President Bush recently asked the United States Congress to extend the mandate of a strategy to relieve the global HIV/AIDS crisis, which is particularly prevalent in Africa. Since its introduction in late 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR) has been credited with saving the lives of many people infected with HIV by providing them with essential medicines and implementing initiatives to curb the spread of AIDS. A few months ago, President Bush asked Congress to approve another $15 billion for PEPFAR, which would extend the plan to 2013. But, almost since its inception, PEPFAR has been extremely controversial. AIDS activists maintain that it has worsened, rather than alleviated, the AIDS pandemic because of what they term an “unrealistic” emphasis on abstinence and faithfulness as prevention methods. In a series focusing on PEPFAR, we’ll look at the plan’s impact so far in Africa. In this, the first part of the series, VOA’s Darren Taylor provides an overview of PEPFAR, the context in which the program functions in Africa, and some of its achievements.
When attempting to analyze PEPFAR’s response to AIDS in Africa, one necessarily becomes submerged in a sea of statistics.
“We have to speak about stats when speaking about HIV/AIDS. But sometimes I really feel saddened when funders, NGOs, governments and all the rest start treating people living with this disease as if they are just numbers,” says Beatrice Were, one of Africa’s most prominent AIDS activists and a fieldworker with the Action Aid international agency in Uganda.
There are many organizations dedicated to stopping the AIDS pandemic, with many of them using different strategies to prevent the spread of HIV/AIDS and to save and improve the lives of those living with it. That situation continues, despite the fact that the concerned players in the global arena, from the various governments to non-governmental organizations, activist groups and HIV-positive people, have a common goal: to halt the spread of a virus that, according to the United Nations, has infected 65 million people and killed 25 million – mostly in Africa – over the past 25 years.
PEPFAR has divided the world’s AIDS sector, with the differences of opinion having exploded into open enmity between those who support it and those who condemn it.
“I wish all the fighting about (this plan) would come to an end; it’s really a waste of time we don’t have,” says Prof. Salim Karim, a South African medical researcher who’s done groundbreaking work in the HIV field.
“I’m a very strong believer that the proof is in the number of lives that you save, when you get on and do the job. There are always opinions that go this way and that way. But, from my experience, what we have to do is a difficult task, and we’ve got to do it the best we can,” says Karim.
According to the UN, 12,000 people around the world are diagnosed with HIV every day. UNAIDS projects that the number of children orphaned by AIDS will increase from the current estimate of 11 million to 20 million by 2010. It’s in sub-Saharan Africa where the impact of HIV/AIDS is being felt the most. Up to 28 million of the 40 million people currently infected worldwide live in this region – and the numbers are rising rapidly, despite growing prevention efforts. UNAIDS statistics show that in 2005, 3.2 million people were newly infected and 2.4 million people died of HIV-related illnesses.
In early 2003, President Bush announced PEPFAR, with its aims of addressing the spread of AIDS, treating those infected with life-prolonging medicines and caring for the sick and dying and the resultant orphans. It was billed as the largest foreign-aid effort directed at a single disease in the history of the United States – and further enhanced America’s status as the world leader in providing resources for the fight against AIDS.
PEPFAR’s efforts – save for its work in Guyana, Haiti and Vietnam – are concentrated in 12 African countries: Botswana, Ivory Coast, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia.
Warren Buckingham, PEPFAR country coordinator in Kenya, spells out the “overarching priorities” of the Plan in its first five years in these countries: “To provide antiretroviral treatment to two million people who would otherwise not receive it, to prevent seven million infections that would have happened if PEPFAR resources had not become available, and to provide a continuum of care and support – including to orphans – to a total of ten million people worldwide who are being affected by HIV and AIDS.”
He says with about 18 months to go of the original implementation phase, PEPFAR is “well on track to meet or exceed all of those goals.”
