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*This is a joint post with Steve Rosenzweig

After months of wrangling, the U.S. Senate last night finally passed legislation to reauthorize the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. global AIDS program that has been allocated nearly $19 billion over its first 5 years. The bill authorizes spending $48 billion for the next 5 years, including approximately $5 billion for malaria and $4 billion for tuberculosis. Contributions to the Global Fund will amount to about $2 billion per year. With Senate passage, it appears likely that the bill could be signed into law by President Bush within days.

While the increase in funding is welcome, Congress has missed a prime opportunity to improve PEPFAR by responding to the growing body of evidence from the last few years on what's working and what's not. Instead, several policies that research has shown to limit the program's effectiveness remain in place. There are even some new provisions that could further confuse the way PEPFAR does business. One bright spot is the bill's commitment to increase PEPFAR's role in addressing the African health worker crisis and the requirement for an impact evaluation of PEPFAR this time around. Some of the most salient issues arising from the new bill include: failure to completely remove restrictive funding earmarks; failure to improve prevention efforts; a muddled treatment target; a mixed bag on gender; but a step forward on health workers and evaluating the impact of PEPFAR.

Stay tuned for a series of blog posts from CGD's health team elaborating on the issues raised above.

We begin the series today with a short analysis on the issue of earmarks:

Failure to remove restrictive funding earmarks

Perhaps the most disappointing aspect of the new bill is its failure to remove earmarks that restrict how funding can be used. Under the original authorizing legislation, PEPFAR is required to spend 55% of its global funding on ARV treatment and 10% on programs for orphans and vulnerable children; in addition, it is required to spend 1/3 of prevention funding on abstinence-only activities (although the Office of the Global AIDS Coordinator, which administers PEPFAR, has implemented this by requiring that half of prevention funding go toward preventing sexual transmission of the disease, with 2/3 of sexual transmission funding going toward abstinence and "be faithful" activities.)

Several government reports (IOM 2007, GAO 2008) as well as CGD's own HIV/AIDS Monitor (see Following the Funding and The Numbers Behind the Stories) have called for PEPFAR to remove the earmarks because they constrain countries' ability to tailor programs to local contexts. Despite the available evidence, the Senate caved in to pressure from a few conservative senators led by Senator Coburn to ensure that more than half of funding goes toward treatment and care. In addition, country teams that fail to allocate 50% of funding for the prevention of sexual transmission toward abstinence and "be faithful" activities face a burdensome reporting requirement to justify their decision. Although less restrictive than previous requirements, experience shows that these new earmarks will continue to hinder PEPFAR country teams in their ability to work with host country stakeholders to allocate funding where it is most needed.

Why did Congress ignore the evidence by maintaining an earmark for treatment and care? One reason is that some senators, mired as usual in the desire to demonstrate short-term results at the expense of longer-term progress, wanted to ensure that funding was spent on activities where short-term gains are easy to measure and report. As a result, the reauthorizing legislation will continue to focus PEPFAR funding more on counting pills and patients and less on preventing new infections, despite the fact that 5 new people are infected with HIV for every 2 that are put on treatment. PEPFAR country teams and host country stakeholders will continue to be limited in their ability to fund activities crucial to long-term, sustainable AIDS responses.

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Disclaimer

CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.