Prescription for PEPFAR II: Sharpening the Focus in the Global Fight Against AIDS
By Eric Goosby, MD, CEO, Pangaea Global AIDS Foundation and Mark Cloutier, MPH MPP, Executive Director, San Francisco AIDS Foundation
San Francisco, June 1, 2007 - On Wednesday, May 30, President Bush announced a commitment to extend and expand the U.S. response to the global AIDS disaster with an additional $30 billion for the President’s Emergency Plan for AIDS Relief (PEPFAR) over the next five years.
There can be no question that PEPFAR has created hope and a “can-do” spirit and is already saving lives. In the three years since the program has been implemented, more than 1 million people in have been provided treatment. Over half a million HIV+ pregnant women have received essential medicines that have prevented 100,000 babies from becoming infected. Through the combined efforts of PEPFAR and other donors, an infrastructure of care and treatment is being put in place in regions most affected by AIDS, and country governments and local community-based organizations are gaining a foothold in providing essential services.
This is truly a time of unprecedented opportunity to take the fight against AIDS to the next level. As the Congress, the Bush Administration, and the global AIDS community join forces in shaping PEPFAR II, we would urge everyone to maximize this opportunity to sharpen the focus of the program by embracing the following key principles:
- Support country ownership and leadership. The legacy of PEPFAR will rest with countries on the front lines, which must ultimately design and oversee a sustainable response in their own countries. What began as emergency relief must now be focused on the development of country-owned systems that can stand the test of time and reach out to all areas where people are living. The time has come for PEPFAR and all donor activities to be fully integrated with host government partners, not developed in parallel.
- Integrate prevention and treatment. There is an urgent need to intensify and scale up effective prevention. Worldwide, for every new person starting treatment, another six will become HIV infected. We cannot treat our way out of this epidemic. PEPFAR has contributed greatly to developing an infrastructure to deliver treatment, and now it is time to broaden our thinking and harness these capacities to push prevention at every opportunity.
- Support evidence-based prevention. We must also push past either/or propositions that pit prevention strategies against each other, such as abstinence vs. condoms or drug treatment vs. needle exchange. Scientific evidence has shown in multiple studies that abstinence only strategies are ineffective and can put women at greater risk. Extensive research on needle exchange programs has demonstrated their effectiveness in reducing risk of HIV transmission. There is merit in adopting multiple strategies depending on the particular target audiences. PEPFAR should leave formulating an effective balance of evidence-based prevention strategies to each country, rather than mandating specific set asides in Washington that can do more harm than good.
- Invest in health workers and health systems. Health workers are the backbone of systems of care. Yet PEPFAR countries already face severe shortages of doctors, nurses and community health workers, jeopardizing the ability to get the job done. Sub-Saharan Africa has only 3% of the world’s health care workers to combat 25% of the global burden of disease. More attention must be given by PEPFAR to working with host countries to increase the numbers of health care workers, to retain them with fair salaries and improved working conditions, and to build the capacity of community health workers to bring care close to the people.
- Share lessons learned to battle emerging HIV epidemics. Finally, there is a window of opportunity for countries that are now experiencing rising infections rates to learn from those that are already highly impacted. Sharing expertise as well as providing technical assistance and support to these “second wave states”can help to prevent burgeoning epidemics from spiraling out of control.
The President’s recommitment to the global fight against AIDS sends a strong signal to the rest of the world that global efforts are making a difference, but that there is much more to be done by everyone to win this fight. Let’s build on the success of the first five years of PEPFAR by supporting sensible and sustainable programs that provide measurable results — bringing much needed help and hope to our fellow global citizens.