Could PEPFAR birthday party be followed by budget brawls?

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Sec. John Kerry

U.S. Secretary of State John Kerry spoke of PEPFAR’s accomplishments, work ahead at a State Department event June 18, commemorating the program’s 10 year anniversary.

As policy makers and legislators celebrated PEPFAR’s 10th birthday with pledges of ”strengthened” commitment to the goal of an AIDS-free generation, and researchers compared findings on the challenges ahead, events on Capitol Hill left the funding for the work yet to be done uncertain.

On Tuesday, Secretary of State Kerry told those gathered to commemorate a decade of PEPFAR to “rest assured that the commitment of President Obama, the State Department, myself, this country’s commitment to fighting HIV/AIDS is as undiminished as our work is unfinished. Our commitment has only been strengthened by the progress that we’ve made and the lives that we’ve saved and this story that we are able to tell today.”

On Thursday Senate Appropriations Committee announced topline allocations for 12 spending bills totaling $1.058 trillion. That’s a whopping $91 billion over the Republican-controlled House’s proposed spending ceiling of $967 billion for fiscal year 2014, adopted last month, in line with the Budget Control Act of 2011.

The Senate approved $44.079 billion in spending for the Subcommittee on State and Foreign Operations, an increase of $2 billion over FY 2013 enacted levels.  In contrast, the House Subcommittee on State and Foreign Operations received a top line sub-allocation of $34.1 billion – a cut of 19 percent compared to FY 2013 levels.  The House and Senate Subcommittees on State and Foreign Operations have budget authority over most global health spending, including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, TB, and Malaria.

The Senate Appropriations Committee also allocated more money to the Subcommittee on Labor, Health and Human Services, and Education than the House, allocating $164.3 billion compared to the $121.8 billion proposed by the House.  The Senate proposal is above the FY 2013 level of $156.5 billion. The Subcommittee has funding jurisdiction over the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC).

The Senate’s budget is welcome news to global and domestic health and research advocates.  “The Senate level breathes hope into the appropriations process.  If Congress can work with the Senate level it means we do not need to squander the huge opportunity we have to make great progress against AIDS, malaria, TB, and other diseases,” said Chris Collins, vice president and director of public policy at amfAR, the Foundation for AIDS Research.

At the same, the House and Senate top-line allocations for spending bills are so different that it is hard to imagine the two bodies coming to consensus. This leaves a high likelihood of yet another continuing resolution – a bill to allow the government to keep funding most agencies to avoid a government shutdown when the current fiscal year ends on September 30 — which could also impact global health spending.

Which would leave not only the commitment that Kerry, echoed by Senators Enzi and Cardin said was stronger than ever in doubt, but even leave questions of whether gains could be sustained.

While PEPFAR has expanded treatment coverage from 1.7 million people in 2008 to 5.1 million people currently receiving antiretroviral therapy under the program, 7 million people who are eligible for treatment under current World Health Organization guidelines who remain without treatment.  That number is expected to increase by 5 million when the WHO releases new eligibility criteria next month.

At a recent event held on the Institute of Medicine’s evaluation of PEPFAR and the Government Accountability Office’s PEPFAR studies, Bridget Kelly of the IOM  described that unmet need will continue grow with some countries deciding to adopt “Option B+” of antiretroviral treatment for life for HIV-infected pregnant women.

“Any decision has the potential to exacerbate existing coverage problems,” she said

Advocates are hoping legislators remember that includes the decisions they make, sooner rather than later.

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