PEPFAR Should Be Strengthened, Not Blocked

The "hold" that seven U.S. Senators have placed on PEPFAR reauthorization by Congress (see Michael Gerson's column Moral Scales in the Senate in today's Washington Post and Josh Busby's related blog) literally threatens the lives of over a million people in Africa. In my recent working paper I said that these people whose lives now depend totally on continued U.S. funding have an "entitlement" to U.S. support that is every bit as compelling as U.S. citizens with Social Security pensions. In a recent blog I suggest that our commitment to these patients is just as compelling as our commitment to the people of Iraq. Backing away from either of these commitments would severely damage the reputation of the U.S. in general and the responsible politicians in particular. So I urge the Senate to work to resolve the impasse and quickly reauthorize PEPFAR.That said, I believe that the pause engendered by this hold can be used to improve the PEPFAR reauthorization bill. I suggest that the Senate consider the following three improvements:Set hard goals for preventionIn my recent chapter, I chastise PEPFAR for setting hard numerical goals for treatment, but soft unverifiable goals for prevention. The goals set are measured in number of cases of HIV prevented. But this is a meaningless concept: does the prevention of 100 cases mean that 20 persons were prevented from getting infected each year for five years or that 100 persons were prevented from EVER getting infected? And how do we know how many would have gotten infected without PEPFAR's intervention? The goal should instead be to COUNT the number of new infections every year in the 15 PEPFAR countries and then REDUCE that number by 90 percent over the duration of the program. A very rough estimate based on UNAIDS numbers suggests that 1.4 million people were infected this year in the 15 PEPFAR countries. This number needs to be verified through a large scale, comprehensive, statistically sound sampling process, the like of which has never been attempted in any African country. Then the number should be reduced to something like 140,000 per year in these countries before the end of the authorization period.Set goals for the quality as well as the quantity of AIDS treatmentThe objective of placing 3 million persons on AIDS treatment, which appears in the current version of the reauthorization bill, is incomplete. Senator Coburn's advocacy of even more ambitious quantitative treatment targets is laudable, but generates a reputation risk by growing the AIDS treatment entitlement. The higher priority should be to assure the continuity and quality of treatment to patients who already depend on us.As PEPFAR-supported AIDS treatment expands, more of the patients under treatment will have greater difficulty adhering to treatment. Poor adherence not only reduces the health benefit from US-funded treatment, but also spreads drug-resistant strains of HIV. The Senate could assist by writing into the law explicit goals for adherence and patient survival as well as for the number of patients to be offered treatment. For example, the goal should be that the proportion of AIDS patients started on treatment who die or are lost to follow-up be no more than 10 percent the first year and no more than 5 percent in every subsequent year. Relax the earmarking in order to better hold country managers responsible for numerical prevention and treatment targetsCGD's HIV/AIDS Monitor has recently argued for a relaxation of the earmarks that Senator Coburn wants to reimpose. They found that the earmarks are unnecessarily constraining PEPFAR country teams' ability to tailor programs to individual country contexts. Because different countries have different epidemics and different needs, imposing an arbitrary spending mandate (even if a global mandate) is not the way to ensure the most effective use of funds. A recent GAO report echoes these findings and the recommendation for pursuing a country-based approach. Removing the treatment earmark would not force country teams to do more prevention, but rather allow them to allocate resources based on available evidence for what is needed in a particular country (not to mention based on host country priorities). Nor would earmarks effectively curb expenditure on consultants and channel money to widows and orphans, as Senator Coburn claims. Under the earmarks, any funding that contributes to treatment, prevention, or care is allocated under these categories, including for example the hiring of consultants for the implementation of treatment programs. And keeping the treatment earmark might in fact reduce funding for widows and orphans because these activities fall under PEPFAR's "care" category, which could presumably get less funding under a 55 percent treatment mandate. I agree with Senator Coburn that Congress should insist that its AIDS funding be spent efficiently. However, the way to address Senator Coburn's concern is not with a return to earmarking, as he promotes, but with explicit and measureable targets like those I suggest above.The Senate must get to work immediately to take PEPFAR authorization off of "hold." More lives are at stake than was the case for Hurricane Katrina or the Cyclone in Myanmar. While they are working to unblock the bill, they might also take the opportunity to improve it in the above three dimensions and in other ways that I suggest in my working paper.