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| Facts about PEPFAR Reauthorization For a list of suggested changes to the House and Senate current versions of PEPFAR, click here. Click on the links below to go to each section: Top 11 Facts to Know about PEPFAR Funding Treatment Absorptive Capacity Health Workforce Family Planning Integration Sexual Prevention Funding Prostitution Pledge and PEPFAR Food Security and Nutrition Global Fund to Fight AIDS, TB and Malaria Prevention of Mother to Child Transmission Tuberculosis Malaria Linkages Educating Girls Youth Women and Girls TOP 11 FACTS TO KNOW ABOUT PEPFAR
FUNDING President Bush and House Republicans have proposed $30 billion over 5 years (2009-2013), and has referred to this commitment as a "doubling" based on his initial pledge of $15 billion from 2004-2008. However, the $15 bn pledge really only included $9 billion in new funds, with the remainder comprised of no substantial increasing in funding for pre-existing programs ($5 bn for five years total) and insufficient levels of funding for the Global Fund to Fight AIDS, TB, and Malaria ($1 bn over five years total). Nonetheless, Congress and the Administration together exceeded the $15 billion sum over five years, and have appropriated $19 billion over the same time period. The total funding appropriated for FY08 is $6 billion. In order to... (A) continue progress towards meeting U.S. policy goals and keeping U.S. pledges at the G8 on universal access to treatment and prevention, and (B) contribute the U.S. Share of one-third of what the U.S.G's GFATM Board Delegation agreed last year, and (C) to address the critical shortages of health workers that are frustrating every effort to achieve or sustain success, *at least* $50 billion is necessary over the next five years. [Truthfully, to complete the full program of work in this bill including new efforts for malaria and TB, $59 billion will be closer to what is needed.] The "doubling" being referred to by President Bush and House Republicans is not even flat funding--$30 billion over the next five years is a slight reduction from existing FY 08 appropriations levels. U.S. Global AIDS initiatives cost substantially less at the beginning, since almost no people were receiving treatment- and frankly because we had let this epidemic get away. Now that we have turned a corner and infections rates have started to come down in some hard hit countries and we have powerful new tools to reduce Infection rates like male circumcision, now that there are very powerful new medicines that are transforming the lives of people with HIV in wealthy countries, now that other countries have finally started to meet some of the funding challenges* now is NOT the time to turn back. $50 billion would fund:
its original 15 focus countries to include small, high-prevalence countries which would benefit from PEPFAR programs. There will not be sufficient funding to address the dire shortage of healthcare workers, the biggest obstacle to meeting our 2003 goal of treating two million people by the end of 2008, let alone continuing to increase the number of people on treatment. (* notably UK, Norway, France, Canada have stepped up funding for AIDS and health) back to top TREATMENT Bush and Republicans proposed that we dramatically scale- back the pace of treatment scale up. In 2003, President Bush pledged that the United States would provide treatment to two million people by 2008-- this was about one-third of the people in immediate clinical need of medicine to stay alive at that time. Now we are supporting 1.4 million on AIDS treatment. And, due to a one-time change of the time in which HIV patients should begin therapy, UNAIDS estimates that a minimum 14 million people will be in immediate need of HIV drugs by 2013*. There are now very powerful new medicines that are transforming the lives of people with HIV in wealthy countries, and treatment expert Martin Delaney from Project Inform in San Francisco reports that pretty much everyone with HIV should be able to achieve undetectable levels of virus in their blood stream, and that no longer should people with HIV be experiencing harmful side effects. New data confirms that HIV-positive people who are able to sustain undetectable HIV virus in their blood streams are greatly less infectious, and therefore ensuring people receive treatment contributes to reductions in new infection rates (when balanced with all other comprehensive prevention strategies, of course). The Republican proposal to treat only 2.5 million people effectively slows an ambitious bipartisan five-year program treating one-third of people with HIV in poor countries in clinical need to become a much more modest ten-year program to only support treatment for about 17% of those who will die without our help. We can--and must-- do better than this. We have come too far to turn back now, and we should continue to treat at least one-third of those in need --about 4 million by 2013. [* 14 million in clinical need: this is under the UNAIDS "go-slow" scenario where U.N. member states pledges to achieve universal access by 2010 are not achieved until 2015. The U.S. agreed and has repeatedly reaffirmed this pledge in international policy settings.] back to top ABSORPTIVE CAPACITY Some have claimed that countries in Africa cannot absorb increases in aid because there is nowhere for the money to go. To the extent t that this is true, it is simply a reason to address the greatest barrier to scaling up access to treatment - the lack of trained health workers. By addressing the shortage of healthcare workers, the US can build poor countries' own capacity to address critical health needs and have a lasting