How Ideology Trumped Science

Why PEPFAR Has Failed to Meet its Potential

Scott H. Evertz discusses how the Obama administration can reform the President’s Emergency Plan for AIDS Relief.

Secretary of State Hillary Rodham Clinton talks with South Africa's Health Minister Aaron Motsoaledi after attending a President's Emergency Plan for AIDS Relief, or PEPFAR, Transition Signing, Wednesday, August 8, 2012, at the Delft South Clinic in Delft South, a suburb of Cape Town, South Africa.
Secretary of State Hillary Rodham Clinton talks with South Africa's Health Minister Aaron Motsoaledi after attending a President's Emergency Plan for AIDS Relief, or PEPFAR, Transition Signing, Wednesday, August 8, 2012, at the Delft South Clinic in Delft South, a suburb of Cape Town, South Africa.

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When President George W. Bush signed into law the United States Leadership against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, also known as the Global AIDS Act, he created “the largest commitment by any nation to combat a single disease in human history.” This legislation authorized PEPFAR, the President’s Emergency Plan for AIDS Relief, and the U.S. government has committed more than $25 billion to the fight against global AIDS through this program since 2003.

PEPFAR has helped to bring life-prolonging antiretroviral treatment to more than 2.1 million people and provided HIV counseling and testing to nearly 47 million. It has contributed to the care of more than 4 million orphans and vulnerable children, and it has made services available to nearly 1.2 million pregnant HIV-positive women to prevent mother-to-child HIV transmission. And PEPFAR plans to work in partnership with host nations worldwide by 2013 to support treatment for at least 3 million people, prevent 12 million new infections, and care for 12 million people, including 5 million orphans and vulnerable children.

When President Bush called on Congress to reauthorize PEPFAR in 2008 and double the current funding levels to $30 billion for five years, his words were greeted with near-unanimous applause from all sectors, and the program was hailed as his signature achievement.

Activist and lead U2 singer Bono called the president’s request “great news at a time when good news is hard to find.” “These AIDS drugs are a great advertisement for American leadership, innovation,” he said, “and the kind of John Wayne ‘get it done’ mentality that the greatest health crisis in 600 years demands.” Then-Senator Joe Biden (D-DE) said of the president, “His decision to launch this initiative was bold, and it was unexpected. I believe historians will regard it as his single finest hour.” And Rick Warren, pastor of Saddleback Church and author of the bestselling book The Purpose Driven Life, declared: “Certainly one of the president’s greatest legacies will be his insistence on putting compassion into action. No other president or world leader has ever done as much for global health as he.”

PEPFAR has meant nothing less than another chance at life for millions of people around the world. And it provided a positive image of the United States at a time of controversial foreign policy entanglements.

Yet the reality is that the Bush administration’s PEPFAR legacy is far more complicated and problematic. The program has proved deficient in many respects, most notably in prevention and reaching out to populations most in need of services. Some of these limitations are rooted in the statute or implementing regulations; others have played out on the ground through different interpretations of U.S. government policies; but most are due to a framework that placed ideology above science. The Obama administration now seeks to reverse these trends and infuse PEPFAR with its own vision and principles, in the context of its new $63 billion, six-year Global Health Initiative to help the world’s poorest countries.

This report looks at PEPFAR’s development and considers how its flawed framework hindered, rather than supported, preventive efforts to stem the spread of HIV/AIDS. It also examines recent efforts to improve PEPFAR and offers recommendations to Congress and the Obama administration for how to make future PEPFAR programs more effective and better serve the needs those who have HIV/AIDS or are at risk of getting it.

The recommendations seek to build a response to the HIV/AIDS epidemic that is grounded in science—and not religious ideology—and that advances the human rights of lesbian, gay, bisexual, and transgender, or LGBT, populations as well as other specific subpopulations. These recommendations include the need to:

  • Eliminate funding quotas and rules around abstinence and “be faithful” programs.
  • Adopt a rights-based approach to intervention, including encouraging the repeal of laws that criminalize homosexual conduct and/or relationships, or impede LGBT groups’ ability to register or provide services to their communities.
  • Ensure PEPFAR funds are not directly or indirectly distributed to organizations or individuals engaging in antigay rhetoric.
  • Integrate reproductive health services and family planning into PEPFAR programming.
  • Ensure accountability and transparency measures are adequately applied to PEPFAR.
  • Eliminate the antiprostitution loyalty oath.
  • Fund syringe-exchange programs, now that Congress has lifted the federal ban on supporting such programs domestically.
  • Support community-based sustainable development models.

The Obama administration has a historic opportunity to reframe PEPFAR as a program that champions the rights of all people, helps effectively stop the spread of HIV/AIDS, and humanely and competently treats those who already have it. The recommendations outlined in this report will help the administration navigate this reframing process and ultimately support a program that advances human rights, uses precious public health dollars efficiently, and signals America’s commitment to funding programs based on facts.

Download the full report (pdf)

Download the executive summary (pdf)

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