Another $30 Billion for PEPFAR:
Analysis of President Bush's Recent Announcement on PEPFAR Reauthorization

06.13.07

The President’s Emergency Plan for AIDS Relief (PEPFAR) was announced by President Bush in his 2003 State of the Union Address as a five-year, $15 billion initiative to combat global HIV/AIDS. On May 30, 2007, President Bush announced that he would work with Congress to reauthorize PEPFAR and provide $30 billion in funding over the next five years. If Congress meets the President’s FY2008 Request and provides $30 billion from FY2009-FY2013, the total amount of money committed by the U.S. to fight global HIV/AIDS over ten years will reach $48.3 billion.

 

The President’s announcement, while significant, will provide $3 billion (out of the $30 billion total) in “new” financing over the next five-year period. This is a good starting point, but providing only small increases to current high levels of funding will not allow PEPFAR to have the transformative impact envisioned at its creation and realized up to this point. Congress has consistently increased the President’s Request for HIV/AIDS and DATA hopes the $30 billion will be seen as a base from which to build, rather than a cap.

 

Details on the President’s Announcement: Financing and Results
While many of the details of the President’s plan for reauthorization are not yet available, new treatment, care and prevention goals have been announced and projected funding levels can be discerned. According to PEPFAR, the next five years of the initiative will aim to transition from the initial emergency response to a more sustainable response, working with host governments to pursue “Partnership Compacts” to align efforts more closely and ensure that increases in funding from the U.S. continue to be met with increases in funding from host governments, along with improved policies.

The Administration has announced that PEPFAR’s second five years will include a focus on strengthening health systems and integrating HIV/AIDS efforts into broader health and development efforts, including child and maternal health, water, nutrition and education—though details of how this will be achieved have not been outlined. Multilateral partnerships and financing for multilateral efforts, including The Global Fund to Fight AIDS, Tuberculosis and Malaria, will also continue to be a component of PEPFAR’s second five years, though no details on specific allocation of funding have
been provided—and, as explained below, the relatively modest growth in financing each year does not leave significant room for a U.S. contribution to the Global Fund to
grow.

 

PEPFAR Financing FY04-FY13
Year	Funding
FY2004	$2.3b
FY2005	$2.7b
FY2006	$3.3b
FY2007	$4.6b
FY2008 Req	$5.4b
FY2009 (proj)	$5.6b
FY2010 (proj)	$5.8b
FY2011 (proj)	$6.0b
FY2012 (proj)	$6.2b
FY2013 (proj)	$6.4b
Total	$48.3b

Funding will increase, but at a significantly slower pace
Annual appropriations to PEPFAR have increased significantly from $2.3 billion in FY2004 to $4.6 billion in FY2007. The FY2008 Request includes a total of $5.4 billion for global efforts to fight HIV/AIDS. Though precise details are not yet available, it looks likely that to reach $30 billion from FY2009-FY2013 the initiative would scale up from the FY2008 Request of $5.4 billion with an additional $200 million added each year (for a total of $3 billion in “new money” over the five-year period). The table to the right shows annual appropriations through FY2007, as well as projected appropriations to 2013, based on the assumption that Congress will have appropriated a total of $48.3 billion from FY2004-FY2013.

 

Modest increases to projected results during PEPFAR’s next five years
PEPFAR’s original goals were to reach 2 million people with life-saving antiretroviral drugs (ARVs), prevent 7 million new infections and provide care to 10 million people affected by the disease. The additional funding will allow the initiative to deliver increased results, reaching a total of 2.5 million people with ARVs, preventing a total of 12 million new infections and providing care to more than 12 million people, including five million orphans. The slower scale-up in treatment results, in particular, can be attributed to the cost of maintaining existing people on treatment and increased costs expected as some patients move to more expensive second-line drug therapies.

 

Slower scale up of funding and results from FY2009-FY2013
As the chart to the right demonstrates, the scale up in both funding provided and results delivered will be slower during PEPFAR’s second five years than in its first. For example, a total of 2 million people are expected to be put on treatment by the close of 2008, but just 500,000 more will be added over the initiative’s next five years. The scale-up in financing will also be slower during the initiative’s second five years, growing by an average of $200 million per year, compared to an estimated average of $600 million during the initiative’s first five years.

 

 

Background on PEPFAR
The majority of PEPFAR financing is focused on 15 of the countries hardest-hit by HIV/AIDS in Africa, the Caribbean and Asia¹. Though many believe PEPFAR refers only to the 15 focus countries, it includes all global HIV/AIDS and TB efforts through bilateral and multilateral mechanisms. Prior to the announcement of the President’s Malaria Initiative (PMI) in 2005, bilateral malaria programs were also included under PEPFAR. While most of the funding is directed through bilateral programs in the focus
countries, the initiative maintains existing bilateral HIV/AIDS and TB programs in 108 other countries, as well as research efforts. PEPFAR also includes the U.S. Government’s annual contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which operates in a total of 136 countries. To date, the U.S. has provided just under 30% of all Global Fund financing since its creation in 2002.

For several years preceding PEPFAR’s authorization, bipartisan leaders in Congress had been considering legislation on global HIV/AIDS. After the President’s announcement, Congress passed the “United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003” (PL108-25) in May 2003, which authorized the framework under which PEPFAR would operate: the law provided for expansion and
better coordination of U.S. bilateral and multilateral efforts on AIDS, tuberculosis, malaria and AIDS related research with a focus on 15 countries. The law authorized spending $15 billion over 5 years for HIV/AIDS, TB, malaria and research and created the Office of the Global AIDS Coordinator (OGAC) to manage and coordinate all HIV/AIDS programs in developing countries. PEPFAR is centrally managed by the Department of State through OGAC, which is currently led by Ambassador Mark Dybul. In all countries, OGAC relies on U.S. Embassies and key implementing agencies including USAID and CDC, as well as the Departments of Defense and Labor and the Peace Corps, to implement PEPFAR programs.

Results Delivered to Date
PEPFAR-sponsored programs are delivering substantial results around the world, including the following:

• 1.4 million people put on life-saving antiretroviral treatment
• 6.7 million people provided with care, including more than 2.7 million orphans and vulnerable children
• 30 million people provided with voluntary counseling and testing (VCT) for HIV
• Services to prevent mother-to-child transmission of HIV provided during ten million pregnancies.

¹ The 15 focus countries are Botswana, Cote d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia.