Critical questions surrounding the performance and future of the President’s Emergency Plan for AIDS Relief (PEPFAR) were publicly aired last week at a full-committee House Foreign Affairs hearing.
Government witnesses included U.S. Global AIDS Coordinator Eric Goosby, MD; head of the National Institute of Allergy and Infectious Diseases Anthony Fauci, MD; and Director of the Centers for Disease Control and Prevention Thomas Frieden, MD. (click on links to view testimony).
They presented detailed updates on PEPFAR and U.S. backing for the Global Fund, while civil society witnesses, Ms. Paula Akugizibwe of the AIDS & Rights Alliance of Southern Africa and Wafaa El-Sadr, MD, of Columbia University’s International Centers for AIDS Treatment and Prevention Programs (ICAP), each gave an impassioned plea for greater financial support in the run up to this week’s Global Fund Replenishment meeting. Dr. El-Sadr sits on the Center’s Scientific Advisory Committee.
A notable feature of the U.S. government’s testimony was the strong endorsement of the role of treatment in preventing new HIV infections.
Dr. Frieden presented several fascinating graphs, one of which showed the enormous impact that combination prevention could have on the epidemic in Lesotho, with the largest contributions to reduced HIV incidence being made by treatment as prevention, addressing the needs of discordant couples and by male circumcision. (Links here to slides, page one, two and three)
A statement by Rep. Ileana Ros-Lehtinen (R-FL), the ranking Republican on the Committee, stated that the U.S. national debt was “undermining the ability of the American taxpayer to continue to shoulder over 58 percent of the entire, global response to the HIV/AIDS crisis.”
However, Ms. Akugizibwe noted that, “According to the Kaiser Family Foundation, the U.S. contributes 27 percent of the global investment in HIV when contributions by national governments and by patients themselves are included.”
Akugizibwe described last week’s Day of Action in which activists in a dozen African countries rallied to demand greater contributions to the fight against AIDS by their own governments as well as the U.S. and other donor nations. She noted the exciting prospect of biomedical prevention and said that, “The good news is that we are not fighting a losing battle – there is ample evidence we are bending the curves, that the once-elusive dream of an HIV-free generation is eminently achievable. The bad news is that without increased resources now, our chance to defeat HIV may slip from our grasp and the carnage of AIDS could return.”
Dr. El-Sadr, who heads up one of the largest and longest-standing PEPFAR implementing programs, sought to dispel what she called myths about PEPFAR, including that “PEPFAR has contributed little to countries’ health systems.” This view has gained considerable currency, as seen in the recent Center for Global Development report, which stated that programs like PEPFAR have done “little to address the long-term sustainability and capacity of the workforce to handle all health needs.” Instead, Dr. El-Sadr stated that:
[A] major contribution has been in the realm of health workforce innovations. … ICAP programs have also supported new health worker cadres, from adherence counselors and outreach workers to advanced physician-assistant equivalents, such as the technicos in Mozambique—efforts aimed at addressing the severe shortage of health care workers. These models, systems, and investments position the health system to respond to other threats.
Dr. El-Sadr said PEPFAR’s contributions to other outcomes beyond strictly HIV targets, are “a major achievement.” As an example, she cited ICAP-supported programs in Nigeria that offer pregnant women insecticide-treated bed nets for malaria prevention, water purifying systems and “mama packs” to encourage safe pregnancy and facility-based delivery—thus impacting maternal and child health. She said that renovation of antenatal care, labor and delivery wards, and support of orphans and vulnerable children, are just a few examples of the broad impact of PEPFAR.
Dr. El-Sadr warned that “All of these achievements cause great apprehension that if we stall the expansion of PEPFAR, in the name of ‘greater balance’ in global health spending, then we will also be stalling advances in maternal and child survival, as well as many other advances that go far beyond AIDS per se. “
Thirteen members of Congress attended the hearing, most of whom posed questions to the witnesses. Chairman Howard Berman (D-CA) raised a concern, echoed by Rep. Diane Watson (D-CA), about whether PEPFAR was moving so fast to country ownership and program integration that it could “overwhelm” countries.” Dr. Goosby said these challenges are dealt with in a spirit of dialogue during the negotiation of the Partnership Frameworks.
Rep. Barbara Lee (D-CA) mentioned the enormous concern voiced at the Vienna AIDS conference about “funding drying up” and she asked pointedly about whether President Obama would be pledging the $6 billion over three years to the Global Fund, which she and 100 other members of Congress had requested of the president in a letter. Dr. Goosby responded that this was still being considered by the administration, and he said he was excited that PEPFAR and the Global Fund were “merging” and “moving aggressively to a shared plan.”
She also asked about HIV services that protect the privacy and safety of men who have sex with men (MSM), and Dr. Goosby spoke directly to the issue, stating that PEPFAR was working to engage countries on the legal issues affecting MSM and to create safe spaces to enable them to access services.
There were a number of questions about maternal health, safe delivery and linkages to family planning information and services, in particular from Rep. Brad Miller (D-NC), Rep. Watson and Rep. Lynn Woolsey (D-CA). Specifically, a question was raised about whether the conscience clause—which allows health care providers to opt out of providing information and/or services out of step with their moral beliefs—was impeding the integration of family planning with HIV services. Congressman Chris Smith (R-NJ) wanted assurances that the “conscience clause” was operative in the context of partnership framework agreements negotiated between the U. S. and other countries. Dr. Goosby responded that while the conscience clause applies to the negotiation of partnership frameworks, “a referral mechanism to family planning is usually doable.”
Rep. Ros-Lehtinen raised a concern in her statement about a loss of focus by PEPFAR, given the push for it to provide complementary services, and Rep. Smith said he felt it was inappropriate for the administration to be pursuing the Global Health Initiative (GHI) in the absence of authorizing legislation. Dr. Goosby’s testimony responded directly to the “perception that GHI will diffuse the focus of PEPFAR and limit our ability to deliver on our core work.” He said, “[USAID Administrator Dr. Rajiv] Shah, Dr. Frieden and I all recognize that the mission is not program integration for integration’s sake, but smart integration to improve and save lives.”