As of September 2006, PEPFAR had administered treatment to only about 822,000 people of its target 2 million.

When President Bush first announced the five-year, $15 billion President’s Emer­gency Plan for AIDS Relief (PEPFAR) in his State of the Union address on January 28, 2003, the plan was met with welcome ears. The State Department billed PEPFAR as the “largest international health initiative in history dedicated to a single disease,” outlining plans to treat 2 million people, prevent 7 million new infections, and care for 10 million AIDS-afflicted individuals in fifteen target countries over the five-year period. As the President restated in his 2007 State of the Union address, “[o]ur work in the world is also based on a time­less truth: to whom much is given, much is required…We must continue to fight HIV/AIDS.” Yet even as the U.S. government pours increasing amounts of funding into the initiative, allocating $10 billion for fi­nancial years 2007 and 2008 alone and bringing the five-year total to more than $18.3 billion, outspoken critics of the plan and its implementation have caused many of the ears that were so welcome five years ago to begin going noticeably deaf.

The history of HIV/AIDS and its treatment is a short but rapidly-evolving one. Barely 25 years have passed since a New York Times article on an outbreak of Kaposi’s Sarcoma and Pneumocystis car­inii pneumonia (PCP) among young homo­sexual men in New York and San Francisco alerted the world to the presence of AIDS. In the months following the July 1981 re­port, the additional emergence of the unusu­al tumor and the rare lung infection among injection drug users, blood transfusion re­cipients, and heterosexual couples across the United States and abroad drew the im­mediate attention of concerned doc­tors and medi­cal researchers world­wide. In 1993, scien­tists at the Insti­tute Pasteur in France first isolated and identified Lymphade­nop­athy-Associat­ed Virus (LAV), later renamed Human Im­munodeficiency Virus (HIV), as the cause of AIDS. In 1987, azidothymidine was approved as the first antiretroviral drug for the treatment of AIDS. In 1990, Congress signed the Ryan White Comprehensive AIDS Resource Emergency Act to improve the quality and availability of care for HIV/AIDS-afflicted persons in the United States. And in 1998, more than 15 years after the predictions of an AIDS vaccine “within two years,” the first human trials in the United States of an AIDS vaccine began.

PEPFAR comes as the next install­ment in the history of humanity’s fight against HIV/AIDS and one of the U.S. government’s first major attempts to com­bat the pandemic outside the United States. Whereas domestic HIV/AIDS expenditures have averaged already close to $20 billion per year in the past three years, American contributions abroad totaled a mere $840 million annually as of late 2001 and showed only marginal growth until the introduction of new spending policies in 2003. The Pres­ident’s current initiative aims to increasing funding and “turn the tide against AIDS” by targeting fifteen “focus countries” that are home to approximately half of the world’s 40 million HIV-positive people: Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia. An estimated more than 6,000 people contract HIV every day in these countries alone, and in these focus countries and elsewhere, the HIV/AIDS pandemic has killed more than 20 million of the estimated 60 million people it has infected in the past 25 years, leaving 14 mil­lion orphans worldwide. Close to a tenth of all AIDS cases in Africa and the Caribbean concern children under the age of 15.

In light of these statistics, the Bush administration adopted a three-part ap­proach to fighting HIV/AIDS. First, by raising HIV/AIDS awareness and increas­ing knowledge about prevention measures, it aims to prevent 7 million new infections, or 60 percent of the new infections that were predicted for the target countries over the five-year period. Second, by providing widespread advanced antiretroviral treat­ment to the “poorest, most afflicted countries,” it aims to treat two million HIV-infected people. Third, by establishing more than two hundred new medical centers and facilities, it aims to care for 10 million HIV-infected individuals and AIDS orphans. Many of these measures have become possible only recently, with the price of advanced antiret­roviral drugs that can effectively suppress the AIDS virus in most infected persons falling in the past decade from over $12,000 to under $300 per year. In addition, a 2002 United States decision to permit the cur­rent target countries to override patents on certain imported drugs to fight HIV/AIDS, malaria, tuberculosis, and other infectious epidemics has also significantly increased access to emergency life-saving pharma­ceuticals.

