Jason Wright, U.S. Director of the International HIV/AIDS Alliance, explains how the recently discovered PEPFAR pipelines have built up and calls on U.S. government staff to act quickly and work alongside key stakeholders in each country to create investment strategies which will translate the goal of an AIDS-free generation into a reality.
An AIDS-Free Generation
In November 2011, the global HIV/AIDS community celebrated when Secretary of State Hillary Clinton declared “creating an AIDS-free generation” to be a policy priority for the U.S. Government. Secretary Clinton stated that the world has a “historic opportunity … to change the course of this pandemic.”
President’s Budget Request
In February 2012, the White House released the President’s Fiscal Year (FY) 2013 budget request. The HIV/AIDS community saw the budget request as a mixed bag.
The request included a large increase for the Global Fund to Fight AIDS, Tuberculosis, and Malaria from the $1.05 billion appropriated for FY 2012 to $1.65 billion. With the additional transfer of PEPFAR bilateral funding to the Global Fund for FY 2012, the $1.65 billion would meet the Obama Administration’s three-year, $4 billion pledge to the Global Fund made in October 2010.
However, the request also included a large decrease in PEPFAR bilateral funding of about $500 million to $6.4 billion for FY 2013. The Obama Administration had cited numerous reasons for the decrease.
The Office of the Global AIDS Coordinator (OGAC) noted that PEPFAR is “improving its efficiency, reducing costs through steps such as lowering commodities costs, switching from air to sea and land freight, and collection and use of economic and financial data in programming” with the costs of supporting an individual on treatment decreasing from more $1,100 to $335 per year with an expectation of further decreases. The White House and the State Department noted that PEPFAR is “consolidating programs and shifting responsibility to host governments, which lowers costs dramatically and allows us to save more lives.”
In April 2012, the community found out another reason for the decrease in the budget request. The Global Post released an article and an interview with Global AIDS Coordinator Eric Goosby which revealed that there have been almost $1.5 billion stuck in the PEPFAR pipeline for 18 months or more.
The 22 countries and two regions affected include Kenya ($502 million), Ethiopia ($138 million), Mozambique ($130 million), Zambia ($91 million), Uganda ($57 million), and Haiti ($44 million). The Alliance has Linking Organizations in all six of these countries.
The Case of Kenya
Kenya alone has about one-third of the pipeline. The country had already expected a 44% decrease in PEPFAR bilateral funding. 17 civil society organizations (CSOs) – including the AIDS Alliance Linking Organization, the Kenya AIDS NGO Consortium (KANCO) – quickly came together to strategize. They sent a letter to Ambassador Goosby, who met with Kenyan Minister of Health Beth Mugo in April in Washington.
In late April in Nairobi, hundreds of AIDS activists demonstrated and presented a memorandum to U.S. Ambassador to Kenya Scott Gration, Kenya PEPFAR Coordinator Katherine Perry, and Ministry of Health officials demanding that PEPFAR release the funding stuck in the pipeline.
KANCO Executive Director Allan Ragi states:
Only slightly over 400,000 people are on ARV treatment while we need to scale up to over one million people. PMCT uptake is low, and hence we need to scale up if we are to realize the Three Zeros [zero new HIV infections, zero discrimination, and zero AIDS-related deaths]. We cannot afford to lose $500 million from PEPFAR. This will bring us down to our knees. We need these resources now, and we have the capacity to use the money.
Challenge and Opportunity
While the pipeline situation globally and in individual countries such as Kenya is a political challenge, it is also a programmatic opportunity. The Alliance sees this opportunity in the context of the Investment Framework for an effective HIV/AIDS response published in The Lancet in June 2011.
The Alliance notes in a discussion paper that the Investment Framework prioritizes basic programmatic activities and “critical enablers”. The Investment Framework positions human rights-based programming such as advocacy, stigma reduction, and efforts towards supportive laws and practices as not optional or additional but “critical.”
As Secretary Clinton stated in November 2011, successful HIV responses “depend on institutional and social changes like ending stigma; reducing discrimination against women and girls; stopping gender-based violence and exploitation, which continue to put women and girls at higher risk of HIV infection; and repealing laws that make people criminals simply because of their sexual orientation.”
The Investment Framework projects an increase in spending until 2015 followed by a decrease from 2015 to 2020. This short-term increase would allow 12.2 million new HIV infections and 7.4 million AIDS deaths to be averted.
New OGAC Guidelines and Beyond
The Alliance is pleased that OGAC has already released guidelines on reprogramming explicitly citing the goal of creating an AIDS-free generation. The guidelines refocus PEPFAR investments toward three major areas:
- Investing in commodities
- Investing in systems (human resources for health, supply chains, and management and use of program, epidemiological, and financial data) and institutions
- Investing in program strengthening for greater impact including: expanding existing programs (treatment, male circumcision, PMTCT, counselling and testing, and condoms), supporting key populations and identifying new investment countries.
The Alliance appreciates in particular the focus on supporting key populations. In our What’s Preventing Prevention campaign, we call on national governments to:
- Break the barriers that impede access to HIV prevention programs and services for vulnerable and most-at-risk populations and empower those key populations to be at the center of the HIV response
- Respect, promote, and protect the human rights of key populations and remove the political, cultural, social, and legal barriers that affect effective HIV prevention measures, including combating stigma and social discrimination
- Remove legislation that hinders access to HIV prevention for key populations, especially laws that criminalize specific groups or behavior; these include laws targeting sex workers, drug users, MSM, and HIV exposure or transmission
The Eighth Annual PEPFAR Report to Congress stated that “PEPFAR is making smart investments by investing in the interventions that will have the biggest impact on prioritized outcomes … [and] focusing dollars on interventions that have been shown to have the greatest impact.” This reprogramming exercise is an opportunity for PEPFAR to show its smarts.
The funding in the PEPFAR pipeline is needed now to reach the tipping point laid out in the Investment Framework. PEPFAR must consult with key stakeholders – including governments and civil society – to quickly develop investment strategies for the affected countries, spend down their pipelines, and help translate the goal of an AIDS-free generation into a reality.
Read this article by a Kenya based Key Correspondent on the recent demonstrations in Nairobi on this issue.