The President's Emergency Plan for AIDS Relief (PEPFAR), which focuses significant assistance on fifteen countries that contain about 50 percent of people infected globally, is widely lauded as a success in improving AIDS treatment and prevention in those countries. When Congress reauthorized the program for another five years early this summer, it increased funding to almost $50 billion through 2013, up from $15 billion in its first authorization. The law also includes billions to combat malaria and tuberculosis, the number one killer of AIDS patients. Few dispute the program's success. CFR Senior Fellow Michael J. Gerson points to Rwanda (WashPost), where thanks to PEPFAR, 92 percent of HIV/AIDS patients now have access to AIDS drugs, up from just 4 percent in 2003.
Yet, for all the accolades, some health advocates worry that focusing on just a few diseases has come at the expense of other health and development issues, including infant mortality and clean water. Daniel Halperin, a senior research scientist at Harvard's School of Public Health, notes the United States spent $3 billion on HIV/AIDS in Africa compared with just $30 million for safe drinking water (NYT)-calling the imbalance "disastrously inequitable." He notes that Ethiopia, Congo, Nigeria have "relatively low" HIV/AIDS rates but represent one-fifth of global deaths from diarrhea-often caused by poor water sanitation. In 2008, HIV/AIDS represented around 60 percent of total U.S. funding for global health. That year, U.S. funding for maternal health and child survival was roughly 27 percent. About 2 million people die from AIDS each year. That compares to nearly 10 million children (PDF) who die of a variety of other preventable causes before their fifth birthday.
Though PEPFAR and other HIV/AIDs initiatives have helped build new clinics and labs, as well as trained health professionals, some advocates assert it has created two-tiered health systems in some countries-because HIV/AIDS patients are often sequestered away from other patients. CFR Senior Fellow Laurie Garrett notes the "resulting segregation has reinforced the anti-HIV stigma and helped create cadres of health-care workers who function largely independently from countries' other health-related systems" (Foreign Affairs).
Some experts are also worrying that PEPFAR's massive effort to treat at least 3 million patients for the rest of their lives amounts to the world's first global entitlement program (PDF). The program is already treating about half that number. Once treatment has started, experts argue it would be "immoral to withdraw the financial assistance that pays for the therapy" since it would amount to a death sentence for those who rely on it (WashPost).
The debate over disparities in HIV/AIDS spending versus other health needs extends beyond America's development budget. The issue pits HIV/AIDS advocates against other health constituencies, and has spawned a dialogue about priorities. Roger England, head of the Health Systems Workshop in Grenada, points out that AIDs funding (BMJ) receives about 25 percent of global health funding, though the disease represents less than 4 percent of global mortality. He argues the disparity cannot be justified. But HIV/AIDS advocates counter that the disease is exceptional and resources channeled to treat it have been instrumental in improving healthcare (BMJ) overall. Brook K. Baker, a law professor and policy adviser for Health Gap (Global Access Project), says other health issues were neglected long before HIV/AIDs gained attention and maintains that "AIDS programming does not divert attention from other health needs."