impact. To train an additional 140,000 new healthcare workers will cost the US $8 billion over five years. Additionally, the US delegation to th Global Fund decided, at the April 2007 Board Meeting, to expand the size of the Global Fund to $6-8 billion per year. In order to reach this goal, the US needs to increase its contribution to the Global Fund to at least $2 billion per year, from the current level of $500 to $700 million per year. The Global Fund works in over 170 countries to provide life-saving treatment and prevention services, and the US has a responsibility to ensure our contribution keeps pace with the epidemic and keep our commitment to increase the size of the Global Fund. The House bill also expands PEPFAR to include tuberculosis and malaria programs (including the President's Malaria Initiative). TB and malaria are the leading killers of people with HIV, and addressing them is critical to fighting AIDS effectively. The malaria provisions in the bill will cost $4 billion, and the TB provisions will cost $5 billion. back to top HEALTH WORKFORCE According to Ambassador Mark Dybul in testimony before the House Committee on Foreign Affairs --as well as the World Health Organization, the World Bank, and many others--the critical shortage of trained health workers is the central impediment to scaling up access to treatment and prevention, and the biggest challenge to putting our investments to work effectively. As the Institute of Medicine review found, "[T]he growing consensus is that existing capacity for HIV/AIDS services is nearing exhaustion, and donors need to focus more on helping to expand capacity ... The shortage of health care workers of all kinds was particularly acute." UNAIDS estimates that the full-time equivalent of 427,500 new health workers are needed to deliver HIV services required to keep our commitment to universal access. Corresponding with US leadership on AIDS, we need to train and retain at least 140,000 new health professionals (1/3 of the need). Without these health workers, PEPFAR will fail to meet its targets and U.S. will not be able to keep its international commitments to universal access. And PEPFAR will cause harm to other aspects of the health system. The IOM report found: "PEPFAR's HIV/AIDS activities have sometimes negatively affected other aspects of public health systems and exacerbated resource constraints, particularly those related to national human resource settings. If Focus Countries' national plans for expanding their health workforce are not supported, PEPFAR can worsen national shortages by shifting a disproportionate share of the workforce to HIV/AIDS activities, which might cause other health areas to be neglected...." Indeed, PEPFAR can only meet its goals and sustain its success if the United States does much more to support national plans to train, retain, and deploy health workers. The crisis is acute -- 36 countries in sub-Saharan Africa have fewer than the 2.3 doctors, nurses, and midwives per 1,000 people that WHO considers a minimum for delivering essential health services. With proper investments in training new health workers, providing living wages and incentives to work in rural areas, and improved working conditions, countries can develop the health workforces required to deliver on HIV/AIDS goals -- and not at the expense of other health services (including for mothers and children). Consider: Sub-Saharan Africa's second most populous country, Ethiopia, has fewer than half the physicians that Washington, DC has -- even though DC has less than 1% of Ethiopia's population. The 140,000 healthcare workers that are trained with US funds must be new healthcare workers. It is not sufficient to train primary care physicians in AIDS care, as this draws doctors away from primary care and increases the strain PEPFAR places on already overburdened health systems. Additionally, Sub-Saharan Africa is suffering a shortage of nearly 1.5 million health workers, including more than 800,000 doctors, nurses, and midwives. PEPFAR must have a leadership role in responding to this broader shortage, and cannot focus narrowly on developing “HIV health workers.” When HIV services are provided in primary health settings, or are integrated with other health services – as must be the case to expand access to these services – health workers are providing both HIV and non-HIV health services. Developing the health workforce needed to deliver HIV services is therefore inextricably linked with countries’ overall efforts to develop and implement strategies to overcoming their health workforce crises. back to top FAMILY PLANNING INTEGRATION More information here. back to top SEXUAL PREVENTION FUNDING According to the Global AIDS Act, it is the “sense of Congress” that an effective distribution of funds includes 20% for prevention of HIV. Congress mandated that 33% of prevention funds be ear- marked for abstinence-until-marriage programs starting in 2006. The Office of the Global AIDS Coordinator (OGAC) adopts the “ABC” approach to HIV prevention (Abstain, Be faithful, use Condoms) and interprets the abstinence-until-marriage earmark to apply to programs that exclusively teach abstinence and/or being faithful (AB only). OGAC also determines the ways in which PEPFAR recipient countries must incorporate the ABC model and the abstinence-until-marriage earmark into their plans to prevent HIV within populations at risk. In the next five years of PEPFAR, Congress should: • Remove the 1/3 abstinence-until-marriage earmark and fund comprehensive, integrated, and evidence-based HIV prevention programs that promote and protect women’s health. • Expand access to HIV prevention programs and reproductive health services