The Global AIDS Alliance in Washington, despite being one of the most vehement critics of PEPFAR, calls it a “historic initiative.” Dr. Paul Zeitz, the group’s executive director and a former official with the U.S. Agency for International Development (USAID), says, “It’s the first time that the U.S. government committed billions of dollars, per year, to combat an epidemic that’s being waged in Africa and other parts of the world. So we went from a small, incremental response – several hundred million dollars a year – to a six billion dollar a year fund. And that’s a huge accomplishment. The other significant accomplishment has been a commitment to provide long-term support for life-saving HIV/AIDS medicine – antiretroviral drugs. People are living because of that initiative.”
Even so, Karim says PEPFAR remains “bogged down in dissention – conflict that is, frankly, taking us nowhere fast.”
And, despite the clarity of its motives, more than four years after its auspicious start, “confusion reigns,” about PEPFAR, says Nathan Geffen, of South Africa’s Treatment Action Campaign (TAC), which advocates for drugs for the country’s estimated five to six million people infected with HIV.
“Activists, governments and those trying to save lives often don’t know what exactly the PEPFAR requirements are. This includes some of the groups who’ve actually signed up to receive PEPFAR money!” says Fatima Hassan, of the University of the Witwatersrand’s AIDS Law Project in South Africa.
“Are people who receive PEPFAR funding allowed to aggressively promote condom use? Are they allowed, in terms of PEPFAR rules, to do interventions amongst sex workers? Are they allowed to promote reproductive choice for women? These are questions I hear every day from people in the field,” says Geffen.
Were adds that this confusion has created a “void that’s leading to less people being treated, less people being educated about the most sensible ways to prevent infection, and, ultimately, more deaths…. Because of the confusion, people are afraid to act because they’re afraid that they’ll lose their PEPFAR funding if they do something that the PEPFAR people don’t like.”
Zeitz characterizes the international response to AIDS as “directionless” and maintains that PEPFAR should bear a “large part of the responsibility” for this.
But Buckingham counters that activists often “willfully misunderstand and misinterpret” the Plan and its conditions to “satisfy their own requirements.”
Critics say PEPFAR is “forced” on host countries with “strings attached.” The US government gives billions of dollars to partner countries – provided they agree to implement PEPFAR’s much-maligned “ABC” HIV-infection prevention strategy, which requires organizations that accept funding to instruct people to “Abstain” from sex and to “Be faithful” to their partners as primary prevention methods, and also to provide “Correct and Consistent Condom” education to people who may be at risk of contracting HIV – but only to those older than 14 years of age.
Critics slam the ABC principles for being “unrealistic,” especially in developing countries, where women are often forced into sexual relationships and don’t have the option of abstaining – whether for economic reasons or otherwise – where youngsters, and especially girls, begin to have sex at very early ages, and where people who are faithful are at risk of being infected by their partners who engage in multiple sexual relationships.
They want PEPFAR to concentrate more on condom education, as they say this is a far more “sensible” approach than ABC.
Yet AIDS activists, even those who are amongst the most vocal critics of PEPFAR, are united in praise of some aspects of the Plan. They laud it for providing increased access to counseling and testing, for preventing mother-to-child transmission of HIV, and for supporting orphans. But their highest praise is reserved for PEPFAR’s provision of antiretroviral drug therapy to people living with AIDS. These medicines make it possible for people with the virus to live longer and healthier lives.
“The good thing about PEPFAR is that it has scaled up treatment. More than 50 per cent of Ugandans on treatment receive their medicines because of PEPFAR,” says Were. “Today in Uganda it’s the biggest provider of antiretroviral treatment to people with HIV. It’s brought hope to people, prolonged people’s lives. PEPFAR has demonstrated to the world and also to our (Africa’s) own governments that antiretroviral treatment is critical in the AIDS response and that it can be provided even in resource-poor settings, which before was something that was always contested.”
