Nine years of PEPFAR

The United States President’s Emergency Plan for AIDS Relief (PEPFAR) was initially launched in 2003 as a five-year commitment of $15 billion for 2003–2008. At that time the programme pledged to provide antiretroviral treatment (ART) for two million HIV-positive people, to prevent seven million new infections, and to support care for ten million people (the ‘2–7–10 goals’) by 2010. PEPFAR soon grew to be the largest bilateral health contributor worldwide. The programme’s major achievements include:

• nearly four million people placed on ART;
• 200,000 infant HIV infections prevented thanks to greater investment in prevention of mother-to-child transmission (PMTCT) programmes;
• 13 million people supported on care, including four million orphans and vulnerable children;
• cost of treatment per patient decreased from $1,100 to $335 through the use of generic drugs and cheaper shipping;
• task-shifting to nurses and community health workers;  and
• HIV/AIDS services linked to other programmes such as those for maternal and child health.

The savings shown above allowed PEPFAR to more than double the number of people it directly supported on treatment during the first five years of the programme. In many African countries PEPFAR has been fundamental to increasing treatment coverage. Botswana, for example, has seen its coverage rise from nearly zero to almost 80%. Other nations such as Zambia and Ethiopia have increased their coverage to at least 50%.

Budget cuts bring down targets

2011 brought exciting breakthroughs in HIV research showing that it is possible to curb the epidemic. The HPTN-052 trial demonstrated that putting people on ART earlier in the progression of the disease could reduce the risk of HIV transmission by 96%.

Drawing on this outcome, US Secretary of State Hillary Clinton announced a major shift in the US global AIDS response. She noted, “Creating an AIDS-free generation has never been a policy priority for the United States Government until today, because this goal would have been unimaginable just a few years ago.”  Clinton highlighted certain interventions as key to reaching this goal, including the scale-up of ARV treatment to prevent new infections.

Further commitments followed, this time from President Obama. He announced PEPFAR’s pledge to reach an additional two million people with ART and 1.5 million HIV-positive pregnant women with PMTCT by the end of 2013.

However, it is unclear how the US can achieve these goals in the face of proposed budget cuts to PEPFAR and other bilateral AIDS programmes. The newly-released 2013 US national budget proposes a dramatic cut of $542.9 million for worldwide PEPFAR programmes. This would put PEPFAR in the position of having to treat 40% more people in 2013 than in 2012, but with 13% less funding.

The US Congress could impose even more severe cuts. According to the State Department budget proposal for the 2013 fiscal year—to which most PEPFAR funding in the national budget request is directed—many PEPFAR-funded countries face hefty cuts. These could range from 10% in South Africa to as high as 50% and 80% in Kenya and Ethiopia respectively. Furthermore, total US funding for HIV/AIDS could be slashed by almost 11%, while TB funding is expected to fall by 7%. These potential reductions could spell disaster for country-level programmes. What is more, PEPFAR cutbacks would do little to solve the US budget crisis. Global health represents just one quarter of one percent of the federal budget.

A shift in focus

The reduced funding coincides with a shift in focus at PEPFAR, away from direct service provision and towards technical assistance. A recent study of PEPFAR operational plans highlights a significant fall in HIV treatment funding since 2008. This can be seen both as a proportion of total budgets and in absolute amounts. According to PEPFAR Operational Plans up to 2010, the percentage of total funding that goes toward the supply of ARVs, both adult and paediatric, has decreased from 35% to 28%. Declines varied by country. Some saw their grants flatlined, while others – including Namibia, Mozambique, Kenya, and Tanzania – had lost between 10% and 30% of their total treatment budgets by 2010.