by integrating these programs to help prevent HIV infections among women and girls, avert HIV transmission from mother-to-child, and support HIV-positive women’s reproductive rights and fertility choices. • Strike the anti-prostitution pledge and support programs that advance effective HIV prevention interventions, promote fundamental human rights and free speech, and reduce stigma and discrimination against marginalized populations. (See www.pepfarwatch.org for more information on the anti-prostitution pledge.) back to top PROSTITUION PLEDGE AND PEPFAR There are two provisions related to prostitution in the Global AIDS Act. One ensures that US government funds may not be used to “promote or advocate the legalization or practice of prostitution and sex trafficking.” The other, referred to as the pledge requirement, requires all funding recipients to “have a policy explicitly opposing prostitution and sex trafficking.” 1. The pledge has led to a chilling effect on HIV programs serving sex workers. What does it mean to oppose prostitution? Some think it is supporting prostitution to give women condoms to protect themselves. The pledge has forced groups to cut back on their life-saving HIV prevention activities – even when those programs are funded by other donors.
Charitable organizations oppose the pledge requirement, including InterAction, the Global Health Council, International Rescue Committee, Save the Children, and CARE. Women in prostitution are at very high risk for contracting HIV and passing it on to others, but are often hesitant to seek out health services if they think it will put them at risk for arrest, further stigma, or fines. Large numbers of sex workers are already HIV infected. In parts of Senegal, HIV prevalence among female sex workers is as high as 30%. In Burma, almost 40% of sex workers are HIV positive. In parts of Russia, one out of four sex workers is HIV-positive. In Guyana, one out of three sex workers is HIV-positive. (All from 2007 UNAIDS report.) back to top FOOD SECURITY AND NUTRITION There are currently approximately 820 million undernourished people in the developing world. The situation is particularly acute in sub-Saharan Africa where, for at least the last three decades, hunger has steadily worsened, becoming more widespread and persistent over time. In many parts of Africa, events that would not have triggered major food emergencies twenty-five years ago now do so. HIV/AIDS has made a bad situation worse, adding an especially heavy burden to individuals and families already struggling to grow or afford the nourishing, sustainable food and agriculture they need to live. HIV and food insecurity compound and exacerbate each other—AIDS epidemics are most devastating in sub-Saharan Africa where famine or malnourishment are also most severe. Families often face tough choices, deciding on a daily basis between food or lifesaving ARVs for a sick parent. Causes and consequences run in both directions. Food insecurity can contribute to adverse HIV and AIDS impacts in several ways: in order to survive, hungry people may turn to unsafe transactional sex, increasing their risk of infection, while malnutrition increases susceptibility to opportunistic illnesses and speeds the onset of full-blown AIDS. A recent study in Botswana and Swaziland detected a clear association between food insufficiency and HIV risk behavior, especially for women. When the health of HIV-positive people declines, they are often less able to engage in farming and other productive activities and they divert or sell basic resources like seeds or fertilizer to support medical care and other expenses. The phenomenon of cascading incapacity undermines the economic security of AIDS-affected families and results in ill health, diminished productivity and ‘reverse development’ for whole communities. Integrating and expanding food security and nutrition efforts within PEPFAR will strengthen our fight against global AIDS and help individuals and communities help themselves. Building linkages and enhancing coordination across U.S. programming directed at HIV and AIDS and other vital health, development and humanitarian relief efforts will increase our effectiveness in preventing and treating HIV/AIDS while enhancing the efficiency and cost-effectiveness of U.S. foreign aid resources we invest worldwide. As the Institute of Medicine (IOM) concluded in its recent evaluation of U.S. global AIDS programming, PEPFAR must begin to transition away from an emergency focus and adopt a greater, more holistic emphasis on sustainable impact over the long-term. The Food Security and Nutrition provisions— • Puts the Congress on record in support of stronger food and hunger policies in the context of HIV/AIDS; • Aligns U.S. policies and programming to more fully integrate food and nutrition support into care, treatment and support programs related to HIV/AIDS; • Ensures that PEPFAR conducts status and needs assessments and nutritional counseling related to food security and hunger, and establishes more effective linkages, coordination and referral when HIV-affected populations experience food insecurity; and Provides for enhanced food and nutritional support to HIV-affected individuals who need assistance, along with higher, WHO-established body mass index thresholds (qualifying at 18.5 or less), for an appropriate period of time, either directly or through referrals back to top THE GLOBAL FUND TO FIGHT AIDS, TB & MALARIA Success to Date
o 1.4 million people have been treated with lifesaving AIDS treatment;
o 3.3 million cases of TB have been treated under DOTS; and, o 46 million bed nets have been distributed to protect children and their families from malaria.