Dr. Tom Kenyon, chief medical officer at the US State Department’s Office of the US Global AIDS Coordinator, says PEPFAR has so far provided 1.1 million people in sub-Saharan Africa with “lifesaving” antiretroviral treatment. In 2003, he noted, only 50,000 people in the region were receiving antiretroviral medication.
But up to 28 million people are infected in sub-Saharan Africa, and many of them will need antiretroviral drugs in the future. Kenyon acknowledges it’s a “daunting” task.
Nevertheless, says Buckingham, progress – albeit slow – is being made.
“With the receipt of increased resources, we have been able to massively expand availability of antiretroviral treatment,” he says. “In Kenya, for example, before the Emergency Plan was launched, the US government had three pilot projects with 340 people on antiretroviral drugs. And just three and a half years later, we’re supporting almost 300 sites, and over 110, 000 people on antiretrovirals.”
But Hassan tempers her praise for PEPFAR’s drug rollout.
“One of the criticisms against PEPFAR is that it takes too much credit for actually supporting patients which it may not be funding a hundred percent. I think PEPFAR sometimes takes too much credit for work that it’s not doing.”
Nevertheless, Hassan describes PEPFAR as “one of the most important and useful donors to have had in South Africa. If PEPFAR wasn’t involved in our public facilities and our not-for-profit facilities, there would be a hundred thousand people less on treatment. And PEPFAR actually collects really good clinical data that really helps in taking action against the epidemic.”
South Africa was an obvious choice to be one of the PEPFAR host countries. An international AIDS NGO, AVERT, says more HIV-positive people live in South Africa than in any other country in the world except India. Every day, more than 800 South Africans die of AIDS-related illnesses, according to UNAIDS. Yet the vast majority of those infected don’t have acesss to treatment. PEPFAR has been addressing that need.
“We provide direct treatment to people with PEPFAR funds. We buy drugs with PEPFAR funds, and we have close to 2,000 people directly on treatment from PEPFAR. With help from the South African government, we also support another 13,000 to 15,000 people with treatment,” says Helen Struthers, who’s in charge of administrating PEPFAR funds at Johannesburg’s Perinatal HIV Research Unit.
Prof. Karim also runs treatment programs that are partially funded by PEPFAR in South Africa’s KwaZulu/Natal province. Much of his work is “very innovative,” he says, and he credits PEPFAR for allowing him to pursue actions he’s convinced could have a “big impact” in the future on the way in which HIV/AIDS is managed and combated.
“The TB clinic program in Durban is particularly important because it’s looking at how best to integrate AIDS and TB care. There’s no question that in the setting of southern Africa, one cannot deal with the HIV epidemic without dealing with the concurrent epidemic of tuberculosis – and with that has come the specter of drug-resistant tuberculosis. And we are not going to be able to deal with and ameliorate the TB epidemic, if we do not tackle HIV at the same time. Our program attempts to integrate care for these two diseases as one package – trying to provide AIDS and antiretroviral treatment to patients on TB treatment,” Karim explains.
There’s also praise for PEPFAR for finally allowing host countries access to cheaper HIV drugs, after initially insisting that they use only expensive American brand-name medicines.
“The US Food and Drug Administration – the FDA – now has a system to authorize procurement of generic drugs for use outside the US. In Kenya, for example, in the current year we’ll be spending close to 70 per cent of our drug budget on generic antiretrovirals from generic manufacturers,” Buckingham says.
But Zeitz describes the US government’s increased provision of generic HIV drugs to poor countries as a “mixed blessing.”
“Firstly, they’ve set up a parallel system to the already-existing WHO (World Health Organization) system of approving drugs, and that’s hampering progress and still creating confusion out there. Secondly, the US trade representative has promulgated policies that prevent or limit these countries from generic production, or parallel importing of generically manufactured drugs. So the US authorities have taken aggressive, concerted action to limit or reduce the ability of countries to produce or import generically manufactured drugs.”
