US Funding for HIV/AIDS The PEPFAR Program

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US Funding for HIV/AIDSThe PEPFAR Program
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PEPFAR the Presidents Emergency Plan for
AIDS Relief

• Proposed 15 billion over 5 years. Funding first
  approved in 2004.
• All USG HIV/AIDS money is PEPFAR money.
• Focus on scaling up treatment, prevention and
• care in 15 countries.
• Includes funding for research, the contribution
  to the Global Fund, and spending in more than 100
  countries.

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Federal Funding for HIV/AIDS FY 2003 FY 2007
Global Program/Account USD in Millions FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 Budget Request
USAID bilateral (Child Survival and Health Fund) 587.6 513.4 347.2 346.5 325.0
USAID other bilateral economic assistance 38.5 39 37.5 27.3 30.0
State Department Global AIDS Initiative (GAI) 0 488.1 1,373.9 1,777.0 2,794
Foreign Military Financing 2.0 1.5 2 1.98 1.6
CDC Global AIDS Program (GAP) 182.6 124.9 123.8 122.6 121.9
CDC GAP PMTCT 0 149.0 0 0 0
Department of Defense (DoD) 7 4.2 7.5 5.2 0
Department of Labor (DOL) 9.9 9.9 2.0 0 0
Department of Agriculture Food Aid 24.8 24.8 24.8 24.8 0
Subtotal bilateral prevention, care, treatment 852.3 1,400 1,918.7 2,305.4 3,272.5
Global Fund 347.7 458.9 435 544.5 300.0
Subtotal bilateral prevention, care, treatment Global Fund 1,200 1,812.2 2,353.7 2,849.9 3,572.5
NIH international HIV research 278.6 317.2 370.0 371.0 368.0
CDC international HIV research 11 11 14.0 0 0
Total Global (with international research) 1,500 2,112.2 2,737.7 3,220.9 3,940.5
Source Kaiser Family Foundation Figure
includes unused funding carried over from FY 2004
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Focus Countries

• 15 Focus countries Botswana, Cote d'Ivoire,
  Ethiopia, Guyana, Haiti, Kenya, Mozambique,
  Namibia, Nigeria, Rwanda, South Africa, Tanzania,
  Uganda, Vietnam and Zambia
• 5 Focus-light countries Zimbabwe, Malawi,
  Russia, India, and Cambodia

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Examples of Country Spending Levels

• Focus countries
• South Africa 148,187,427
• Cote dIvoire 44,375,766
• Vietnam 27,575,000
• Focus-light countries
• Russia 12,920,000
• Cambodia 14,300,000
• Non-focus country
• Georgia 1,100,000

All figures from U.S. State Dept., Office of the
Global AIDS Coordinator and USAID, FY 2005
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Concerns with PEPFAR

• Areas of Concern
• Earmark for Abstinence until Marriage programs
• Prostitution pledge requirement
• Areas of Potential
• Earmark for Palliative Care
• Support for substitution therapy (such as
  methadone)
• Legal reforms, such as inheritance rights

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PEPFAR and Abstinence Until Marriage

• The US Government Accounting Office found
• Ambiguities in the ABC guidance have led to
  uncertainty in implementation
• The spending requirements can limit efforts to
  design prevention programs that are integrated
  and responsive to local prevention needs.
• Some countries have cut prevention funds in
  certain areas

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Prostitution Pledge Requirement

• US Law
• Prohibits funds from being spent on activities
  that promote or advocate the legalization or
  practice of prostitution and sex trafficking.
• Provides that no funds made available to carry
  out this Act may be used to provide assistance
  to any group or organization that does not have a
  policy explicitly opposing prostitution and sex
  trafficking.

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Grounds for Lawsuit

• The OSI/AOSI lawsuit charges that the pledge
• requirement
• Violates the First Amendment by forcing private
  organizations to adopt the governments ideology
  and by restricting what they can say and do with
  their private funding and
• Is unconstitutionally vague, which allows for
  arbitrary application and violates the First
  Amendment as well as the due process clause of
  the Fifth Amendment.

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The Courts Decision

• The judge issued a preliminary injunction against
  the enforcement of the pledge requirement
• The organizations seek to cooperate with the
  Government in furtherance of a shared purpose
  combating the devastating consequences of the
  HIV/AIDS pandemic. They seek to do so, however,
  without forfeiting the critical role they play in
  stimulating public discourse on controversial
  themes The Policy Requirement, to the extent it
  prevents NGOs from speaking openly on such
  questions with their private funds, contravenes
  our national commitment to open debate and our
  First Amendment values.
• The courts decision applies directly only to
  AOSI and Pathfinder, but it could impact many
  other organizations.

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Other US NGOs In Support of the Lawsuit

• AIDS Action
• Alan Guttmacher Institute
• American Foundation for AIDS Research
• American Humanist Association
• Center for Health and Gender Equity
• Center for Reproductive Rights
• Center for Women Policy Studies
• Community HIV/AIDS Mobilization Project
• Feminist Majority Foundation
• Gay Mens Health Crisis
• Global AIDS Alliance
• Human Rights Center, University of California,
  Berkeley
• Human Rights Watch
• Interaction

• Institute of Human Rights at Emory University
• International Planned Parenthood Federation,
  Western Hemisphere Region
• International Womens Health Coalition
• Physicians for Human Rights
• Planned Parenthood Federation of America, Inc.
• Population Action International
• Population Council
• Religious Consultation on Population,
  Reproductive Health and Ethics
• Sexuality Information and Education Counsel of
  the U.S.

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Palliative Care

• 15 of PEPFAR funding must be used for
• palliative care.
• The State Department uses a very broad definition
  of palliative care
• Increasing opiod availability is part of the
  PEPFAR program, but does not appear to be a focus
• TB/HIV co-infection is included as part of
  palliative care

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Harm Reduction

• US cant fund needle exchange, but can fund
  wrap-around
• activities.
• USAID policy expressly permits USAID
  implementing partners to cooperate with other
  donors and governments that fund activities not
  permitted with USAID funds (such as the purchase
  of needles), provided that USAID funds are
  segregated and coded for separately.
• -- USAID Communication to US Congress, February
  15, 2005
• US can fund substitution therapy, such as
  methadone.
• Substance abuse programs may include behavioral
  models or medication-assisted treatment, or a
  combination of the two, and should also include
  case management and counseling services.
  Medication-assisted treatment that uses
  methadone, buprenorphine or naltrexone, is an
  effective option for treatment of heroin
  dependence.
• -- US Office of the Global AIDS Coordinator, HIV
  Prevention among Drug Users Guidance 1
  Injection Heroin Use, March 2006

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Engaging with PEPFAR

• Engage at country level
• Feed country level insights into DC advocacy
• Insist that USG not over-reach on legal
  requirements
• Choose messages carefully. Frame requests in
  terms of meeting prevention, care and treatment
  goals
• Decide
• When does the OSI name help or hurt?
• Do we have something unique to contribute?
• Conflict between implementer and advocate?

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Advocacy Examples

• Monitoring
• Public Health Watch
• OSISA
• Informing policy guidance
• Commenting on new guidelines for Prevention
  Among IDUs
• Commissioning research on substitution therapy
  to inform
• scale-up
• Cultivating new leadership on OSI issues
• Center for Strategic and International Studies
• Physicians for Human Rights
• Changing legal requirements
• Prostitution Pledge Lawsuit
• Advocacy through Open Society Policy Center