few years, and the vote passed. In order to achieve this, the US will need to increase its annual contribution to at least $2 billion per year. Additionally, the current language that prohibits the US from contributing more than 33% of the Global Fund's overall budget must be removed. Other countries should step up and fund their fair share, but the US must lead the way, and not condition the amount of money given to the Global Fund on the donations of other governments. back to top PREVENTION OF MOTHER TO CHILD TRANSMISSION Prevention of Mother-to-Child Transmission: Preserve the 80% PMTCT target in the Lantos bill • Every day, more than 1,100 children across the globe are infected with HIV, the vast majority through mother-to-child transmission during pregnancy, labor or delivery or soon after through breast-feeding. We know how to prevent such transmission from happening, yet, tragically, only 10% of women in need of PMTCT services in low and middle income countries have access to the necessary medical interventions. • Congress must take steps to dramatically scale-up PMTCT efforts by establishing a five-year target for PMTCT efforts: in those countries most affected, 80 percent of pregnant women receive HIV counseling and testing, and all of those testing positive for HIV receive anti-retroviral medications for prevention of mother-to-child transmission. Pediatric Treatment: Preserve the 15% Pediatric Treatment Target in the Berman bill • Globally, children’s access to ARVs is approximately half that of adults. While the rate at which both adults and children become infected far outpaces the rate at which they are treated, the disparity is particularly severe for children. • For the 2.5 million children HIV-infected children around the world, access to anti-retroviral (ARV) therapy is critical to growing up healthy and reaching adulthood. • Because children are not just small adults, providing HIV care and treatment presents special challenges, including: limited access to reliable HIV testing for the youngest children; a shortage of providers trained in delivering pediatric care; weak linkages between services to prevent mother-to-child transmission and care and treatment programs; and the need for additional, low-cost pediatric formulations of HIV/AIDS medications. • While children account for almost 16 percent of all new HIV infections, they make up only 9 percent of those on treatment under PEPFAR. Without proper care and treatment, half of these newly-infected children will die before their second birthday, and 75% will die before their fifth. • To ensure equity for children, Congress must establish a target requiring that, within five years of PEPFAR reauthorization, 15 percent of those receiving treatment under PEPFAR be children, to keep pace with the infection rate. back to top TUBERCULOSIS Fight Against Tuberculosis:
MALARIA Background: Each year, as many as 515 million people are affected by malaria, and more than 1 million people die from this devastating disease, the majority of these being children and pregnant women. Malaria is the number one killer of African children – though it remains a preventable and treatable disease. Insecticidal spraying and long-lasting insecticidal bed nets cost only $5-10 per home, protecting an entire family for 1-5 years. And effective drugs costing as little as $1 each can cure malaria. Led by the Global Fund to Fight AIDS, TB and Malaria and the US President’s Malaria Initiative (PMI), the global community is making tremendous strides to control malaria. Over 170 millions doses of Artemsinin-based combination therapy drugs and over 100 million insecticide-treated nets have been distributed to date. Notably the PMI is helping all 15 of its target countries developed indoor residual spraying programs – some for the first time ever. While there are new tools to combat malaria effectively, we must also maintain their effectiveness. The authorization provided for malaria in the PEPFAR reauthorization bill will help the US to lead investment in research and development efforts including operational and implementation research as well as the development of new tools and new classes of insecticides. This is key to future successes in malaria control globally. It is imperative that we not only sustain this momentum, but it is equally important to build upon the current wave of successes. New funding in the order of $5 billion USD is needed to continue to scale up key interventions, as well as strengthen health systems, regulation and mechanisms of measurement on which long term malaria control depends. back to top LINKAGES HIV/AIDS