AIDS: The U.S. Anti-AIDS Program

February 7, 2005

Backgrounder
Current political and economic issues succinctly explained.

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What’s the status of President Bush’s anti-AIDS plan?

Congress has authorized $2.4 billion for the first year of President Bush’s landmark $15 billion, 5-year plan to dramatically reduce HIV/AIDS infections worldwide. However, the money has not yet begun to flow because of delays in passing congressional spending bills. The legislation appropriating the funds is expected to be approved by December or January, and the program will begin soon afterward.

How does this funding compare to past years?

It’s some $1 billion more than U.S. international HIV/AIDS funding in 2003, and some $1.4 billion more than in 2002. U.S. spending on global HIV/AIDS activities has shot up since 2000, when it totaled less than $500 million.

Was there a fight over the funding?

Yes. The legislation passed by Congress--the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003--authorizes $3 billion to be spent in each of the next five years. The White House originally asked for $2 billion for 2004, saying that ramping up spending on the program over time would be more efficient. AIDS activists criticized this decision. Congress ultimately raised the funding level in the appropriations bill to $2.4 billion.

How does the president’s plan divide the money for AIDS?

Of the $15 billion:

  • $5 billion is devoted to existing activities to prevent, treat, and research HIV/AIDS in some 50 countries around the world. These programs are run by USAID (the U.S. Agency for International Development).
  • $9 billion in new funds will target 14 countries deeply affected by the HIV/AIDS pandemic. According to the White House, these nations are home to 50 percent of the 42 million HIV-infected people in the world and 70 percent of the HIV-infected individuals in Sub-Saharan Africa and the Caribbean, the regions most devastated by the virus.
  • $1 billion will go to the two-year-old Global Fund to Fight AIDS, Tuberculosis, and Malaria, a U.N.-affiliated international agency that coordinates funding from private organizations and governments to battle the disease. Total pledges to the fund through 2008 are now $4.7 billion. The United States is barred from contributing more than one-third of the total resources of the fund, according to recently passed U.S. legislation. The fund’s chairman in 2003 is U.S. Secretary of Health and Human Services Tommy G. Thompson.

How will the extra $400 million approved by Congress be spent?

In part, it will increase the U.S. contribution to the Global Fund. President Bush’s plan calls for $200 million to be given to the agency annually, which some critics charge is insufficient. The contribution will now be about $400 million, according to Erin Chapman, policy director for DATA--Debt, AIDS, Trade, Africa--the nonprofit organization founded by Bono, the singer for the Irish rock band U2, to raise awareness of Africa’s debt and health crises.

How does the U.S. program compare with other countries’ anti-AIDS programs?

Experts agree that the program dwarfs other global efforts to fight the disease. The 2002 USAID HIV/AIDS budget was $790 million, which already made the U.S. government the world’s largest bilateral donor of HIV/AIDS assistance. The new plan will, over five years, nearly triple this amount--making it "certainly the largest single increase in funding for global health in memory," says Dr. Nils Daulaire, president of the Global Health Council. While much remains to be done--and while the effectiveness of the new effort is still untested--the president’s AIDS plan is "a very strong indication that health has moved to center stage in U.S. foreign policy," Daulaire says.

What does the United States spend on domestic AIDS programs?

Almost $15 billion annually, including $2.6 billion for vaccine and cure research, according to the White House.

How much money is needed to control AIDS/HIV?

The World Bank estimates that some $10 billion in donations to low and middle income countries is required annually.

Who are the other major funders of international anti-AIDS programs?

In 2002, some $1.8 billion was spent on international HIV/AIDS programs, according to UNAIDS, a U.N. agency that coordinates anti-AIDS efforts.

Major donors included the European Community, the United Kingdom, Japan, Germany, and the Netherlands. World Bank loans accounted for $95 million in aid, and the Bill and Melinda Gates Foundation contributed more than $100 million.

Which 14 countries are covered by the U.S. plan?

There are 12 countries in Africa and two in the Caribbean.

  • In Africa: Botswana, Cote d’Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia.
  • In the Caribbean: Guyana and Haiti.

Adult HIV-infection rates (the percentage of people aged 15-49 with the disease) in these countries range from 38.8 percent in Botswana--the world’s worst-afflicted country--to 3.1 percent in Guyana, according to statistics compiled by the World Health Organization (WHO) and UNAIDS.

Do these countries have the highest AIDS rates worldwide?

Some do, but there are some countries with extremely high infection rates missing from the list. Among them: Zimbabwe, with 33.7 percent of adults infected; Swaziland, with 33.4 percent of adults infected; Lesotho, with 31 percent of adults infected; and Malawi, with 15 percent of adults infected.

Why were those countries excluded?

White House officials say they have chosen countries with "among the highest prevalence of HIV-infection" but have not explained why some countries were included and others not. AIDS experts say the decisions appear to be based on a variety of factors. In some highly populated countries, such as Nigeria and Kenya, the total number of cases is very high, even if the rate of infection is lower than in other nations. Cote d’Ivoire has fewer HIV sufferers than some non-targeted nations, but the highest rate in West Africa. Another factor: the White House appears to have selected countries with which it already has a good working relationship, DATA’s Chapman says.

Do experts agree that the right countries were selected?

No. "If you put a bunch of AIDS experts in a room, you’d get a room full of different opinions," Daulaire says. There is also a discussion among experts about whether more spending should go to regional or multilateral programs such as the Global Fund. On the other hand, there is broad agreement that all the countries included are in desperate need of help.

