The persistent shortchanging of PEPFAR, the President's Emergency Plan for AIDS Relief, is one of the more significant and perplexing trends in America's global health policy. Funding for PEPFAR (America's bilateral global AIDS program) has been falling consistently from its peak in fiscal year 2010. In fiscal year 2012, $250 million was transferred out of the program to the Global Fund to Fight AIDS, Tuberculosis and Malaria. For fiscal year 2013, the White House proposed cutting PEPFAR by $550 million (11 percent) and in March of this year Congress went part way, taking $176 million from the program in the Continuing Resolution.
Funding for PEPFAR has fallen 12 percent since 2010 in the State Department HIV bilateral budget line. Last week, the White House proposed an additional $50 million cut for 2014. When the mandated sequestration cut is taken into account, the program is now at its lowest funding level since 2007.
This downward funding spiral might make sense if there was a consensus that tackling AIDS has become less important, or if PEPFAR was not producing results. But the opposite is true. In November 2011, Secretary of State Hillary Clinton announced that achieving an AIDS-free generation was a "policy priority" for the U.S. government. President Obama went on to set bold new targets for AIDS treatment and other services through PEPFAR. In November 2012, the Administration released a PEPFAR Blueprint lauding the program's accomplishments and affirming the need to "rapidly scale-up core ... interventions." Doing so, the Blueprint argued, would accelerate declines in HIV incidence globally.
In February of this year, President Obama inspired all those engaged in the response to AIDS when, in his State of the Union address, he reaffirmed his commitment to the goal of an AIDS-free generation. The same month, the Institute of Medicine (IOM) weighed in with their assessment of PEPFAR, four years in the making. It concluded that the program has been "globally transformative" and has "had major positive effects on the health and well-being of individual beneficiaries, on institutions and systems in partner countries, and the overall global response to AIDS."
Why the mismatch between results, rhetoric, and financing? Budget deficit pressures do not explain it: total U.S. global health spending is just a quarter of one percent of the federal budget. Politics doesn't explain it either, with PEPFAR maintaining a unique level of bipartisan Congressional support.
The more likely reason for steady reductions in PEPFAR funding is an Administration decision to gradually de-emphasize bilateral AIDS investments in favor of multilateral institutions and multiyear commitments to these institutions. Increased investments in the Global Fund and other multilateral health organizations are a badge of honor for President Obama. These institutions have demonstrated clear results in countries around the world, and U.S. funding leverages investments from others.
The question is not whether increased funding for the Global Fund is good, because clearly it is. The question is whether those increases justify year-on-year reductions in our bilateral AIDS program. It is not a matter of choosing between multilateral and bilateral approaches, but of marshaling sufficient resources to end AIDS.
One concern is that as Global Fund and PEPFAR funding trends head in opposite directions, net U.S. resources dedicated to tackling AIDS are in decline. Since on average approximately 57 percent of Global Fund resources are allocated to combating HIV/AIDS, the $600 million increase in support for the Global Fund since 2010 and the $543 million decrease in funding for PEPFAR during that time adds up to an overall decline in U.S. government funding to tackle the global AIDS epidemic.
Another problem is the lost opportunities to strengthen health systems when PEPFAR is cut. According to the distinguished IOM panel, the program is helping build health systems through improved laboratory capacity, supply chains, and staff training. The IOM observed that PEPFAR is "uniquely situated as a platform for research to spur innovation and to address knowledge gaps" in the global AIDS response.
And then there is the move toward to greater "country ownership" of healthcare financing and decision making. Clearly country ownership is an important goal and should be pursued at a rate that is appropriate for each individual country setting. But a reduced commitment to PEPFAR could lead to an accelerated and premature hand-off of AIDS programs with potentially disastrous consequences. Already there are concerns. A Center for Strategic and International Studies (CSIS) report released in March noted the "legitimate fears" that a rushed transition in South Africa could disrupt the delivery of AIDS treatment to people there.
In many countries where PEPFAR operates, those groups most severely affected by the epidemic, including gay men, people who inject drugs, and sex workers, are socially and legally marginalized. Last year UNAIDS reported that more than 90 percent of funding to address HIV among these populations in low- and middle-income countries came from external sources, not the countries themselves. Though PEPFAR still needs to pay greater attention to these most-at-risk groups, the program has been a leader in tending to their HIV-related needs. If PEPFAR is scaled back, real progress to address the epidemic among the most vulnerable could be in serious jeopardy.
Congress has been broadly supportive of domestic and global AIDS funding for many years. And the President deserves praise for his leadership on AIDS, which includes game changers like the Affordable Care Act, the National HIV/AIDS Strategy, and funding increases for domestic AIDS and the Global Fund. The President is to be commended for being outspoken against HIV-related stigma and for equality for gay people, including young Black gay men, who are perhaps the most vulnerable in America's epidemic.
With the end of AIDS within reach, it is time to think about legacy—the President's and our own. The most damaging consequence of continual reductions in funding for PEPFAR is slower than necessary progress in pursuing the end of the AIDS pandemic. The PEPFAR Blueprint shows how expanded delivery of proven interventions will yield falling HIV incidence and mortality rates within a few years. The Global Fund has an essential role to play in this effort, and other donors and affected countries need to invest more.
But the honest truth is that the world won't end AIDS without PEPFAR. Some will say, judge PEPFAR on its outcomes, not its funding. But when PEPFAR's own Blueprint calls for rapid scale-up of effective services in order to show tangible gains, it's hard to understand why now is the time to cut back. The urgency of delivering lifesaving services remains acute, with the IOM observing that there is a "substantial remaining unmet need for all services ... that are part of an effective response to HIV."
Congress and the President should not set the AIDS budget based on short-term expediency. Instead they should recognize the longer game: defeating a major infectious disease, and securing this generation's legacy as beginning the end of AIDS. To achieve that goal, both the Global Fund and PEPFAR need appropriate funding.
The IOM panel assessing PEPFAR's work concluded that the program "has the opportunity and the potential to once again transform the way global assistance for health is envisioned and implemented." The question is, will we allow it to seize the opportunity and fulfill its potential?