The President's Emergency Plan for AIDS Relief (PEPFAR) has provided unprecedented support for the expansion of programs addressing HIV and AIDS worldwide, primarily through access to anti-retroviral therapy. And while progress has been made, the HIV and AIDS pandemic remains an enormous challenge for global health and social and economic development - disproportionately affecting women and youth. This challenge and its consequences will only grow over time. As PEPFAR continues to grow the number of people enrolled in treatment, decreasing new infections by improving and increasing funding and access to prevention programs must be addressed. The urgency of the prevention imperative is real given that we know that for every two people who gain access to treatment, five more are newly infected with HIV. The impact on women is even more clear with HIV and AIDS being the leading cause of death and disease among women between the ages of 15 and 44.
Throughout the Bush Administration, the PEPFAR program came up short on prevention and more. The Obama Administration has the opportunity - and is beginning to - bolster PEPFAR prevention programs by fully embracing evidence-based approaches, outcome measures, and cost effectiveness based on internationally agreed-upon standards.
To guide these changes, the IWHC worked with CHANGE and 18 other organizations to develop actions steps in 12 key areas to massively improve prevention programming.
PEPFAR 5-Year Strategy
The Office of the Global AIDS Coordinator released the next 5-year strategy for PEPFAR - setting the course for the second phase of the program, shifting from an "emergency" program to a sustainable one. The main framework is that over the next five years, PEPFAR will work to achieve five overarching goals:
1. Transition from an emergency response to promotion of sustainable country programs.
2. Strengthen partner government capacity to lead the response to this epidemic and other health demands.
3. Expand prevention, care, and treatment in concentrated and generalized epidemics.
4. Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems.
5. Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.
In working to prevent 12 million new HIV infections between FY2010-2014, the strategy calls for three key efforts:
1. Ensuring that every partner country with a generalized epidemic has both 80% coverage of testing for pregnant women and 85% coverage of ARV for those found to be HIV infected.
2. Double the number of at-risk babies born HIV-free from 240,000 during the first 5 years of PEPFAR.
3. In every partner country with a generalized epidemic, provide 100% of youth in PEPFAR prevention programs with comprehensive and correct knowledge of the ways HIV/AIDS is transmitted and ways to protect themselves, consistent with Millennium Development Goal indicators in this area.
The strategy states that prevention is the major priority for PEPFAR in the next five years - scaling up proven programs while supporting innovative and promising new efforts. It states that successful prevention programs require a "combination of evidence-based, mutually reinforcing biomedical, behavioral, and structural interventions." Additionally it calls for expanding investments in "high-impact" interventions such as prevention of mother to child transmission (PMTCT), male circumcision, and services for people who inject drugs.
The new policy calls for expanding integration of HIV prevention, care and support, and treatment services with family planning and reproductive health services, so that women living with HIV can access necessary care, and so that all women know how to protect themselves from HIV infection. Additionally, it calls for an expansion of PEPFAR's "commitment" to integration of gender equity in programs and policies, with a new focus on addressing and reducing gender based violence. Much of the integration called for is HIV and AIDS with TB, food, nutrition, and economic activities.
On treatment, it points to PEPFAR's role in both essential medications as well as in strengthening health care systems. There will be an effort to double those on treatment through PEPFAR from 2 to 4 million, focusing on the sickest individuals, pregnant women, and those with HIV/TB coinfection.
An emphasis will be on improving health outcomes overall through sustainability, integration, and strengthening health systems. This includes training and retention of more than 140,000 new health care workers. The strategy also points to a bit more flexibility than there has been in the past, to "enhance the ability of governments to manage their epidemics, respond to broader health needs impacting affected communities, and address new and emerging health concerns." Partnership frameworks and other bilateral efforts will factor heavily in this area.
Country ownership and partnership is a strong emphasis overall and it recognizes some of the problems of the past when PEPFAR plans did not fully complement existing national structures or plans, lacked field input, and had overly extensive reporting requirements. It states that cooperation with other implementers and stakeholders is necessary in responding to the country-level epidemic.
However, it is not so clear about what while happen when the United States might have issue with a national policy - for example, what happens to U.S. funding in Uganda if they enact the anti-homosexual law?
In terms of working with other governments, there is a strong call for expanding multilateral engagement to strengthen the institutions and leverage their work - including the Global Fund, UNAIDS, WHO and multilateral development banks.
Key areas of concern for us are a lack of inclusion of language on the importance of protecting human rights and civil society involvement in the effort (except for help with ensuring transparency). With all the mention of country driven programming, it does not specifically call out civil society engagement in this process - which is of vital importance in addressing these issues in an effective and sustainable way.
PEPFAR in the Law
The PEPFAR programs are directed by a law passed in 2008. After an intense deliberative process, the new law made some positive changes, while at the same time facing some challenges in effectively addressing human rights of all people, and efforts to prevent HIV/AIDS.