Could the U.S. list of countries change?

Yes, AIDS activists say. Some experts hope that in the future, the program will also target nations outside Africa and the Caribbean where the epidemic is starting to explode. India--which already has 4 million infected--is a key nation that needs more assistance, says Dr. Helene D. Gayle, the director of HIV, TB, & Reproductive Health at the Gates Foundation. "Should there be more consideration given to where we know the disease will spread over the next decade? That question needs to be asked," she says.

How will the funding be split between prevention and treatment for AIDS sufferers?

Congressional legislation mandates that:

  • 55 percent of the funds are for AIDS treatment, with a focus on providing antiretroviral (ATV) drugs that suppress the virus and extend the life of an AIDS sufferer. This is a major innovation in U.S. AIDS policy--which up until now has provided ATV drugs only in limited pilot programs overseas--and will be the first global effort to provide advanced antiretroviral treatment on a large scale in the poorest, most afflicted countries. In late September, the WHO announced a plan to provide ATVs to 3 million additional patients.
  • 15 percent of the funds will be used for care of AIDS patients who cannot be treated with ATVs. This so-called palliative care includes home-health care visits, hospital stays, and other treatment to make patients more comfortable.
  • 20 percent of the funds will go toward prevention. In a special stipulation lobbied for by U.S. fundamentalist Christian groups, at least one-third of this funding should be used to promote sexual-abstinence-until-marriage programs. Many AIDS activists are skeptical that abstinence-only programs--compared with, for example, distribution of free condoms--will significantly reduce HIV infections.
  • 10 percent of the funds will be used to help AIDS orphans and vulnerable children. Half of this money, according to the law, should be channeled through nonprofit organizations, including so-called faith-based organizations run by religious groups that operate orphanages in local communities.

How will the requirement regarding abstinence programs affect the initiative?

It’s not yet clear, AIDS experts say. In large part, this is because many details about how the program will be implemented have not been worked out. If the statute is interpreted strictly, $1 billion over five years in funding would be reserved for abstinence-only education, with $2 billion for other prevention efforts. A looser interpretation would allow abstinence funds to be spent on programs that encourage abstinence along with other behaviors, such as the approach used to help control the epidemic in Uganda. That country’s ABC program--Abstain, Be Faithful, Use a Condom--has had impressive success in curbing Uganda’s AIDS epidemic. But experts warn that local conditions differ from country to country, and that what worked in Uganda may not work elsewhere. "There is no one-size-fits-all approach," says Todd Summers, the deputy director of the White House Office of National AIDS policy under President Bill Clinton and now president of Progressive Health Partners.

Does the program emphasize faith-based organizations and care?

Yes. While churches and other religious networks have partnered with USAID in the past to some degree, there is specific language in the new legislation encouraging that money be channeled through faith-based organizations. In large part, this reflects the reality on the ground in Africa, where religious organizations are often the primary provider of health and social care and "harnessing these organizations is a good idea," Summers says. However, some activists have expressed concern that church groups may withhold services based on a patient’s religion, or proselytize, directly or indirectly, with the funds.

Can organizations that provide abortions receive the new U.S. funds?

It is unclear. The appropriations bill before Congress stipulates that the new AIDS program will be subject to a current U.S. policy that bars funding of international family planning organizations that perform or promote abortions, even if they use their own money to do so. The policy has been enforced by every Republican president since Ronald Reagan; it was lifted during the Clinton administration and restored by the Bush administration. Because, in some parts of the world, clinics that perform abortions may be the only health-care provider available, "I think this policy compromises our ability to respond to the disease to some degree," says Sandra Thurman, the president of the non-profit International AIDS Trust and former head of President Clinton’s White House AIDS office. Some Bush administration officials have said publicly that, when it comes to anti-AIDS efforts, the administration may exercise a degree of flexibility in applying the policy.

What are the program’s goals?

If the plan is funded at its full amount, the White House projects it will:

  • Prevent 7 million new infections (60 percent of the projected new infections in the target countries). In addition to abstinence programs, other prevention efforts will include voluntary testing and counseling and help for organizations that provide condoms and distribute information about other ways to prevent the spread of AIDS.
  • Treat 2 million HIV-infected people with ATV drugs.
  • Care for 10 million HIV-infected sufferers and AIDS orphans.

Will the program use generic drugs?

It’s still being decided. President Bush has emphasized that the highest quality drugs will be used, whether name-brand or generic. The cheapest name-brand drugs available in developing countries cost approximately $675 per person per year; that figure can drop to less than $300 for generic drugs. Further cutting costs, the Clinton Foundation HIV/AIDS Initiative recently negotiated an agreement with four generic drugmakers in India and South Africa to provide ATV drugs for $132 a year. Many AIDS experts say that given the number of patients the initiative plans to treat, low-cost generic drugs are the only option in the program’s price range, though experts also warn these drugs can vary in quality. Because of patent protections and other costs, ATV prices in the United States and other developing countries remain high, often topping $12,000 per year.

Who will run the program?

Randall Tobias, the chairman of major U.S. pharmaceutical company Eli Lilly and Company from 1993 to 1999, was confirmed as President Bush’s Global AIDS coordinator in early October. He has the rank of ambassador and will be responsible for overseeing all U.S. international HIV/AIDS assistance and coordinating the efforts of the various agencies and departments that deliver it.

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