[box]Thirty years after the discovery of HIV, it now seems possible that we can break the back of the epidemic. The number of new cases is declining in 22 sub-Saharan countries, including Ethiopia, Nigeria and Zimbabwe, as more people are put on antiretrovirals. New science has shown that treatment not only saves lives but reduces new infections. Yet just as we are making headway, the world is seeing a decline in HIV funding that could devastate this progress. Our hope of controlling HIV can only become a reality with renewed political commitment and sufficient funding. And we will need these soon, if we are to save lives and prevent costs from spiralling out of control.[/box]

A dangerous transition in SA

South Africa is experiencing first-hand the effects of PEPFAR’s shift from direct supporter of ART to provider of technical assistance. PEPFAR-supported clinics have begun closing down and redirecting patients to often-overburdened public health facilities. The shift poses an enormous challenge for South Africa as the largest recipient of PEPFAR grants. Between 2004 and 2011 South Africa received $3.1 billion from PEPFAR that allowed a significant scale-up of HIV treatment and care. By 2010 PEPFAR is estimated to have helped South Africa

• support 920,000 people on treatment;
• give 2.2 million people care and support for HIV and TB;
• place 680,000 pregnant women on PMTCT services; and
•  avert 40,000 infant infections.

Furthermore, in 2009 PEPFAR contributed $120 million to the bulk purchase of ARVs for South Africa. This one-time funding would help meet the increased demand generated by the HIV Counselling and Testing (HCT) campaign which kicked off in April 2010. The investment supported South Africa’s shift towards greater use of generic drugs, and helped to double the country’s ARV supply. It also facilitated the later adoption of WHO treatment guidelines requiring earlier ART initiation.

However, long-term budget requirements for South Africa’s AIDS response are likely to dwarf these sums, reaching a staggering R35-R45 billion (approximately $4.5-$5.9 billion) per year by 2020. Collective spending on the disease by public and development partners was estimated at R17 billion for 2010, up from R9 billion in 2008. Yet PEPFAR’s contributions to South Africa—$548 million in 2011—are expected to halve by 2016/2017. It is clear that government faces a considerable challenge to bridge the funding gap.

Building a framework

PEPFAR’s renewed mandate in 2008 directed the US government to develop framework agreements with partner countries to increase country ownership of the HIV/AIDS response. These partnerships are intended to build the capacity of national governments to manage health programmes. Ultimately, the framework agreements aim to migrate PEPFAR-funded programmes to the control of government-coordinated systems. PEPFAR’s five-year Partnership Framework between the US and South African governments, signed in December 2010, is one such agreement. The Framework highlights the South African government’s future leadership role in decision-making and planning for PEPFAR activities in the country. It looks at the alignment of PEPFAR operations to national plans, and anticipates the shift of PEPFAR-supported staff and programmes to the South African government. Furthermore, the Framework acknowledges the likely decline in funding for South Africa and the need for larger domestic contributions.

A detailed plan of how this transition will work is only expected in June 2012 with the late completion of the PEPFAR Partnership Framework Implementation plan. This plan will make it possible to assess the feasibility of the transition. It will also be useful for monitoring how the transition is implemented, to avoid any interruptions to essential services or to the employment of health staff.

Shifting PEPFAR-funded programmes to the control of the South African government is a huge endeavour, involving all nine provinces. The transition will affect over 30,000 health professionals who are currently PEPFAR-funded, over 1.79 million people now receiving treatment, and close to 400,000 orphans and vulnerable children. Despite assurances from the US and South African governments that efforts will be made to avoid disruptions to HIV services during the transition, uncertainties exist. The scale of HIV services in South Africa and the complexity of the transition process are such that Médecins Sans Frontières (MSF) and other organisations—including the Treatment Action Campaign (TAC) and SECTION27—remain concerned. These organisations plan to monitor how the implementation affects people on the ground.

As PEPFAR begins a new phase in South Africa, we need the US government to provide a clear and comprehensive view of the funding flow. To date there has been a lack of transparency in the way that PEPFAR’s investment in South Africa is spent. It is now vital to identify clearly which NGOs receive PEPFAR funding and to pinpoint the operational costs of PEPFAR programmes. The transition process will involve costing the absorption of thousands of PEPFAR-funded staff into the public sector. Many of these workers are paid much higher wages than those offered in the public sector. As a result salary structures may need adjustment in order to retain health workers. Ultimately, PEPFAR must be accountable for ensuring transparency in how it spends its country-specific financial commitments.

