PEPFAR, the Sequel

On July 30, 2008, President Bush signed into law a five-year continuation of the President's Emergency Plan for AIDS Relief (PEPFAR). Since 2003, PEPFAR has provided HIV medications to nearly two million people, mostly in Africa. While the new law contains many improvements, it still falls short of the need.

The new law does not include a target for the number of people who will receive treatment. It relies instead on a complicated formula that may lead to fewer people on treatment overall and actually lower funding levels. Advocates are calling for the U.S. to support treatment for four million people by 2013.

In many places in Africa, people receiving HIV treatment must take drugs that have harsh side effects, even though better versions are available. These higher quality medications should be made available through PEPFAR. This will also have the effect of reducing the cost of these better treatments.

PEPFAR now includes provisions calling on countries in the program to offer HIV-prevention programs for men who have sex with men (MSM), and research on HIV incidence among MSM in countries that receive PEPFAR funding. This provision will address the fact that MSM are at much higher risk for HIV than the general population.

The new legislation also affects the response to HIV in the U.S. It removes the ban on HIV-positive noncitizens gaining immigration status and travel visas that was passed by Congress in 1993. The U.S. was one of only 13 countries to ban short-term HIV-positive visitors. Until the final call to pass the bill, conservative policymakers threatened to propose amendments to strike the language that lifts the ban. At the time this article went to print, the decision to remove the ban completely rests within the Department of Health and Human Services (HHS), since HIV remains on a list of "communicable diseases of public health significance."

PEPFAR countries must still spend 50% of their prevention funding on unproven "abstinence-only" programs. Or they must do burdensome reporting to justify other approaches, which could lead to possible defunding. The legislation also fails to support integration between family planning services and HIV programs for vulnerable populations like women and youth. Lastly, groups seeking funding must still oppose commercial sex work, even though prevention programs for sex workers have been proven to reduce HIV infection dramatically.

The renewal of PEPFAR and its increased funding is a remarkable step in the fight against HIV around the world. However, the importance of prevention efforts cannot be overstated. For every person who starts HIV treatment, 2-3 more become infected. It is critical that countries be able to both treat and prevent HIV without ideological restrictions.

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