affects the same populations who already suffer from diseases of poverty. Sub-Saharan Africa a region with extremely high HIV prevalence rates shares 24% of the disease burden. PEPFAR focus countries of Mozambique, Ethiopia and Rwanda are not only experiencing high HIV prevalence rates but also fall under the list of countries with high child mortality rates. Children affected by HIV are also at a high risk of dying from pneumonia, diarrhea, measles and other treatable diseases due to lack of immunizations. In the absence of a U.S. coordinated/integrated global health strategy, it is critical that when and where possible, PEPFAR’s HIV specific services must be coordinated or integrated with non-HIV services. This on-the-ground coordination will further enable efforts to increase the focus on prevention and to make efforts to provide a range of health services to an HIV affected community. back to top EDUCATING GIRLS The data on the link between education level and HIV/AIDS underscore what people know intuitively – education is one of the best defenses against HIV infection. Data compared across countries and regions and disaggregated by education levels show that young women and men with higher levels of education are more likely to have increased knowledge about HIV/AIDS, a better understanding of ways to avoid infection, and an increased likelihood of changing behavior that puts them at risk of contracting the disease. A very recent review of research from 11 countries in sub-Saharan Africa found that, since 1996, studies were more likely to find a lower risk of HIV infection among the most educated and concluded that "increasing school attendance may reduce HIV transmission among young people." For example, In Ethiopia, more than four out of five educated young women aged 15 to 24 knew that a healthy-looking person could be HIV-positive, compared with less than a quarter of women with no education. Educated young women were also more likely to know where to go to be tested for HIV. Survey data from Zambia demonstrate that women with secondary and higher education are more likely to delay sex, while those with no education are more likely to have sex with one partner without a condom. Sources: Girls, HIV/AIDS and Education, UNICEF, 2004; Hargreaves, J.R. et al. “Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa.” AIDS, 22: 403-414 (2008). back to top YOUTH
WOMEN AND GIRLS The President’s Emergency Plan for AIDS Relief (PEPFAR) has established the following five priority strategies to address women’s and girls’ vulnerability to HIV infection: 1. Increasing gender equity in HIV/AIDS activities and services; 2. Reducing violence and coercion; 3. Addressing male norms and behaviors; 4. Increasing women’s legal protection; and 5. Increasing women’s access to income and productive resources. However, advocates who monitor PEPFAR activities are deeply concerned about the implementation of these strategies. Specifically, they are concerned about the quality and effectiveness of some programs; and the willingness of OGAC to fund stand-alone projects to address gender concerns. They are also concerned that OGAC suggests it cannot fund many primary prevention programs around improving women’s legal and economic status, ending violence against women and girls, or male engagement if they do not show an immediate and direct relationship with lowering the rate of HIV/AIDS infection. Additionally, it appears that gender issues still remain marginalized and are not recognized as critical to the success of broader PEPFAR goals. Given HIV/AIDS’ disproportionate impact on women and girls, it is imperative that women be at the center of PEPFAR in the next reauthorization. We recommend that the PEPFAR reauthorization bill require the Office of the Global AIDS Coordinator to develop a prevention strategy to confront the soaring HIV infection rates among women and girls. The strategy must adopt a broad approach that addresses such factors as widespread physical and sexual violence against women and girls, women’s poverty and their economic dependence on men, their relative lack of education, male attitudes and behaviors that reinforce inequality, insufficient access to female-controlled prevention methods, and insufficient legal protection for property rights or against harmful practices such as violence or child marriage. In addition, the strategy must reflect a strong institutional commitment to addressing gender issues, through appropriate leadership, training, guidance to the field, and monitoring and evaluation tools back to top |
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