WASHINGTON, Feb 21 2013 (IPS) - A major audit of the United States' flagship global anti-HIV/AIDS programme, prepared for the U.S. Congress, notes “remarkable progress” over the past decade. However, it is also warning of insufficient monitoring and urging a stepped-up process of handing over greater control to partner countries.
Known as the President's Emergency Plan for AIDS Relief (PEPFAR), the initiative is the largest such programme in the world, credited with saving millions of lives, particularly in Africa. Since its authorisation in 2003, at the behest of then-president George W. Bush, PEPFAR has disbursed more than 30 billion dollars through bilateral agreements in over 100 countries.
The legislation that created PEPFAR requires Congressional re-authorisation this year, however. As part of that process, Congress required the national Institute of Medicine (IOM) to conduct an audit on the efficacy of the programme's first decade.
In many regards, the findings of PEPFAR's impact over the past decade are extremely positive. IOM committee chair Robert Black, an international health expert, notes that his team “repeatedly heard PEPFAR described as a lifeline” during visits to partner countries.
“PEPFAR has achieved - and in some cases surpassed - its initial ambitious aims,” the IOM committee's 700-page report, released Wednesday, states.
“These efforts have saved and improved the lives of millions of people around the world. That success has in effect 'reset' the baseline and shifted global expectations for what can be achieved in partner countries.”
Yet the report also notes that much work remains to be done, particularly to safeguard “hard-fought gains”.
The reporting committee is calling on PEPFAR to increase emphasis on funding for the far more difficult task of HIV prevention, rather than treatment. It is also pushing the agency to focus more on the ultimate impact of its funding on the ground.
“The report does a good job of being explicit about these data gaps and the need for better information on spending,” Victoria Fan, an international health specialist with the Center for Global Development (CGD), a Washington think tank, told IPS. “As PEPFAR wants to shift from measuring funding-related activities to measuring actual outcomes, they are going to need better data-monitoring systems.”
Of particular prominence in the IOM evaluation is the move towards strengthening “ownership” of PEPFAR programming by partner countries, both in finances and programmatic approach.
“Today, the ability of many countries to respond to HIV relies heavily, and sometimes exclusively, on external funding,” the report states, noting later: “PEPFAR will gradually cede control, as partner countries take on more central roles in accountability and setting strategic priorities for investment in their HIV response … such an evolution in PEPFAR's mission is vital.”
In part, this process relates to the willingness of the U.S. government to continue these investments over the long term.
“The United States may be thinking that it's already been engaged in these programmes for the past 10 years, and in that time the epidemic has changed,” CGD's Fan says. “So, maybe it's time to let other countries take more ownership and invest more financially in these programmes - that's a reasonable assertion.”
At the same time, HIV-positive people around the world are today able to live far longer due to new treatment innovations, while a generation of children that would have otherwise risked exposure is being born without HIV. Fan notes that this creates a “moral entitlement” that may have caught some U.S. legislators by surprise.
“Remember, when you start taking [anti-HIV drugs], you have to do so for the rest of your life,” she says. “That's a long-term commitment that U.S. policymakers may not have been thinking about when they started investing in HIV/AIDS. It's much harder to pull funding that will directly cause people to die.”
Others have stressed that as PEPFAR moves into a new phase of post-emergency funding, particularly as the U.S. government wrestles with concerns over debt and austerity, it will be increasingly important to determine where exactly that money is going.
“Country ownership doesn't necessarily mean governments taking control, but rather is about partnerships between national governments, international donors and civil society,” Serra Sippel, the president of the Center for Health and Gender Equality (CHANGE), a Washington advocacy group, told IPS.
“Civil society engagement is particularly important when you look at countries that are not that friendly towards women's rights or LGBT rights. It's very important that PEPFAR continue to support and work with civil society to make sure no one is left out of HIV/AIDS-related access to care.”
Ultimately, country ownership today may mean ensuring that the money that has already been spent has a longstanding impact and sustainability.
Keeping Congress out
President Barack Obama is set to indicate his own vision for new PEPFAR funding when he unveils his national budget proposal for 2014, slated to take place in March.
CHANGE's Sippel points out that funding for PEPFAR won't actually halt if legislative re-authorisation does not take place, and she is urging that the president simply circumvent the politically fractious Congress.
“Given the climate with Congress right now, we don't think we have a positive political climate in which to pass effective legislation,” she says.
Certain PEPFAR policies required in the past by the Congress have angered some advocates, and in 2007 a previous IOM report criticised Congress for too tightly controlling how PEPFAR programmes functioned. Yet the new report now vindicates stripping these out, particularly supporting moving away from a previous focus on sexual abstinence and fidelity within marriage.
More problematic is a continued requirement that groups receiving PEPFAR funding must declare their opposition to sex work. While the IOM cautions it didn't have a mandate to work on this issue, it does note that sex-worker groups are best positioned to deal with prostitution-related HIV/AIDS issues - and warns that their efforts are currently being hampered by this requirement.
The report also shows that PEPFAR still hasn't figured out how to comprehensively address gender, Sippel says, with the committee researchers noting that responses to women are still “ad hoc”.
“That tells us women are still a blind spot in the global AIDS fight, despite being half of the population living with HIV,” she says. “Until PEPFAR develops a gender strategy with clear objectives and outcomes, we can't get ahead of HIV.”