Bush's War on AIDS

As the country grapples with US$85 billion in across-the-board spending cuts, set in motion after a US Congressional committee failed to pass bipartisan federal budget legislation, it is worth remembering how legislators from both sides of the aisle just a decade ago launched one of the largest US humanitarian efforts since the Marshall Plan. 

It all began when President George W. Bush, apparently in the full blush of “compassionate conservatism”, proposed that the US spend $15 billion over five years to combat HIV/AIDS, tuberculosis (TB), and malaria (see Vaccine Briefs, IAVI Report, Feb.-Apr. 2003). He then unveiled the framework for what would come to be called the President’s Emergency Plan for AIDS Relief, or PEPFAR, during a Jan. 23 State of the Union address. 

That was just two months before Bush ordered the invasion of Iraq. By the time the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 was signed into law on May 27—having passed both houses of Congress with wide bipartisan support—the truly historic public health initiative was overshadowed by rapidly escalating protests against the Iraq War and its authors. 

The law authorized funds for PEPFAR and created an Office of the Global AIDS Coordinator to manage the fund. About $9 billion went to 15 developing countries where an estimated 50% of all HIV-infected individuals lived at the time. Another $5 billion was earmarked for research and other bilateral HIV/AIDS, TB and malaria programs, and $1 billion went to the Global Fund to Fight AIDS, Tuberculosis and Malaria. 

Turned out the president had more up his sleeve. Five years ago, in the twilight of his presidency, he signed into law a revised version of PEPFAR. This version authorized $48 billion in funding over five years to expand existing HIV/AIDS prevention, treatment and care efforts worldwide (see Vaccine Briefs, IAVI Report, July-Aug. 2008). 

By most accounts, including those of activists long skeptical about the US government’s response to AIDS, both domestically and internationally, PEPFAR has achieved a lot. Topping the list is the continued scale-up of ARVs, a major success story in the annals of global health. 

According to PEPFAR’s most recent data, funds have directly supported antiretroviral treatment for nearly 5.1 million men, women and children through September 2012. PEPFAR also directly supported HIV testing and counseling for more than 11 million pregnant women last year, and provided ARVs to nearly 750,000 HIV-infected pregnant women to prevent mother-to-child transmission. The result: 230,000 more infants got to start their lives free of HIV. 

Though HIV/AIDS drugs have claimed the largest slice of the PEPFAR pie, the program has paid for 2 million adult male circumcisions through September, 2012. It also provided 15 million people with HIV care and support last year, including 4.5 million orphans. 

Yet while PEPFAR remains a cornerstone of US efforts to develop a comprehensive US strategy for global health (seeDespite Recession, New Funding Stimulates Scientific Research, IAVI Report, May-June 2009), PEPFAR funding has been declining in recent years, according to data compiled by the Kaiser Family Foundation. After peaking at $6.8 billion in fiscal year 2010, it slid to $6.5 billion in fiscal year 2013. It should be noted, however, that PEPFAR spending for TB in FY 2013 was $1.6 billion—the highest ever—and that HIV spending was $4.7 billion, the lowest since 2007. These year-to-year declines in PEPFAR dollars, particularly for HIV treatment and prevention, are occurring despite the Obama Administration’s stated goal of achieving an AIDS-free generation. 

Last year, former US Secretary of State Hillary Clinton released a 64-page blueprint that spells out, in some detail, how this might be achieved (see A Blueprint for an AIDS-Free Society, IAVI Report blog, Nov. 30, 2012). It outlines plans for eliminating HIV infections among children by 2015, and expanding access to ARVs, adult male circumcisions, and HIV testing and counseling, and the scale-up of combination prevention and treatment interventions in countries hardest hit by HIV. 

But given the funding declines, advocates are worried. “Congress has been broadly supportive of domestic and global AIDS funding for many years, and [President Obama] deserves praise for his leadership on AIDS,” blogged Chris Collins, vice president and director of public policy for The Foundation for AIDS Research in The Huffington Post recently. “With the end of AIDS within reach, it is time to think about legacy–the President’s and our own. The most damaging consequence of continual reductions in funding for PEPFAR is slower than necessary progress in pursuing the end of the AIDS pandemic.” 

PEPFAR figures to be one of the bright spots in both the former president’s legacy and at the George W. Bush Presidential Library in Dallas, which is being dedicated tomorrow [April 25] and will bring Obama together with four of his predecessors. Among the library’s holdings: a letter from Irish rocker Bono applauding the 43rd President for fighting the good fight. 

If Obama wants a copy of his own, he’ll probably have to do something about PEPFAR’s funding.