Hassan also criticizes the condition that obliges PEPFAR-funded countries to buy only generic medicines that have been approved by the FDA, as well as by their own medicines regulatory councils.
“That condition creates a whole number of problems, particularly for countries that don’t have independent and efficient regulatory authorities – say for example Zambia and Mozambique. This condition creates almost a situation where the poorer countries are forced to use brand-name drugs. So the (PEPFAR) money comes into the country, but the money goes back out to the drug companies – a lot of who are actually US-based,” she explains.
In addition to this, says Hassan, the PEPFAR requirement that host countries use only FDA-sanctioned AIDS drugs has “grave consequences because the process to get FDA approval is either going to be very time-consuming, or quite expensive. And a government could wait for years before both the FDA and its local regulatory authority have given the necessary approval. This means an effective medicine can’t be used in a particular treatment program, which again further limits the number of patients that you can put on treatment.”
Kenyon responds that the US has an obligation to make sure that the medicines it distributes, or allows to be distributed in the name of PEPFAR, are safe for people to use.
“The best way of doing this is through the FDA,” he stresses.
Hassan says the US government is being “unreasonable.”
“We’re not saying that just any generic drug should be used. We’re saying that if something conforms to WHO standards, if it has been tested and found to safe by the WHO, then a country should be able to use it, and PEPFAR should be able to support it.”
Many activists, including Beatrice Were, acknowledge that PEPFAR’s achievements are often lost in a “haze of emotions” surrounding the man in whose name the Plan is implemented, namely President Bush.
Some commentators regard PEPFAR as essentially a means by which President Bush is able to counteract the negative fallout from the war in Iraq, and more: “People in Uganda, for example, say PEPFAR is a way for Bush to force his conservative, Christian viewpoints, such as abstinence from sex, upon us,” says Were.
Fatima Hassan says “many people don’t trust PEPFAR, because most of its funding for HIV prevention goes to faith-based organizations, who are seen as being aligned with Bush’s fundamentalism, and who don’t promote safe sex, for example.”
She adds that in certain respects, an intelligent critique of PEPFAR becomes “nearly impossible,” because the plan is “pervaded by politics and the cult of personality – in the form of George W. Bush.”
Nathan Geffen of South Africa’s Treatment Action Campaign agrees.
“Some people see PEPFAR as Bush’s baby – and so, in their minds, the plan is a bad plan, because they consider Bush and his government to be bad…. By the same token, there are those who are Bush supporters, who refuse to see anything wrong with PEPFAR. Both these approaches are flawed,” he says.
Zeitz also calls for a “distancing from linking PEPFAR with any one character” and a focus, rather, on the impact it is having on the global AIDS pandemic.
“President Bush committed to universal access (to AIDS treatment) by 2010. We’re saying that his program is hindering progress and hampering global progress towards meeting the universal access goal (because of its unrealistic emphasis on abstinence and fidelity). That’s what (PEPFAR) should be held accountable for – not for its link with President Bush,” Zeitz emphasizes.
But Hassan believes President Bush can’t escape any criticism for the “many negative aspects” of a plan he has “clearly claimed ownership of” and a strategy that is “seriously undermining a lot of the reproductive and sexual health care gains that many organizations and many countries have made in the last ten years.”
She adds: “The problem is that the conditions were put on the table and accepted and became part of the program during the Bush administration, at the insistence of the Bush administration. I don’t think they (PEPFAR’s administrators) can ever overcome the PR problem, because that link with Bush is one of the biggest obstacles to PEPFAR being accepted, and also why it’s achievements often don’t receive recognition.”
PEPFAR officials such as Warren Buckingham say they are “fatigued” at constantly having to defend a plan that has at its core the saving of lives. “People will say a lot about the Emergency Plan, and that’s their right. But, no matter what they say, it’s saving lives. Now that may not be good enough for some people, but it’s good enough for an awful lot of people in Africa and elsewhere.”