Hopes are high that the change promised by incoming US President Barack Obama will extend to his foreign policy, but for more than two million people living with HIV, mainly in Africa, the changing of the guard at the White House may elicit mixed feelings.
For them, outgoing President George Bush's term in office has meant nothing less than an extension of life. In 2003 he launched the US President's Emergency Plan for AIDS Relief (PEPFAR), which has provided US$18.8 billion in HIV/AIDS funding - the largest international health initiative dedicated to a single disease.
The money has helped provide life-prolonging antiretroviral (ARV) drugs to more than 2.1 million people, most of them living in 15 focus countries, according to the programme's 2009 annual report to the US Congress.
It has also contributed to the care of more than four million orphans and vulnerable children, provided HIV counselling and testing to nearly 57 million people, and made prevention of mother-to-child HIV transmission services available to nearly 1.2 million pregnant HIV-positive women.
Although PEPFAR has generated its share of controversy, the decision to extend it for another five years and increase funding to US$48 billion received bi-partisan support in the US Congress in July 2008.
The question then, is not whether PEPFAR will continue under Obama's administration, but whether it will continue in the same form.
The programme's achievements in providing treatment and care are on fairly solid ground. Although there have been questions about precisely how it counts its beneficiaries, there is no question that it has saved lives.
"Several 100,000 people in South Africa are alive, thanks to the PEPFAR programme," said Dr Francois Venter, president of the Southern African HIV Clinicians Society. "They've patched up gaps in provision to groups like illegal immigrants and refugees. I think there's fairly universal acknowledgement it's been a successful programme."
|Several 100,000 people in South Africa are alive, thanks to the PEPFAR programme|
Among the early criticisms of PEPFAR was the Bush administration's decision to take a bilateral approach rather than increasing funding to multilateral organisations like the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Its focus on one disease was also seen as unlikely to strengthen weak health systems in the target countries.
Today, it is generally accepted that the bilateral approach was necessary. "I think it was the right decision in terms of bringing [HIV/AIDS] services to people," said Michael Bennish, a senior associate with the Bloomberg School of Public Health at Johns Hopkins University in Baltimore, and executive director of Mpilonhle, a PEPFAR recipient in South Africa.
"I think there were inefficiencies in the Global Fund programme in terms of reaching out to NGOs like ourselves," he said.
The issue of whether PEPFAR has strengthened health systems by investing in equipment, infrastructure and staff, or weakened them by creating vertical programmes that have drawn manpower and resources away from dealing with other health problems is still up for debate.
"The health system [in South Africa] is weak, not because of PEPFAR, but because of the health ministry," Venter commented. "Arguing for donors to fit in with local agendas is terribly politically correct, but under Manto's leadership [former South African health minister Manto Tshabalala-Msimang], it wasn't a good idea."
Science instead of ideology
It is in the area of HIV prevention that PEPFAR has most irked AIDS activists. They have maintained that requirements such as that a third of prevention funding be spent on programmes promoting abstinence outside of marriage were influenced by religious conservatives in the Bush administration, and have no scientific basis.
Current policies also prohibit funding for organisations that target sex workers with HIV prevention, or for needle exchange programmes to prevent the spread of HIV among injecting drug users.
In the new mandate authorised by Congress in July 2008, the abstinence requirement was removed, but a new reporting rule requires recipients who spend less than 50 percent of prevention funds on abstinence programmes to justify their decision.
"We don't know the impact [of the new reporting requirement] yet, but implementers on the ground suggest it pushes a bias towards abstinence interventions," said Serra Sippel, executive director of the Centre for Health and Gender Equity, a US-based non-governmental organisation focused on the effects of US international policies on women's health.
|Under Obama, I'd hope that they'd look at the science of things and base decisions on facts and not beliefs|
The policy regarding sex-workers remains in force and, according to Sippel, would require a lengthy process of legislative reform to revise. "We feel we might be able to accomplish more by trying to change the way the programmes are implemented," she told IRIN/PlusNews.
Changing the policy would require action from President Obama, who has already indicated that he plans to overturn a policy banning funding to international organisations that perform or promote abortion. Activists have long argued that the 'global gag rule', as the policy is unofficially called, is detrimental to family planning efforts and to maternal and reproductive health.
Obama disappointed many in the HIV/AIDS sector when it emerged recently that he would not be immediately replacing Ambassador Mark Dybul as the Global AIDS Coordinator. Dybul is strongly associated with PEPFAR's ideologically driven approach to HIV prevention.
"It's a problem, Dybul's being kept on," commented Sippel. "He's been implementing these policies that aren't evidence-based. We're hoping he'll be given explicit guidance from the Obama administration."
Several organisations that receive PEPFAR funding, while full of praise for the programme's achievements, told IRIN/PlusNews that they would also like to see Obama make some changes in the way it is implemented.
"I think the evidence is overwhelming that abstinence programmes aren't effective, that they don't reflect the reality of the world we live in," said Bennish, adding that his organisation struggled with a PEPFAR ban on the use of its funding to distribute condoms at schools, a rule that clashes with national policy in South Africa, which states that any child over the age of 12 can consent to reproductive health services.
"There's no sense preaching the gospel of condoms and then not having them available," he said. "Under Obama, I'd hope that they will look at the science of things and base decisions on facts and not beliefs."
Bennish and other recipients also expressed the hope that under Obama, PEPFAR would relax some of its more onerous reporting and record-keeping requirements, and demonstrate greater flexibility in adapting to local realities.
"We feel much more can be done if we're prepared to take into consideration communities' cultures and own ways of viewing things," said Alfred Mikosi, executive director of Lifeline Southern Africa, a PEPFAR beneficiary organisation that provides HIV/AIDS counselling, education and training.
During their election campaign, Obama and his deputy president, Joe Biden, released a plan to combat global HIV and AIDS in which they pledged that "best practice, not ideology" would drive US funding for HIV/AIDS programmes.
They said they would "support the rights of sovereign nations to access quality-assured low-cost generic medication to meet their pressing public health needs". This will mean going up against the big pharmaceutical companies and pushing through licensing policies to make the latest ARV drugs available to people in developing countries.
They also promised to "dramatically increase" HIV/AIDS funding, not only to PEPFAR but also to the Global Fund, a goal the new administration may be forced to re-evaluate in light of the international financial crisis and the many priorities competing for US government spending.
"We have to keep the pressure on them to uphold their promise to increase [HIV/AIDS] funding," said Sippel. "We're trying to make the case that it's the poor and most vulnerable that are going to be hurt the most by this [financial] crisis, so we [the US] need to make sure we step up to the plate and provide the funding we've committed to."
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John Prendergast and John Norris of Enough, a US-based project to end genocide and crimes against humanity, took a different view in a recent strategy paper: "While responding to the HIV/AIDS pandemic is a crucial priority, if US development assistance becomes skewed too far in this direction, it will become very difficult to make long-term investments in state-building, the rule of law, basic education, and economic growth."
To what extent Obama's campaign promises regarding HIV and AIDS will translate into policy remains to be seen, but expectations are high.