Peter Mugyenyi runs the Joint Clinical Research Center (JCRC), one of the most successful AIDS-treatment providers in Uganda. Back in 2003, he went to Washington on a day’s notice to help the Bush administration draft its plan for what would become PEPFAR (the President’s Emergency Plan for AIDS Relief), the most ambitious public-health initiative ever to tackle the AIDS crisis, then sat beside Laura Bush at the State of the Union address when the program was announced. In the years since, he has been applauded when he exceeded his enrollment targets.
But today, despite treating 32,000 AIDS patients, he does not have a message of success. Instead, he was back in Washington in March, this time to warn that the stagnation of PEPFAR funding is beginning to “result in chaos.” At the beginning of April he was quoted in The Boston Globe, announcing that he had received word not to enroll new patients unless they are replacing others who have left or died. Midmonth, Health GAP, an independent activist organization, reported that antiretroviral-treatment programs at the JCRC and other clinics in Uganda were being “precipitously” transferred to government hospitals, which did not have the drugs to handle them. On Monday, Mugyenyi was again raising the alarm, having penned the introduction to a new report put out by the International Treatment Preparedness Coalition that warns of a global backslide in the AIDS fight.
Over the past year, the Obama administration has rolled out plans for a new, more pragmatic approach to U.S. global-health initiatives. As NEWSWEEK wrote in the fall, the plan was to get more results for less money, something health experts believed they could achieve by diversifying the U.S. global-health portfolio beyond the singular orientation of PEPFAR and teaming up with multilateral partnerships, like the Geneva-based Global Fund. This would allow HIV clinics to treat an array of health issues, including those not related to HIV, and stabilize funding for a variety of health concerns, independent of transitory fundraising pushes for the cause du jour. At the same time, driven by critiques of PEPFAR’s sustainability, the plan would cut costs by committing to treat the sickest patients first, shifting resources over to prevention efforts, and putting national governments on the hook for delivering services. The new plan isn’t chump change; Obama asked Congress for $63 billion for his new Global Health Initiative, to be spread out over the next six years. Still, the money previously authorized by Congress for PEPFAR ($48 billion over five years, approved in 2008) didn’t make it into this year’s budget. Instead, arguing for a smaller, smarter PEPFAR, the administration increased funding by just 2.2 percent this year, the smallest increase the program has seen since its inception.
AIDS advocates are now wondering whether “pragmatic” is just a euphemism for cheap. In the last year, the number of HIV-positive people that PEPFAR started on treatment was the smallest it has been for four years, even while demand increases as patients live longer and the disease continues to spread unabated. The program’s annual report is a thin 20 pages, consisting mostly of charts, compared with the 60- to 100-page tomes that used to mount vigorous defenses of the program each year. At the same time, the decision to slash $50 million from the U.S.’s commitment to the Global Fund has cast doubts on its commitment to multilateralism and partnership. There is a sense among AIDS advocates that a golden age of treatment has passed, says Emi McLean, the U.S. director of Doctors Without Borders’ essential-medicines access campaign. “Whenever we raise questions about why PEPFAR is flatlining, the response is that we need to move away from the U.S. being the primary actor toward a more multilateral response. But the Global Fund is that multilateral response, and yet there’s no increased commitment there,” she says. McLean has noticed a similar disconnect with PEPFAR’s “partnership frameworks,” jargon for agreements to divvy up responsibilities with recipient governments (and, ideally, to incentivize those governments to put forth more long-term investments). On a recent trip to Uganda, McLean found that the AIDS-control chief there had never even heard of a partnership framework, even as such agreements were being hailed at home as an innovative way to shift responsibilities to local providers.
Such mixed messages on the administration’s support for AIDS programs can have long-term consequences in influencing behavior patterns that affect the pandemic’s spread. “If you’re trying to encourage people to get tested, and then you can’t back that up with treatment for those who are sick, you’re creating a disincentive to get tested,” says Peter Navario, a global health fellow at the Center for Foreign Relations. Since patients tend to share when there are not enough drugs to go around, even those on treatment are likely to start underdosing as treatments are cut off. But perhaps what worries advocates the most is simple momentum. A big part of PEPFAR’s success, says McLean, was its commitment to ambitious targets, like the push to provide universal access to 10 million AIDS patients. With some 4 million people covered, and significant progress in getting reluctant states like South Africa to step up and address the problem, why pull back now?
