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Foreign Policy in Focus

The Flawed ABCs of PEPFAR

Michael Stulman

Several months ago, President George W. Bush called on Congress to reauthorize funding for the President's Emergency Plan for AIDS Relief (PEPFAR). The request was to double current funding levels to $30 billion for five years. The money is slated for prevention, treatment, and care programs.

This announcement generated immediate applause from celebrities. Rick Warren, pastor of Saddleback Church and author of the mega-bestseller The Purpose-Driven Life declared, "Certainly one of the President's greatest legacies will be his insistence on putting compassion into action." Irish rock star Bono wrote, "This is great news at a time when good news is hard to find. These AIDS drugs are a great advertisement for American leadership, innovation and the kind of John Wayne 'get it done' mentality that the greatest health crisis in 600 years demands."

Although the president received accolades from all sides, his AIDS plan is still fraught with miscalculations and unwarranted assumptions. Its major blind spot has to do with youth. An estimated 9,000,000 youth around the world live with HIV/AIDS.This is equal to the entire population of Sweden, or just larger than the population of New Jersey. Over half of these people infected are women. Today, youth account for almost half of all new HIV infections. In addition to being underfunded and poorly targeted, PEPFAR fails to address this critical constituency.

Learning your ABC's

The "ABC" approach, modeled on a program pioneered in Uganda, provides the ideological and methodological core of the PEPFAR prevention efforts. This approach aims to transform social norms by promoting both risk avoidance and risk reduction behaviors according to three criteria:

* Abstinence - for youth and unmarried people, including delay of sexual debut * Be faithful - mutual faithfulness and partner reduction for sexually active adults * Correct and consistent use of Condoms - for those at risk of transmitting or becoming infected

If you're confused about PEPFAR's ABC approach, you're not alone. According to a recent Johns Hopkins survey, the ABC formula of PEPFAR isn't as clear as many U.S. government officials appear to presume. Among youth between the ages of 15 and 25 that John Hopkins surveyed in Namibia, abstinence meant "to be absent" and "faithfulness" meant faith in the context of religion, rather than being faithful to ones partner.

PEPFAR mandates that at least one-third of all funds devoted to prevention efforts must be directed toward abstinence-until-marriage programs. In this context, for example, marriage is notably emphasized over other relationships. However, marriage provides little protection from infection since spousal partners are not always monogamous. In her new book on AIDS in Africa, Helen Epstein argues that the major cause of the rising infection rate in Africa has been the prevalence of concurrent, long-term partners for both African men and women. Effective indicators for understanding the determinants of sexual behavior must therefore be developed in order to ensure effective AIDS prevention programs, which must actively combat stigma, discrimination, and sexual coercion so as to empower women and girls in particular.

The PEPFAR program focuses on a select group of nations: Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia, What varies between each of the focus countries is the proportion of the budget allocated to each area of prevention, care, and treatment. Generally missing from these programs is the promotion of condom use among young people. Condoms supposedly available for these countries are restricted to those engaging in "high-risk activity" rather than regarded as a strategy for preventing HIV transmission among all young people.

There are different ways of interpreting the ABC approach. UNAIDS, for instance, has defined these terms differently. Most notably, UNAIDS neither emphasizes abstinence until marriage nor limits the promotion of condoms to those engaging in "high-risk" behaviors.

However it is interpreted, ABC is not sufficient. To address this monumental health crisis, a much more powerful program - with a different acronym - is essential. ACTION stands for:

* Additional "new" money * Cancellation of international debts * Treatment access * Infrastructure development * Offer preventative measures * Now

Additional Contributions for the Global Fund

During 2005, the eight wealthiest nations in world (G8) pledged to establish universal access to treatment to HIV/AIDS treatment by the year 2010. The fund has had many successes since it emerged, for instance, tripling the number of people treated with anti-retroviral drugs (ARVs) globally. However, the need for ARVs has increased significantly in subsequent years as the HIV/AIDS crisis has grown, and the initial goal of $10 billion per year is now inadequate. Donor countries need to contribute a great deal more money, with contributions equitably assessed according to size of gross domestic product.

