Senate Roadblock

Partisan concerns and side issues must not stop a key U.S. HIV-AIDS initiative.

THE PRESIDENT'S Emergency Plan for AIDS Relief (PEPFAR) is American "soft power" at its life-saving best. Since 2003, PEPFAR has supported HIV testing and counseling for more than 33 million people and care for more than 6.6 million (including more than 2.7 million orphans and other children infected and affected by HIV). The program has funded medicine for about 1.5 million men, women and children worldwide, the vast majority of them in sub-Saharan Africa. Even President Bush's harshest critics concede that PEPFAR, which has cost $15 billion so far, is one of his best accomplishments. When Mr. Bush asked Congress to authorize a five-year, $30 billion extension, Democratic lawmakers in both houses raised the proposed funding level to $50 billion, and legislation sailed through with bipartisan support in both the House and the Senate Foreign Relations Committee.

Then it stopped: Sen. Tom Coburn of Oklahoma and six other Republicans have exercised their prerogative to keep it off the Senate floor. Mr. Coburn wants to mandate that 55 percent of PEPFAR's money go to treating those who are already sick with AIDS -- as opposed to preventing new cases and other purposes. That was the rule during PEPFAR's first five years. And Mr. Coburn has a point: As the program grows to include tuberculosis and malaria and as the definition of HIV-AIDS prevention work expands, PEPFAR risks mutating into all-purpose development aid or taking on goals -- such as changing traditional attitudes toward gender -- which are not only culturally sensitive but hard to measure in terms of progress.

Yet history does not support Mr. Coburn's broader argument for mandated spending targets. In fact, drug prices dropped so much over the past five years that PEPFAR met its treatment goals for less than 55 percent of its budget each year. In devising the next five-year plan, the White House assumed that this positive trend would continue. The epidemic does not follow predictable patterns. In some countries, it is a generalized problem; in others, it is concentrated in a particular region or population subgroup. Last year, the Institute of Medicine, a unit of the National Academy of Sciences, told Congress that it should eliminate fixed directives for PEPFAR. Better to let individual country teams tailor programs to fit their particular needs, the institute said. Last month, the Government Accountability Office reported on a survey of 22 international HIV-AIDS experts, most of whom backed a more flexible approach. The GAO report raised particular questions about the efficacy of a requirement, inserted in the current PEPFAR law by conservative Republicans, that requires 33 percent of all prevention funds to be spent teaching abstinence and fidelity.

Both the House and Senate bills remove rigid mandates for treatment and prevention spending. But, avoiding a new culture war, they meet conservatives' concerns, requiring that PEPFAR recipients promise to stay out of prostitution and that country teams tell Congress if abstinence and fidelity programs fall to less than half of their prevention spending. This is compromise legislation that expands and modernizes America's signature global health initiative. Properly implemented under careful congressional oversight, it could add to PEPFAR's proud record. Mr. Coburn and his colleagues should get out of the way.