The Foreign Service Journal, June 2007

to purchase antiretroviral drugs from U.S. pharmaceutical companies. Only 20 percent of PEPFAR fund- ing is allocated to prevention, despite the millions of new infections that occur each year. And the prevention budget’s resources have largely been offered up to faith-based organiza- tions. PEPFAR requires that one- third of all prevention funding go to abstinence and faithfulness programs, even though there is little evidence to demonstrate their effectiveness. In practice, this one-third requirement, or earmark, is routinely exceeded due to pressure from the administration. In addition, the program has reduced funding for condom procurement and limits distribution to certain high-risk groups, rather than the general popu- lation of sexually active individuals. A Stark Shift in Policy PEPFAR represents a stark shift in U.S. HIV/AIDS policy — away from prevention and toward treatment; away from science-based approaches and toward ideologically-motivated programs. In the midst of the pan- demic decimating Africa, the Bush administration has chosen to abandon the effective, comprehensive strate- gies of transmission education, volun- tary counseling and testing and the provision of condoms, in favor of unproven abstinence and faithfulness strategies that are largely irrelevant in a context where the majority of women and girls are already married, have unfaithful partners already infected with HIV, or have little sexu- al bargaining power. Further, PEPFAR is a unilateral, single-donor approach. As such, it undervalues the vital integration of U.S. efforts with other donors and host governments, and downgrades American interest in, and funding for, multilateral financing instruments such as the Global Fund. There is continued confusion over how U.S. procurement of medications for treat- ment will be coordinated with the Global Fund and other donors. PEPFAR’s requirement that med- ications be FDA-approved (rather than World Health Organization- approved, as the Global Fund requires), and thus only available from U.S. pharmaceutical companies, dramatically increases costs, thereby reducing the number of people served. When Dr. Charles Carpenter, the head of HIV/AIDS research at Brown University’s medical school, visited Africa as part of an Institutes of Medicine oversight panel, doctors complained to him that they could buy three times as much medicine if PEPFAR accepted WHO approvals. The program has been divisive, triggering battles among groups with differing perspectives on prevention and embittering donors. When Ugan- da faced a dire shortage of condoms in August 2005, Stephen Lewis, U.N. special envoy for AIDS in Africa, said: “There is no question in my mind that the condom crisis in Uganda is being driven and exacerbated by PEPFAR and by the extreme policies that the administration in the U.S. is now pur- suing in the emphasis on abstinence.” J U N E 2 0 0 7 / F O R E I G N S E R V I C E J O U R N A L 49 PEPFAR requires that one-third of all prevention funding go to abstinence and faithfulness programs, even though there is little evidence to demonstrate their effectiveness.