christian values were a significant influence in the creation of PEPFAR. PEPFAR has provided significant funding to religious organizations that contribute to AIDS relief. Support for organizations that provide abortions along with AIDS treatment is another example of an ideological dilemma that PEPFAR is forced to address. (Bradley-Springer, 2010)

    There will always be debate on specific issues with PEPFAR as long as the program survives. There will be continual change with the changing political environment, but the main focus of the program has remained intact and likely will in the future. PEPFAR turned out to be a politically popular policy for the president. It has garnered wide support from a variety of constituents. Both liberals and conservatives were able to back the issue for their own variety of reasons. Typically liberal humanitarians and religious conservatives can both identify with the call to help the suffering. PEPFAR will likely leave a legacy as a positive product of George Bush’s presidency.

Outcomes

    PEPFAR began with ambitious goals, but were these goals simply rhetoric or were they realistic? To repeat, the initial goals in 2003 were to treat two million people with antiretroviral therapy, prevent seven million new infections and provide care to ten million people who have AIDS or have been affected by AIDS (Kaiser Family Foundation, 2011). Data released by PEPFAR shows that these goals have been largely met. The US has directly supported antiretroviral treatment for more than 3.9 million people suffering from AIDS. Almost thirteen million people were directly provided with care and support in 2011, 4.1 million of which were orphans and vulnerable children. PEPFAR also supported testing and counseling to forty million people in 2011. About 9.8 million pregnant women received testing and counseling this past year. 660,000 of these women were treated with antiretroviral medication, which enables about 200,000 babies to be spared from HIV infection. Few can disagree that PEPFAR has produced a positive outcome and has improved the lives of millions of people throughout Africa and the world. (PEPFAR, 2011)

Discussion/Conclusion

    It has been nearly a decade since President Bush first announced PEPFAR. The unprecedented act of mercy by our government has achieved great success and has saved and prolonged the lives of millions. It has improved the lives of many millions more. The plan has helped America establish positive relationships throughout Africa and the world that will be beneficial in future foreign policy efforts. In cooperation with other efforts to curb this pandemic, the tide is beginning to turn in the fight against AIDS. There are fewer new HIV infections today than there were in years past. The attention of world powers has been gained and many are responding. There is much that remains to be done to end this pandemic. Millions are still being infected every year and the disease continues to ravage many parts of the world. This disease has garnered the world’s attention. The stage has been set to end the pandemic. The United States has taken up the cause and, with continued support, will succeed in freeing Africa from the oppression of AIDS.

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