By JONATHAN MUNDELL (1)

Five years ago, during his State of the Union address in 2003, President George W. Bush announced the launch of the US Presidents Emergency Plan for AIDS Relief (PEPFAR), which would contribute US$ 15 billion to the prevention, treatment and care of HIV-infected individuals, in fifteen heavily affected nations, over a five year period. PEPFAR has since become the largest and arguably the most successful international health initiative ever implemented by a single nation.

With the end of the initial funding period around the corner (End of September, 2008), the PEPFAR initiative is very much on track to meet it’s originally stipulated goals, having supported HIV testing and counselling for more than 33 million people; provided care for more than 6.6 million (including more than 2.7 million orphans and other children infected and affected by HIV); and funded treatment for about 1.5 million men, women and children worldwide (the majority in sub-Saharan Africa). While President Bush has had his fair share of criticism over the years, even his harshest critics have conceded that PEPFAR is one of the finest accomplishments by any US President, thus far. However, there is still a long way to go if the HIV & AIDS epidemic is to be truly stemmed, and PEPFAR has shown that it will be a critical intervention in future attempts to accomplish this mammoth task.

A REPUBLICAN ROADBLOCK

Last year, in an effort to further this progress, President Bush approached congress to double PEPFAR funding over the next five years, to US$ 30 billion. His plea was answered with interest, as the Democrat-controlled Congress proposed a reviewed plan of US$ 50 billion. The reauthorisation passed smoothly though the House in April this year, and was backed confidently by the White House and the majority of the Senate. It was therefore not expected to have any problems being passed by the Senate, but following significant resistance from a hand full of Republican senators, the reauthorisation hit a roadblock.

This small group of conservatives objected to the level of spending, and also some of the policies outlined in the legislation, and the reauthorisation was blocked, which initiated a three-month process of frustration for all parties involved. Despite their differences, however, these resistant members of the Senate did acknowledge the success of the program. Senator Coburn, who was one of the few who questioned the new bill, stated publicly that, "this is by far the only true foreign policy program that's working. The dollars are actually making a difference". It would seem though that it was not difference enough, as the ‘obstructionist’ conservatives argued that the proposed increase in spending was too high.

SPENDING NOT CONSERVATIVE ENOUGH FOR CONSERVATIVES

It quickly became apparent that the question was not whether PEPFAR is a worthwhile initiative, but rather whether US$ 50 billion is perhaps too much to be spending outside of ones own country. According to Senator Jim DeMint, "it's not a good time to be talking about spending billions of American dollars around the world, no matter how good the cause might be". DeMint was one of the spearheads in blocking the reauthorisation of the new PEPFAR bill in April, questioning the significant increase in spending from the original US$ 15 billion. DeMint’s questioned: “At a time when our country is in debt as far as we can see, why would we as a country create the biggest foreign aid bill in history and borrow more money, $50 billion, and send it all around the world?"

DeMint was not alone in his apprehensions, as Senator Cornyn made the point that “there should be a limit”, and that "it's one thing to say you'll support it at US$ 15 billion. It's another thing to say you'll support it at US$ 35 billion. To me, it's entirely another thing to support it at US$ 50 billion". Despite the various attempts by those apposing the proposed amount, amendments to reduce its cost were rejected. At the beginning of July this year, when some light was finally seen at the end of tunnel, Senate Majority Leader, Harry Reid, openly criticised DeMint and other republicans for holding up the reauthorisation, stating that “while we're fiddling around here on this in Washington, people are dying".

A COMPROMISE ON NEW LEGISLATION

In addition to concerns around the size of the proposed funding, there were also some questions surrounding the new legislation. The new bill, for example, had dropped the provision that 55% of spending should be solely dedicated to treatment programmes. This adjustment to the legislation caused an outcry, headed by Senator Tom Coburn, who insisted that the requirement be restored, so as to prevent the diversion of the funds to prevention, or other related activities. Many experts feared, however, that such a provision would have a negative impact on those countries that would prefer to utilise the funds on other aspects of the epidemic, so as to better meet their specific needs.

A compromise was finally reached, and Coburn reversed his objection to a vote a confidence, with the new legislation allocating more than half of the funds for “broadly defined” medical care. This will therefore not only include the provision of antiretroviral (ARV) drugs, but also clinical monitoring, care for associated opportunistic infections, nutrition and food support, and other essential care. This compromise gives developing countries far more flexibility to meet their specific country needs. In addition to these changes, the bill was amended by Democrats, who removed a provision for a third of prevention funds to be spent on abstinence education, while Conservatives insured that religious groups would not be forced to take part in programmes against their beliefs.

A ROADBLOACK, NEGOTIATED

After months of discussion and negotiation, the Senate finally passed the new PEPFAR bill on July 16th, which was soon followed by the House of Representatives, who passed the bill just over a week later, on July 24th. The negotiated legislation will see US$ 48 billion provided to over 100 countries over the next five years to help treat and prevent AIDS, Tuberculosis and Malaria, with the majority of the funds being directed to sub-Saharan Africa. US$ 2 billion of the originally proposed US$ 50 billion will be diverted to American Indian water, health and law enforcement programmes. It has also been stipulated that 10% of the funds will be allocated to orphans and vulnerable children (OVCs).

An important difference from the original legislation is a new central focus on developing long-term health workforce plans, with PEPFAR now aiming to fund 140,000 new health workers in target countries. The new legislation will also see the lifting of a 21 year old US ban that prohibited HIV-infected foreigners visiting the US. One worry, however, which will be severely questioned over the coming months, is that the new bill does not mention family planning programmes, a proven necessity in fighting the epidemic.

Despite this though, the reauthorisation sets the stage for an exciting five years. President Bush confirmed on July 26th that he will be signing the new legislation into law very soon, and thanked members of Congress from both sides. While Bush's role as US President will come to an end come January 2009, the legacy he has built up through PEPFAR, and the significant funding that has been invested, will without doubt continue to lead the fight against HIV & AIDS.

(1) Jonathan Mundell is Director: HIV & AIDS Unit at Consultancy Africa Intelligence (jonathan.mundell@consultancyafrica.com).