The largest international program responding to the global HIV/AIDS epidemic, the President's Emergency Plan for AIDS Relief (PEPFAR), recently underwent a Congressionally mandated review by the Institute of Medicine (IOM) to assess its performance.
The resulting report, Evaluation of PEPFAR, praises the program, stating that it “has been globally transformative—changing in many ways the paradigm of global health and what can be accomplished with ambitious goals, ample funding, and humanitarian commitment to a public health crisis.” It also notes that the program’s work remains unfinished, especially in curbing HIV incidence and providing HIV-related services to key populations, including gay men and other men who have sex with men (MSM), people who inject drugs, and sex workers.
HIV prevalence among MSM continues to rise in many parts of the world. “Supporting policy progress and scaling up prevention, treatment, and care services to meet the range of HIV-related needs for this population remains an enormous unmet need,” states the report. Despite a decline in HIV infection rates among people who inject drugs, the report notes that services for this group remain “inadequate.” It credits PEPFAR with some success in scaling up education for sex workers, improving their negotiation skills, and empowering them to ask clients to use condoms. However, it calls “the legislative limitation on providing funding to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking” an important concern raised by many people consulted for the IOM report.
In this era of fiscal austerity, however, meeting the needs of key populations while continuing to meet PEPFAR’s overarching goals of scaling up services and strengthening health systems will be challenging. Sequestration will slash an estimated $380 million from PEPFAR. According to an amfAR estimate, cuts of this magnitude could mean that HIV/AIDS treatment would not be available for 162,200 people who would have started this treatment, potentially leading to 37,000 more AIDS-related deaths and 72,800 more children becoming orphans. The FY2014 budget proposed by the House of Representatives proposes even deeper funding cuts for global health programs. “PEPFAR plays a critical role in the global response to AIDS, and a major cut to that program means squandering the potential we have to begin to end the epidemic,” said Chris Collins, amfAR’s vice president and director of public policy.
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