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World AIDS Program Garners Praise
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The law requires that 55 percent of PEPFAR's budget go for anti-retroviral treatment for HIV-infected people, with three-quarters of that going to buy drugs. Twenty percent must be spent on AIDS prevention, with one-third of that sum used for "abstinence-until-marriage" programs. Palliative care gets 15 percent and orphan assistance 10 percent.
The abstinence message is one-third of a strategy called ABC, the other letters standing for "be faithful" and "condom use."
The report's authors wrote that while nobody in the field argued for dropping the abstinence component, "the committee has been unable to find evidence . . . that 33 percent is the appropriate allocation for such activities." They added that endless debate over ABC has distracted from efforts to pay attention to other behaviors, such as alcohol abuse and violence against women, that increase the risk of HIV transmission.
"This earmark has caused confusion at the country level. We have been saying that for years," said Paul Zeitz, executive director of the Global AIDS Alliance, a local advocacy group.
Dybul, however, said the percentages apply only to PEPFAR's overall budget allocations. He said countries do not have to spend money on abstinence messages if they have little sexual transmission of HIV, as is the case with Vietnam, where the injection of illicit drugs is the main route of infection.
But Dybul said evidence shows that in countries with high rates of heterosexual transmission of the virus, ABC is the best strategy. The guidelines are necessary because "we are not quite where everyone has come along with the evidence," he said.
The requirement that AIDS drugs be approved by the FDA initially prevented countries from buying foreign-made generics with PEPFAR money. The FDA then agreed to review and certify those drugs even if they cannot be sold in the United States because of patent protections. Dybul said that practice effectively gives PEPFAR countries access to the cheapest AIDS drugs on the world market.
That view was corroborated by the scientific director of the Elizabeth Glaser Pediatric AIDS Foundation, which gets $80 million a year from PEPFAR and helps pay for the medical care of 98,000 people in Africa. Several years ago, the foundation paid $700 a year for a patient's anti-retrovirals. Now it pays $100.
"I think most of the problem of access to first-line drugs, be they branded or generic, has been resolved," said Richard G. Marlink of the foundation.