To an extent, it’s because policymakers are coming around to some unpleasant realities about PEPFAR’s heralded successes. For one, there is the unfortunate reality that the world can’t treat its way out of the AIDS epidemic. Despite admirable advances, the number of people infected is simply growing at too high a rate. For every two patients put on antiretroviral drugs today, five others contract HIV, a rate that has remained steady even as PEPFAR money made enormous strides in bringing down the death rate. As that death rate drops, patients live longer, requiring ever more years of treatment. Plus, as AIDS awareness grows and more people volunteer to get tested—both good things—the ranks of those qualifying for drugs swell. The number skyrockets further if countries adopt a new World Health Organization standard stipulating that AIDS patients be given drugs earlier, when their immune-system cell count is at 350—the standard in the United States—rather than 200, as it is now. Eric Goosby, who directs PEPFAR, has indicated he is not going to do so, since it would triple the number of people eligible for treatment (though he makes an exception for pregnant women). “When you look at it from a global perspective,” says Navario, “there is a huge mismatch between the number of people requiring treatment and the resources available. PEPFAR scaled up immensely over four years. But did we ever expect that it was going to increase by more than a billion dollars a year forever?” Better to find ways to do more with less, he says, pointing to Malawi as a country widely held up as a model for its efficient, effective AIDS programs.
Then there are the questions of aid effectiveness more generally. The problems in Uganda, to take just one example, run far deeper than just PEPFAR cuts. Despite the influx of millions of dollars each year from PEPFAR, the Global Fund, and the British Department for International Development, the country’s HIV prevalence rate has actually risen, to 6.4 percent, from a record low of 5 percent in 2000. Those foreign agencies pay for more than 90 percent of Uganda’s AIDS-treatment regimens, leaving clinics vulnerable to fluctuations in donor contributions, as in 2005 and 2008, when Uganda lost $12 million from the Global Fund in the wake of repeated corruption problems. This year the Global Fund approved just $4.2 million of the Ugandan government’s $70.2 million request.
Given how fickle those donors can be, it would seem to make sense for recipient governments to keep some funds in the health ministries’ bank accounts for a rainy day. They aren’t. Revealing what was long an open secret in health and development circles, a study published in The Lancet last week showed that sub-Saharan African governments have yanked between 43 cents and $1.14 from their own domestic spending on health for every dollar in health aid they received from foreign donors. This represents a big departure from the trend in developing countries in Latin America, Asia, and the Middle East, where most governments double their health budgets while receiving aid. Lead author Christopher Murray, who directs the Institute for Health Metrics and Evaluation at the University of Washington, notes that it’s relatively common for poor governments to shift money around between ministries to correct for the inequities that result from the ever-changing whims of international donors (to ensure, for example, that they can pay teachers in addition to building shiny new health clinics). But it’s impossible to know how legitimate the shifts are, since in most cases the money can’t be tracked. And the fact that Malawi, the model for success in the sub-Saharan African fight against AIDS, bucked the regional trend and actually doubled its own health spending does not speak well for the habits of its neighbors.
All of which is to say there is no one guilty party responsible for the treatment drop-offs, and there is no magic bullet that will fix some of the systemic problems underlying them. The question is whether the policy is still the right one—and, ultimately, whether a U.S. policy that puts recipient governments on the hook, makes those governments less vulnerable to funding whims, and attempts to increase efficiences is still the best way to go. But as McLean points out, it’s not enough simply to talk about partnership frameworks and multilateral institutions, nor to transition to new approaches for the long haul without making sure the money is still flowing through current arrangements in the interim; if governments commit to giving aid, they should give it, and if they commit to bringing recipient governments into the conversation, they should talk to them. Because as the dizzying array of the world’s global-health bureaucracies figure out how to do the necessary work of reconfiguring themselves, new patients are continuing to be added to the ranks via PEPFAR-funded tests, and to be told they will get help via PEPFAR-funded treatment—only to be referred to government hospitals that have no way to treat them.