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PEPFAR Lays Foundation for Continuing U.S. Commitment to Combating HIV/AIDS Globally; Report Suggests Improvements to Move U.S. Efforts Forward


WASHINGTON — While the U.S. government’s global HIV/AIDS relief program is making significant contributions to addressing the pandemic in hard-hit countries, continued support and increased flexibility are needed to achieve lasting impact against the disease, says a new congressionally mandated report from the Institute of Medicine and the National Research Council. It evaluates the progress of the President’s Emergency Plan for AIDS Relief (PEPFAR) and recommends that the program shift its primary focus from providing immediate, emergency relief to building the capacity of affected nations to sustain their fight against HIV/AIDS over future decades. That shift should include expansion and better integration of prevention, treatment, and care services for all at-risk populations; increased attention to factors that raise the vulnerability of women and girls; and greater emphasis on ensuring that U.S.-sponsored activities are in tune with other anti-HIV initiatives in each country, the report says.

In particular, prevention efforts should be intensified to help keep rising infection rates from overwhelming the capacity of the program’s partner nations to provide treatment and care, added the committee that wrote the report. PEPFAR has not always supported the most appropriate mix of prevention strategies to fit each country’s circumstances, the committee said, in part because congressional mandates have directed how PEPFAR funds must be allocated. Because flexibility is crucial to successful response efforts, Congress should eliminate these restrictions and instead use mechanisms that would give countries greater latitude in directing resources while also ensuring that they meet performance targets for prevention, treatment, and care.

“In its first two years, PEPFAR has demonstrated what many doubted could be done, namely that HIV/AIDS services can be scaled up rapidly in countries with severe resource constraints and other daunting obstacles,” said committee chair Jaime Sepulveda, Presidential Chair and visiting professor, University of California, San Francisco. “These accomplishments are just a start, however. For continued progress toward PEPFAR’s five-year targets and ultimate goals, U.S. efforts should transition from focusing on emergency relief to long-term strategic planning and capacity building. And they should ensure that countries can direct resources where they are needed most.”

The report’s recommendations for improving PEPFAR are based on the presumption that Congress will reauthorize legislation to continue U.S. efforts to provide global AIDS assistance. PEPFAR grew out of legislation passed in 2003 that authorized $15 billion for HIV/AIDS-related relief to be disbursed over five years through a strategy outlined by the president.

PEPFAR’s five-year timeframe has raised concerns about whether the countries receiving its aid will be able to sustain their programs without continued support. However, the Office of the U.S. Global AIDS Coordinator (OGAC), which oversees PEPFAR, has declared “building capacity for sustainable, effective, and widespread HIV/AIDS responses” to be one of the program’s cornerstones. OGAC should continue to focus on planning for the next decade of U.S. efforts to fight AIDS globally, the committee urged.

Intensifying evidence-based prevention activities will be critical for long-term success, the report says. PEPFAR aims to prevent at least 7 million HIV infections in 15 focus countries by 2010. OGAC reports that millions of people have received various prevention services with PEPFAR assistance, but it is not yet clear how many infections these efforts ultimately will avert.

PEPFAR’s prevention planning is controlled in part by budget allocations mandated by Congress, which require that 55 percent of PEPFAR funds go to treatment, 15 percent to palliative care, and 10 percent to assist children affected by the epidemic, leaving 20 percent for prevention. In addition, Congress mandated that at least 33 percent of the prevention funds be directed to programs that promote abstinence until marriage. But HIV infection patterns vary among countries, some of which have relatively high rates of mother-to-child transmission, while others have higher rates of infection acquired via injection drug use.

The budget mandates may have been helpful initially in ensuring that attention would be given to all aspects of HIV/AIDS response — prevention, treatment, and care — and that needs such as caring for orphans would not be neglected. But the mandates are impeding the fully effective use of funds, the committee concluded. PEPFAR teams in the focus countries report having difficulty targeting sufficient resources and interventions to those at greatest risk of acquiring HIV. The budget mandates do not guarantee that the resources and attention being given to treatment and care strategies will yield the greatest impact, either. Inflexibility also hampers the program’s ability to lead the way in using innovative techniques as they are validated and become available, the report concludes.

Another PEPFAR policy that has impeded the program’s ability to harmonize its efforts with partner countries’ other initiatives against HIV/AIDS is the requirement that all antiretroviral medications purchased with PEPFAR funds be approved by the U.S. Food and Drug Administration. Although the goal is to assure the quality of the drugs, most of the focus countries and other donors rely on the World Health Organization (WHO) Prequalification of Medications Project for quality assurance. Many of the generic antiretroviral drugs used in recipient countries have since been FDA-approved for purchase through PEPFAR. In the future, however, OGAC should work to support WHO prequalification as the accepted global standard for quality assurance.

PEPFAR’s strategy has been responsive to Congress’ desire that the program help address the particular vulnerability of women and girls. In the transition from emergency relief to a sustained commitment, the U.S. Global AIDS Initiative will need to keep gender issues at the core of its efforts. It should support improvements in the legal, economic, educational, and social status of women and girls.

The report was sponsored by the U.S. Department of State. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Research Council is the principal operating agency of the National Academy of Sciences and National Academy of Engineering.


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