Today the world is far from the objective of universal treatment. In fact, the G8 recently released a document that announced it would "over the next few years... support life-saving anti-retroviral treatment through bilateral and multilateral efforts for approximately five million people." With an estimated 39.5 million people worldwide now suffering from AIDS, five million people is clearly not universal treatment.

Additional funds are also necessary to expand the program beyond the select group of nations that PEPFAR is targeting. For instance, according to Health Gap, a minimum of $50 billion is necessary to ensure equitable coverage. This would include $6 billion for the expansion of existing programs to those outside the focus countries. As with the Focus Countries, 10% would be spent on programs for children. Another $28 billion would help the world achieve universal access for all HIV/AIDS services, including prevention, and it would double the overall number of people receiving treatment. By law, at least $2.8 billion or 10% of this money would go to a broad range of programs for children. Approximately $8 billion would fund new health systems that train, retain, and support health workers, helping to ensure that U.S. dollars can be used effectively and sustainably. Cancellation of Debt and Treatment Access

The math is simple: more than half of African nations spend more on debt payments than health care for their citizens. Governments in Africa have to cut funding toward clinics, treatment, and infrastructure, investing more toward paying out illegitimate debts to the World Bank and International Monetary Fund. Take Zambia, for example, where treatment fees which made health care unreachable for millions of people. After receiving $4 billion of debt relief, it recently introduced free health care for people living in rural areas.

Another drain on the finances of African nations is the cost of drugs. The relative costliness of ARV drugs purchased by PEPFAR is a consequence of a U.S. policy permitting the purchase with PEPFAR funds of only those generic drugs approved by the U.S. Food and Drug Administration (FDA) or a comparable regulatory agency in Western Europe, Canada, or Japan. By defining "safety and efficacy" in this manner, the majority of available generic anti-retroviral drugs, approved by the World Health Organization (WHO), are not eligible for use by PEPFAR. This policy protects the interests of large, U.S.-based pharmaceutical companies and discourages foreign drug manufacturers from enduring the drug review process.

While PEPFAR requires unnecessary regulation in some cases, it is negligent in others. For instance, it doesn't put enough emphasis on the need for those with AIDS to adhere to their treatment. Lack of adherence to treatment regimens will result in viral resistance and wasted funds. Unless treatment is thus monitored, the trajectory of the disease and the relative effectiveness of different treatment regimens cannot be adequately assessed. Infrastructure and Offering Preventive Measures

As countries build their health infrastructure, delivery and storage issues become major determinants of access to treatment. While PEPFAR emphasizes the importance of locally led responses to disease, citing over 80% of its partners as indigenous organizations, it does not sufficiently address the role of each country in developing its own strategies for prevention, treatment, and care. It's critical that the host country's capacity to create a sustained, long-term response to HIV/AIDS be transferred to each participating country. In order for this accomplishment to be achieved, transparency and honest participation from both African nations and the U.S. government is necessary.

Just recently, the U.S. Leadership Act called for the promotion of "the effective use of condoms." Today, according to the Government Accountability Office, PEPFAR is "creating a culture of fear around condoms." For instance, organizations supported by PEPFAR are concerned about "crossing the line between providing information about condoms and promoting or marketing condoms" and thus losing their funding. Now

Nearly half of the world's population is under the age of 25. Every day over 6,000 youth between the ages of 14-24 are infected with HIV.

Youth would be better served if funds allocated from PEPFAR went to family planning, through USAID's Office of Population and Reproductive Health. Recognizing the correlation between HIV prevention and reproduction healthcare is crucial, and should not be limited to those categorized as engaging in "high-risk activity." A stronger, age-appropriate marketing campaign in schools that provides information on how HIV can be prevented must be made more available.

PEPFAR continues to undermine and destabilize comprehensive programs that employ science, not ideology, and young people are the primary victims of this flawed policy.

Michael Stulman is a student at Bluffton University and a former intern at Foreign Policy In Focus (

© 2007 Institute for Policy Studies

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