Current implementation of the Presi­dent’s plan is based on a “network model” originally employed in Uganda but now in use in most of the target countries. It con­sists of a layered network of central medi­cal centers (CMCs) that support a stratified series of satellite centers and mobile units in both urban and rural communities. The CMCs provide the highest level of care, staffing high-expertise physicians, nurses, and laboratory technicians in preexisting urban hospitals. Primary satellites, the majority of which are independent medical centers run by faith-based groups and other non-governmental organizations, offer anti­retroviral treatment and basic medical care. Secondary satellites, staffing nurses and medical technicians, perform tests to diag­nose HIV but refer HIV-positive patients to CMCs or primary satellites for treatment. Tertiary satellites and mobile units, located in the most remote areas, offer standard clinical evaluations and the distribution of medication pack refills for patients already under treatment.

Due to a Congressional stipulation that 55 percent of PEPFAR funding go to­ward purchasing and distributing antiretro­viral drugs for individuals with HIV/AIDS, with another 25 percent being designated for the palliative care of afflicted persons and the assistance of orphans and vulner­able children, however, comparatively little money is being spent on HIV prevention work. As a result, contention over how this sum is spent is particularly fierce. Critics from several groups of differing political, religious, and ideological views, who orig­inally cooperated to ensure that the 2003 legislation was passed, are now especially dismayed by the requirement that at least one third of the prevention funding must be spent on programs promoting sexual absti­nence before marriage. And even in regard to non-abstinence prevention measures, PEPFAR’s five-year strategy document references condom provision and promo­tion for only those who practice “high-risk behaviors,” namely “prostitutes, sexually active discordant couples, substance abus­ers, and others.” No mention is made in the document of promoting condom use as a means of helping young people in general.

Consequently, despite the many suc­cesses of PEPFAR, increasing disagree­ment among initial supporters of the plan has brought to light a number of logistical problems and difficulties. Most troubling seem to be policy and funding restrictions that critics feel do not adequately take into consideration evidence of what is most effective in combating HIV/AIDS, such as a landmark statement from the plan’s First Annual Report that “Emergency Plan funds will not support needle or syringe exchange.” Although providing drug us­ers with sterile syringes through needle ex­change programs has been proven to help reduce the spread of blood-borne HIV, the U.S. government opposes such measures because it believes they make drug use seem more acceptable.

Another particularly controversial clause of the 2003 legislation states that “[n]o funds made available to carry out this Act, or any amendment made by this Act, may be used to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking.” As a result of the question­able “ethical and human rights principles” of this condition, Brazil refused $40 mil­lion in PEPFAR-related funds in May 2005, and the BBC World Service Trust aban­doned in January 2006 a USAID-funded, multi-million-dollar AIDS awareness cam­paign in Tanzania. And after several non-governmental organizations successfully challenged the constitution­ality of the anti-prostitution clause in two separate cases in May 2006, a higher court overturned one of the rulings and again upheld the policy. As a result, both Brazil and the BBC World Service Trust have openly criticized PEPFAR’s desire to “work with leaders throughout the world to combat HIV/AIDS, promoting integrated prevention, treatment, and care interven­tions” because of certain questionable poli­cies and funding restrictions.

The five-year plan enacted by the 2003 legislation ended this month, but while President Bush signed a bill in late July authorizing an expansion of funding for the program through 2013, PEPFAR clearly still has a long way to go. As of September 2006, PEPFAR had adminis­tered life-saving antiretroviral treatment to only about 822,000 people of its target 2 million, and many individuals in need of treatment in less urban areas still do not have access to it. Officials have made it clear, however, that America fully intends to continue funding international AIDS programs for many years to come. “There is no feeling here that this is just a five-year program,” said Jimmy Kolker, cur­rent deputy U.S. Global AIDS coordinator under the Bush Administration. “There is no question that this kind of funding will stop. We are not walking away from the people who are on this program. We have a commitment to make sure that people who get life-saving treatment…will continue with that course of treatment.” How well this commitment is maintained, and what it might look like in the future, are issues that will rest in the next president’s hands.