PEPFAR Reauthorization in Danger
Just when it looked like PEPFAR would be reauthorized and that Congress would appropriate even more money than the president asked for, seven Senators, led by Tom Coburn of Oklahoma (along with Jim DeMint, Jeff Sessions, Saxby Chambliss, David Vitter, Jim Bunning, Richard Burr), have placed a hold on the bill, dramatically reducing the chances that it will pass this Congress. A hold is an obscure procedure in the U.S. Senate that enables any Senator to stop a bill that they do not like by preventing it from coming to the floor.
Michael Gerson, Bush’s former speechwriter, flagged this egregious action to set up an internal Republican dispute. As Gerson notes, Coburn objects that more of PEPFAR money is being spent on things other than treatment.
The seven, led by Coburn, complain that the reauthorization is too costly. They object to “mission creep” — the funding of “food, water, treatment of other infectious diseases, gender empowerment programs, poverty alleviation programs” — as though people surviving on AIDS treatment do not need to eat, work or get their TB treated.
They want 55% by law to be spent on treatment (which was how the first PEPFAR authorization worked) but this is stupid, as we’re not succeeding on prevention, meaning that more and more people are getting HIV and ultimately needing treatment. As Gerson writes:
Given that there are about 2.5 new HIV infections for every person starting on AIDS drugs, there is no way to control the pandemic through treatment alone. And because treatment is less expensive than it used to be, PEPFAR is meeting its treatment goal for less money. The 55 percent treatment floor would force the program to waste money in pursuit of an arbitrary, nonsensical spending target — the worst kind of congressional earmark.
You may want to give Coburn and company an earful about this nonsense. The ONE campaign has a letter to sign here. Direct contact info is available here.
UPDATE: Here is part of Coburn’s response where he rails against Gerson, touts his own credentials as a physician who has cared for AIDS patients and a consistent champion of HIV/AIDS programs. What he seems to be worried about is that the absence of a directive that 55% of PEPFAR money be spent on treatment will result in the program spending more money on consultants rather than services. I’m not sure if those funding directives are the best or only way to ensure that problem doesn’t occur.
Part of Gerson’s moral outrage is focused on my controversial stance that AIDS treatment dollars be spent on treatment. I want to preserve PEPFAR’s original formula that sends at least 55 percent of all dollars to AIDS treatment so widows and orphans and actual patients, not program officers and consultants, will be the primary beneficiaries of the program. This formula is made all the more important because the new authorization calls for a three-fold increase in funding from $15 billion over five years to $50 billion over five years. Moreover, this smart and well-designed policy, which Gerson once supported but now scorns, is a major reason why PEPFAR has been a Marshall Plan-like response, rather than a Katrina-like response, to the AIDS crisis in Africa.
Gerson’s determination to critique not just our policy concerns but our morality suggests that he is viewing this debate as proxy battle in the broader struggle in the Republican Party between what he views as “seedy” or “anti-government” conservatism and the “compassionate” conservatism he helped shape in the White House. That’s a broader debate that I welcome.
I don’t see a coherent answer to Gerson’s concern about prevention. I suppose that with an increased budget there would be enough money for treatment and prevention, even with the 55% limit, but 55% seems like an arbitrary Congressional mandate.
Filed under: Politics and Policy
I agree that the current congressionally-mandated earmarks for specific PEPFAR activities are arbitrary. Earmarking PEPFAR funds has limited host countries’ flexibility to respond to the particular nature of their epidemics, and in its 2007 review of PEPFAR, which was required by law, the Institute of Medicine recommended replacing the earmarks with a more flexible mechanism.
When PEPFAR was originally authorized in 2003, it was in response to an “emergency,” as the program’s name suggests. Virtually no funding was being spent on HIV/AIDS treatment abroad, because of a lack of commitment by donors and concerns that it was unfeasible to dramatically scale up access to anti-retroviral drugs in developing country settings. Making ARV drugs accessible to so many people living with HIV/AIDS has been a huge PEPFAR success story.
But we have come a long way since 2003. Skeptics about treatment’s feasibility have been proved wrong, and policymakers and donors now recognize the value of providing treatment. Having made great gains in addressing the emergency, we need to refocus energy and resources on making our fight against HIV/AIDS sustainable–and as the blog entry notes, this means greater attention to prevention. With the $50 billion that would be authorized by the pending legislation, PEPFAR will be able to scale up prevention without neglecting treatment.
Additionally, there are new or newly recognized prevention tools at our disposal that should greatly benefit those at risk of contracting HIV in the years ahead. For example, in the past few years, there has been a growing understanding that concurrent sexual relationships play an important role in the spread of HIV, leading to a recognition of the importance of interventions to encourage partner reduction. As another example, less than two years ago, studies provided strong evidence that male circumcision can reduce a man’s risk of HIV infection through heterosexual sex by as much as 60 percent, demonstrating the importance of making safe male circumcision services and related education widely available.
Over the next five years, additional new evidence about how best to respond to HIV/AIDS may come to light. It is evidence, and not earmarks, that should guide how PEPFAR resources are applied.
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PEPFAR 1 was an incredible very good start towards global efforts in the fight against HIV/AIDS. PEPFAR II will be enlightened by the best practices and success stories already achieved. The way forward has interesting challenges…Its an added value and strategic commitment from the US Government, Congress and senate to keep the PEPFAR alive!
[…] requirements also wastes aid resources. As Michael Gerson, President Bush’s former speech writer, points out: And because treatment is less expensive than it used to be, PEPFAR is meeting its treatment goal […]