The Washington Post examines the Obama administration’s goal “to get the ’emergency’ out of the President’s Emergency Plan for AIDS Relief” and integrate HIV/AIDS programs more into the health infrastructure of recipient countries.  A five-year strategy for PEPFAR was released last week. 

“In an outline of a new direction for the global program started by President George W. Bush, the administration hopes to begin handing off day-to-day management of AIDS prevention and treatment programs to the 15 countries where $19 billion has been spent since 2004. The goal is to make the services a routine part of each nation’s health offerings,” the newspaper writes. “Under a strategy described in documents released Monday, the countries’ health ministries would assume the task of delivering services – which many already do – as well as managing all the programs and measuring their effect,” according to the Washington Post.

“It is our honest belief that these programs are in a fragile period,” U.S. Global AIDS Coordinator Eric Goosby said. “We need to transition them into being more embedded in the countries’ infrastructure and for the countries to have true ownership of them.” Goosby added that with the exception of Rwanda and Namibia, none of the PEPFAR recipient countries has “‘really developed the capability to oversee and manage these programs completely.’ The transition will require teaching supply-chain management, logistics, service coordination, program evaluation and other skills while continuing to provide AIDS services to millions of people,” the Washington Post writes.

“The exact amount of money to be spent through PEPFAR in the next few years is uncertain. Last year, Bush signed the Lantos-Hyde Act, which authorized spending up to $48 billion over five years to deal with AIDS, tuberculosis and malaria…,” the newspaper writes (Brown, 12/9).

The New York Times examines reaction to the shifting focus of PEPFAR: “As the Obama administration slowly unveils its global AIDS plan, the drive to put more people on drugs is being scaled back as emphasis is shifted to prevention and to diseases that cost less to fight, including pneumonia, diarrhea, malaria and fatal birth complications.”

According to the newspaper, “AIDS advocates complained bitterly that they had been betrayed and that the Bush administration’s best legacy was being gutted. … Some advocates for overall global health – in contrast to those lobbying for AIDS – expressed regret but said the administration was being practical by shifting to buying goods that save more lives for less money, like water filters, oral rehydration packets and generic antibiotics, rather than putting adults on antiretroviral drugs at a cost of $35 to $2,000 a year.”

Goosby has “denied that the administration’s dedication to fighting AIDS had shrunk, noting that more people would still be put on treatment each year. ‘We’re honoring our commitment, we’re increasing our commitment, we will not veer from that commitment,'” Goosby said, according to the New York Times.

“But it was clear from PEPFAR’s newly released plans that treatment will soon rise more slowly than it has,” the New York Times writes. “[O]ne number [from the plan] stands out: the new goal is to have four million people on antiretroviral drugs by 2014. The program has put 2.4 million on the drugs since 2004, or almost 500,000 a year on average. Adding only 1.6 million over the next five years means adding only 320,000 each year.” This also “signaled that the United States would probably not adopt the new World Health Organization recommendation that people get drugs as soon as their CD4 count drops below 350 rather than below 200,” the newspaper writes.

The newspaper continues: The five-year plan “is nearly silent on several controversial issues: how much PEPFAR will emphasize abstinence, whether and how it will get condoms to patients of the many missionary hospitals that refuse to issue them, whether it will support women’s health clinics that also do abortions, whether it will support giving clean needles or methadone to drug addicts, whether it will require groups working with prostitutes to oppose prostitution, and whether it will cut off countries that criminalize homosexual sex. Dr. Goosby said several of those issues were under discussion.”

The article details a paper published in November 2008 by Obama advisor Ezekiel Emanuel – an NIH bioethicist and the brother of the White House chief of staff. In “U.S. Health Aid Beyond PEPFAR,” Emanuel suggested “[p]aying for ‘simple but more deadly diseases, such as respiratory and diarrheal illnesses, the U.S. government could save more lives – especially young lives – at substantially lower cost,'” the New York Times writes. The article also addresses the funding shortfalls the Global Fund has faced and includes comments by HIV/AIDS and global health advocates, as well as Emanuel (McNeil, 12/8).

The webcast of a Kaiser Family Foundation town hall with Goosby to discuss the PEPFAR five-year strategy is available online.