President’s AIDS Plan Too Narrow to Achieve Long-Term Goals, Conclude 30 Government and Private Organization Experts

May 17, 2004 - The Bush administration’s $15 billion AIDS initiative, while laudable, will not succeed unless it is folded into a broader- and longer-term commitment to developing basic health systems in affected countries. To successfully battle AIDS—one of the most pressing threats known to mankind—the effort must also go beyond health to address social and economic factors that drive the spread of the disease. These are the central findings of Addressing the HIV/AIDS Pandemic: A U.S. Global AIDS Strategy for the Long Term, released today by the Council on Foreign Relations and the Milbank Memorial Fund.

The report calls attention to the President’s initiative (signed into legislation one year ago on May 27) and other international programs, which together constitute a major international commitment to assure treatment for the world’s more than 40 million HIV-infected people, most of them in very poor countries. While this pledge is commendable from a humanitarian and human rights perspective, the report concludes that the long-term costs of treatment ($9-$12 billion a year) and allocation of responsibilities need to be spelled out to the public, the Congress, and the entire international community as they will run well into the middle of the 21st century. "A humanitarian catastrophe of incomparable proportions, the pandemic is also a threat to global economic and geopolitical stability and a critical strategic threat to the United States," the report asserts.

Addressing the HIV/AIDS Pandemic was directed by Ambassador Princeton N. Lyman, the Council’s Ralph Bunche Senior Fellow in Africa Policy Studies, and Daniel M. Fox, president of the Milbank Memorial Fund, in consultation with experts from more than 30 private and government health organizations.

The report was issued in response to President George W. Bush’s initiative—known as the President’s Emergency Program for AIDS Relief (PEPFAR)—which provides $15 billion over five years to combat HIV/AIDS and to fight tuberculosis and malaria. Specifically, the program aims to treat two million AIDS victims, prevent seven million new infections, and provide care for ten million children and others affected by the disease. While it places the United States clearly in the forefront of the international battle against AIDS, experts find it is too near-term and narrow in scope to achieve the objective of eradicating the disease, which is expected to infect 100 million people and orphan 25 million children worldwide by 2010. "The United States should begin to mobilize international support for broader health systems in the countries that PEPFAR focuses on so that such systems are in place in five years. Otherwise, five years from now, not only will the broader health needs not have been addressed, but PEPFAR investment into programs directed to HIV/AIDS may fail to achieve its goals," the report warns.

The Council/Milbank report makes seven specific recommendations for the United States to make the program sustainable and successful:

1. Launch a long-term effort to build politically and financially sustainable basic health systems in the affected countries. "It will not be possible to reach the vast majority of people who do not know they are infected with HIV without having basic health facilities that can make HIV testing a routine part of general health services."
2. Form a high-level international commission to address the long-term issues associated with broad-based AIDS treatment programs. "The long-term costs of lifetime antiretroviral treatment for all those who need it could reach $9 to $10 billion annually for decades to come." The commission should seek to clarify the respective roles and responsibilities of host countries, donors, pharmaceutical companies, and other possible sources of support for this lifetime treatment regimen.
3. Pursue a comprehensive approach to HIV/AIDS, paying particular attention to the factors fundamental to the pandemic’s spread, such as the vulnerability of women and girls and the importance of the military in these countries as both victims and spreaders of the infection. "In acutely affected regions, HIV/AIDS is eviscerating national military forces. . . and rendering [them] increasingly unable to safeguard their national interests and to participate in regional peacekeeping."
4. Be guided by the best available scientific evidence and be "ideology-free" in selecting and administering prevention and treatment programs. "This is especially important in prevention where ideological controversy exists. . . [and] in selection of drug regimens, determination of safe drug sources, and other aspects of the program."
5. Structure monitoring and evaluation from the start of programs. "It is particularly important to monitor resistance and related outcomes of treatment regimens in order to measure compliance, assess the costs and benefits of different regimens, and identify new strains of the virus that may be developing."
6. Utilize flexible and innovative funding devices to reach community-based groups and local non-governmental organizations. "Embassies must engage local people affected by the pandemic, NGOs, and community-based programs in planning and reviewing strategies and in implementing projects."
7. Avoid speaking glibly about "graduation" from these programs as they will require decades of commitment. Developing countries should not be left with the impression that once these programs are under way the entire burden will fall on them—a burden they cannot sustain. "Combating this pandemic will require decades of international involvement and the funding of programs well beyond the emergency focus of the next five years."

Founded in 1921, the Council on Foreign Relations is an independent, national membership organization and a nonpartisan center for scholars dedicated to producing and disseminating ideas so that individual and corporate members, as well as policymakers, journalists, students, and interested citizens in the United States and other countries, can better understand the world and the foreign policy choices facing the United States and other governments.

The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. The Fund convenes meetings of leaders in the public and private sectors and publishes reports, books, and the Milbank Quarterly, a multidisciplinary journal of population health and health policy.

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