Will the opportunity be squandered?

PEPFAR’s budget cuts and policy changes coincide with a period of immense opportunity. South Africa and neighbouring countries are making headway against the epidemic. They are helped by greater political and financial ownership of the HIV response, and by policies and programmes that support accelerated treatment.

Treatment as prevention

In line with the new scientific evidence of ‘treatment as prevention’, MSF has opened a pilot project in KwaZulu-Natal. The project aims to reduce infections in the community through testing and accelerated treatment, along with conventional prevention.

And a new study released in March 2012 by the AfricaCentre’s project in Umkhanyakude district in northern KwaZulu-Natal shows that in areas where ART coverage reached 30-40% of need, HIV incidence was significantly lower than in areas with ART coverage below 10%. People in high ART coverage areas were nearly 40% less likely to become infected with HIV than those in low-coverage areas. Furthermore, researchers found that for every 1% increase in ART coverage there was an associated 1.7% decrease in HIV incidence.

For the first time ever there is hope that a combination of prevention methods—including increased treatment coverage—can bring the HIV and TB epidemics under control. The major barrier to this is the retreat of donors from their promises to help pay for 15 million people on ART by 2015. The donor default is leaving poor countries with insufficient resources to expand their treatment efforts. Inevitably, this will cause increased suffering and lead to the deaths of many people with HIV who cannot access treatment. The world could also miss an incredible opportunity to decrease HIV transmission, which would otherwise reduce our future need for ART.

The principle of national ownership of the HIV and TB response is a worthy one. But coupled with diminished donor support it risks punishing the success of the last decade. It could also waste our chance to treat as many people as possible as quickly as possible. In the coming years, the pace of the global response and of South Africa’s own HIV programmes will be critical to breaking the back of these epidemics.

by Donela Besada. Donela Besada is the Advocacy Manager at Médecins Sans Frontières South Africa and Lesotho.

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Sources: UNAIDS., “World AIDS Day Report.” (2011), ; Speech by Michel Sidibé, Executive Director of UNAIDS, UN General Assembly High Level Meeting on AIDS, New York (8 June 2011); PEPFAR, “Using Science to Save Lives: Latest PEPFAR Results”, PEPFAR Press Room Electronic Press Kit (November 2011), 1-2,; World Health Organization, “Towards universal access: Scaling up priority HIV/AIDS interventions in the health sector”, Progress Report (2010), ; US Department of State, Remarks on “Creating an AIDS’-Free Generation (November 2011), “State and USAID-FY 2013 Budget.” (February 2012), http://www.state.gov/r/pa/prs/ps/2012/02/183808.htm; Henry J. Kaiser Family Foundation, “U.S. Funding for the Global Health Initiative (GHI): The President’s FY 2013 Budget Request” (February 2012), http://www.kff.org/globalhealth/upload/8160-02.pdf; Kavanagh, M. Thorp, M., “PEPFAR’s declining investment in HIV/AIDS Treatment.” Health Affairs Blog, http://healthaffairs.org/blog/2011/11/29/pepfars-declining-investment-in-hivaids-treatment/; PEPFAR Operational Plans, http://www.pepfar.gov/about/c19388.htm; PEPFAR, “Partnership to fight HIV/AIDS in South Africa.”, http://www.pepfar.gov/countries/southafrica/index.htm; PEPFAR, “Partnership Framework in Support of South Africa’s National HIV & AIDS and TB Response 2012/13 – 2016/17 between the Government of the Republic of South Africa and the Government of the United States of America” (December 2010), http://www.pepfar.gov/frameworks/southafrica/161215.htm; Tanser F., “Effect of ART Coverage on Rate of New HIV Infections in a Hyper-endemic, Rural Population: South Africa.”, Conference on Retroviruses and Opportunistic Infections 2012, Seattle (8 March 2012).