The US president's Emergency Plan for AIDS Relief (PEPFAR) has committed about US$32 billion to the global fight against HIV since its launch in 2003, making it the largest donor for HIV/AIDS globally. Following annual increases in contributions, however, PEPFAR has effectively flat-lined funding from 2009.
IRIN/PlusNews spoke to Ambassador Eric Goosby, head of PEPFAR since June 2009, about how lower funding levels are likely to impact HIV programmes:
QUESTION: Why has President Barack Obama retreated on his campaign promise to provide at least $50 billion by 2013 for the global fight against AIDS?
ANSWER: President Obama has taken the number of people that PEPFAR pays for from 1.6 million to 2.5 million and has pledged through 2013 to cover over four million people on ARVs [antiretroviral treatment]. That's not a backing away.
The backing away is a perception because of the drop in the funding trajectory compared to other years. The reason for that is really the economic decline. The US has been heavily hit and as a result the president has flat-funded or decreased funding in every programme in the US government, except the military and development. We come under development and that’s why we have our increase which was small, just 3 percent.
Q: With flat-funding in many programmes, how does PEPFAR hope to achieve increased numbers on treatment?
A: The efficiencies are big; we do not expect any major drop in accrual of patients on treatment over the next couple of years because we have enough fat in the system to redirect resources and get smarter at delivering services. After seven years of doing this, we are better at it. When we started PEPFAR, it cost over $1,000 per patient [on treatment] per year; that figure is now in the low four hundreds.
As a result of the availability of cotrimoxazole [an antibiotic used to prevent HIV-related infections], earlier initiation of treatment and availability of diagnosis and treatment of tuberculosis, we are not treating opportunistic infections at anywhere near the rate we used to. The in-patient need has dropped off; we have moved this thing almost to an out-patient disease in many countries.
All of these are huge cost-savings - with the same PEPFAR amount, we are able to redirect those resources towards treatment expansion.
We are [also] making administrative changes, in procurement-distribution - for example, where we have one administrator for 20 clinics rather than 20 separate administrators for each clinic.
We have pretty much exhausted the move from brand [-name ARVs] to generics. We are more than 90 percent generic in PEPFAR-funded programmes. We need to get generics in second-line and we are a strong motor behind getting that straight.
Q: Why has PEPFAR maintained the so-called "anti-prostitution pledge" that effectively leaves sex workers - a high risk group for HIV - out of PEPFAR’s programmes?
A: What the clause really was focused on was to ensure that PEPFAR did not fund organizations involved in trying to legalize prostitution and traffic women into prostitution. We have changed it so an organization doesn’t have to sign [a separate document pledging to oppose sex work and sex-trafficking]; we have folded in an agreement that the [beneficiary] organization will not traffic women into prostitution - there is no separate document.
|If someone feels they were excluded or dropped put of care for [being a sex worker], we would get on that like a laser|
PEPFAR has not de-funded any programme on the planet for these reasons. We want to care for every sex worker out there. If a sex worker comes into any of our facilities, that person will be embraced and followed for the duration of their life on antiretrovirals.
If there are examples of anybody being turned away [for being a sex worker], if someone feels that they were excluded from or dropped out of care for those reasons, we would get on that like a laser.
Q: Why is there so little pressure from donors on African governments to take responsibility for funding their own HIV/AIDS programmes?
A: Our partner governments don’t feel the need to increase or maintain funding as PEPFAR or Global Fund [to Fight AIDS, Tuberculosis and Malaria] resources come into their countries. We need to hold our partner countries responsible for their populations and they need to maintain and increase funding lines.
Since I’ve been in office, every country I visit, I meet the president and minister of health and often the finance minster and have this discussion. Our partnership framework mechanism - a new process to engage in a different dialogue with countries around country ownership - brings that up as a centre-plate expectation. We are telling our partners: “Here’s how much we’re putting in for the following functions, how much are you putting in?”
We’re translating the human resources, the bricks and mortar, electricity or operational costs of a plant, into their costs as well as whatever resources they put into labs and drugs and procurement - countries do much of that. Once that baseline is established, we will hold an expectation that they maintain it and when they can, increase it, with specific percentages talked about.
The flip side to this is that the US government will not [use] a population that we are currently caring for with drug support or care support or in our prevention activities as a leverage point to force a government into putting more money toward this effort by abandoning or diminishing our contribution.