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Emerging and Re-Emerging Disease: International Public Health

Addressing the HIV/AIDS Pandemic: A U.S. Global AIDS Strategy for the Long Term
Council on Foreign Relations


Executive Summary

The United States has embarked on a major effort to combat the HIV/AIDS pandemic. The success of this effort will be critical. Yet as impressive as the U.S. response has been, more will have to be done on a broader level to achieve the objectives that have been set forth.

The global HIV/AIDS pandemic constitutes one of the most pressing threats known to mankind. Over the past 20 years, more than 65 million people have become infected with HIV/AIDS. More than 25 million have died.1 Roughly 14 million children have lost one or both parents due to AIDS. By 2010 it is estimated that approximately 100 million people will have been infected and that there will be 25 million AIDS orphans worldwide. A humanitarian catastrophe of incomparable proportions, the pandemic is also a threat to global economic and geopolitical stability and a critical strategic threat to the United States.

On January 28, 2003, President George W. Bush announced the President's Emergency Plan for AIDS Relief (PEPFAR), pledging $15 billion over the next .ve years to combat the pandemic, including $10 billion in new monies for 14 targeted countries. The initiative aims to prevent 7 million new infections, provide treatment for 2 million people, and care for 10 million people. It is the most ambitious plan ever proposed by any single country to battle the pandemic. Congress has been strongly supportive, enacting authorization legislation in 2003 and appropriating $2.4 billion for .scal year (FY) 2004. The Senate has con.rmed Randall Tobias as Global AIDS Coordinator. His of.ce has been established at the State Department. In late February 2004 the of.ce released the administration's .ve-year strategic plan (or "strategic statement") for enacting PEPFAR. Congress has suggested guidelines for some aspects of the program — for example, that 33 percent of prevention funds be dedicated to promoting abstinence — and instructed the administration to select a 15th country for the program. Congress also mandated that U.S. contributions to the recently formed Global Fund to Fight AIDS, Tuberculosis and Malaria be matched two for one by all other donors.

The president's initiative constitutes a historic recalibration of the U.S. response to this insidious modern-day plague and places the United States in an excellent position to lead a comprehensive international effort to combat the pandemic. As the title of its program indicates, the administration has chosen to emphasize that the pandemic is an emergency. Fewer than 500,000 of those infected who need antiretroviral (ARV) treatment, estimated at 6 million, have access to these lifesaving drugs. Thus PEPFAR will focus on rapid delivery of health services and an emergency effort to treat persons as quickly as possible. This approach is understandable and justi.ed when looking at the immediate needs. But the current U.S. strategy is near-term and too narrowly focused. It must be upgraded and broadened if it is to reach its near-term goals and achieve long-term success.

The broader and long-term approach that is required must meet the basic health needs of affected developing countries. As urgent and necessary as it is to address the plight of the 20 to 30 percent of a country's population infected by HIV/AIDS, to overlook the health needs of the other 70 to 80 percent with other health needs is neither politically nor .nancially sustainable as host countries and donors strain to support two separate health systems. African countries are quick to point out that 1 million people die from malaria each year, and other diseases take a vast toll in morbidity and lost productivity. This competition between HIV/AIDS and other health programs will become particularly intense as the annual cost of treatment grows and as more infected persons receive treatment.

Moreover, it is now clear that it will not be possible to reach the vast majority of people who do not know they are infected by HIV without having basic health facilities that can make HIV testing a routine part of general health services.2 Thus the United States must build upon the valuable PEPFAR initiative with an equally strong commitment to leading an international effort to help build the basic health systems of developing countries. This is an extensive proposition, but one that has many rewards.

The World Health Organization (WHO) has estimated that providing basic health services to developing countries will take .nancial assistance of $27 billion per year by 2007, and up to $38 billion annually during the following eight years. While those .gures are high, WHO estimates that such an initiative would save 8 million lives per year by 2010 and generate $186 billion in new economic output per year by 2015.

Nevertheless, we do not recommend that the United States and its international partners commit all of the funds upfront or even funds at the full annual level right away. Much of PEPFAR and other international funding for HIV/AIDS can contribute to this objective if so structured. However, the United States should begin to mobilize international support for broader health systems in the countries that PEPFAR focuses on so that such systems are in place in .ve years. Otherwise, .ve years from now, not only will the broader health needs not have been addressed, but PEPFAR investment into programs directed to HIV/AIDS may fail to achieve its goals. But if properly planned, the HIV/AIDS work in these countries can lay the basis, in experience and improved methods, for the larger program envisaged by WHO.

In this context, the long-term implications of a commitment to universal access to treatment, which host countries are urged to adopt, need to be addressed. Contemplating lifetime treatment for 30 to 40 million people or more represents a commitment for that intervention alone of at least $9 to $12 billion a year. Developing countries are deeply concerned about who will bear this cost.

The United States will also have to broaden its use of PEPFAR funds in the next .ve years to address some of the social and economic factors that contribute to the spread of HIV. The U.S. strategic statement does recognize many of these factors, including the legal, social, and economic forces that increase the vulnerability of women and girls to infection and the vulnerability of children affected by HIV/AIDS. But the statement is ambiguous on how much PEPFAR funding will be devoted to these factors. While PEPFAR itself cannot fund such programs like universal primary education, or address alone the impact of gender factors on HIV/AIDS, it can help build support for such programs and for legal and policy changes affecting discrimination; PEPFAR-supported programs can demonstrate that those programs are essential complements to any health-based effort to combating HIV/AIDS.

The strategic statement gives insuf.cient attention to the military. The military in Africa is particularly hard hit by the disease and is a key source of its spreading. The U.S. Department of Defense has begun HIV/AIDS programs with many African military forces, and continuation of these programs is vital for PEPFAR's success. However, the strategic statement makes no mention of how these programs will be funded or incorporated into the overall plan.

The strategic statement commendably highlights the importance of scienti.c evidence in guiding policy decisions. It is imperative that decisions about what prevention programs to implement be buttressed by the strongest scienti.c evidence available. This is particularly important because there are strong ideological and other differences about how to prevent HIV/AIDS. Sexual abstinence, condom distribution, and programs for sex workers and drug users are all controversial approaches, each advocated by one or more groups. The U.S. strategic statement is correct to assert that science must trump ideology. Ensuring that the United States and its international partners analyze the effectiveness of various interventions at the outset will help provide the evidence to make these consequential policy decisions in the best informed manner possible.

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