The Obama administration last week released a 74-page outline of its new President’s Emergency Plan for AIDS Relief implementation strategy, which includes slowing expansion of antiretroviral drug distribution in favor of prevention and fighting other deadly diseases, the New York Times reports. The strategy emphasizes prevention, curtailing mother-to-child transmission and focusing on treatment of the sickest people, pregnant women and individuals with tuberculosis. In addition to HIV/AIDS, funding would be used to battle diseases that cost less to fight, including diarrhea, fatal birth complications, malaria and pneumonia. Since its 2004 inception under President George W. Bush, PEPFAR has provided antiretroviral access to a total of 2.4 million people, with an average of nearly 500,000 new people beginning to take the drugs annually. The new strategy aims to increase the number of individuals receiving antiretrovirals by about 320,000 each year for the next five years, bringing total recipients to four million people by 2014, according to the Times.

According to the Times, the strategy “is nearly silent” on controversial issues like abstinence and distribution of condoms through missionary hospitals that oppose their use. The proposal also does not specify whether funding would be cut off for groups that support abortion rights, groups that work with sex workers but do not condone prostitution or countries that criminalize homosexual sex (McNeil, New York Times, 12/9).

In addition, more of the day-to-day management of the program will be shifted to the 15 countries that have received the bulk of PEPFAR funding to date. According to the Washington Post, the goal is to make prevention and treatments services — such as the provision of antiretroviral drugs, HIV counseling and testing, prevention advice and condoms, and palliative care for people at advanced stages of the disease — a routine part of those countries’ health offerings.

Over the next five years, the Obama administration’s goal is for PEPFAR to provide care for 12 million people and double the number of infants born without HIV. While the U.S. will continue to contribute most of the funding, additional money would come from foreign donors and the Global Fund To Fight AIDS, Tuberculosis and Malaria. According to the Post, the exact amount of money slated to be spent through the program is unclear (Brown, Washington Post, 12/8). The Times reports that President Obama, during the presidential campaign, pledged to increase PEPFAR’s budget by $1 billion annually, though his first budget proposal included a $165 million increase (New York Times, 12/8).

On Monday, administrators of the program also released three supplements that describe how nations’ health ministers would take on the tasks of delivering services — as many already do — managing the programs and gauging their effects, the Post reports. Eric Goosby, the Obama administration’s global AIDS coordinator and chief administrator of PEPFAR, said, “It is our honest belief that these programs are in a fragile period,” adding, “We need to transition them into being more embedded in the countries’ infrastructure and for the countries to have true ownership of them” (Washington Post, 12/8).

The Obama administration has drawn the criticism of some HIV/AIDS advocates who believe that the administration is trying to save money by shifting emphasis from providing antiretrovirals to encouraging preventive measures, according to the Times. Gregg Gonsalves — a longtime HIV/AIDS campaigner — said, “I’m holding my nose as I say this, but I miss George W. Bush,” adding, “On AIDS, he really stepped up. He did a tremendous thing. Now, to have this happen under Obama is really depressing.”

Goosby stressed that more people would be given the treatments each year. “We’re honoring our commitment, we’re increasing our commitment, we will not veer from that commitment,” he said. Ezekiel Emanuel — a bioethicist at the National Institutes of Health and a health care adviser to the White House Office of Management and Budget, who also is the brother of White House Chief of Staff Rahm Emanuel — rejected rumors that he and Goosby have sparred over the number of people that should be treated. “This is [Obama's] policy and the way he wants to approach it, and no individual counselor stands in his way” (New York Times, 12/8).

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