AIDS Funding Binds Longevity of Millions to U.S.

By David Brown
Washington Post Staff Writer
Saturday, July 26, 2008

President Bush plans to sign a bill next week that commits the United States to spending about $40 billion over the next five years to fight AIDS overseas, a major expansion of what many consider his most successful foreign policy initiative.

The legislation also extends an implicit pledge that has little precedent in the history of U.S. foreign assistance: to continue purchasing lifesaving drugs for millions of individual people in developing countries for an indefinite period of time.

Foreign aid for health care has traditionally been used to put up buildings, buy equipment and train workers. Direct medical care of individuals was limited to one-time interventions such as vaccinations, emergency treatment after natural disasters, and curative treatments of limited duration for diseases such as tuberculosis or leprosy.

Bush's program is fundamentally different. So far, it has purchased vast quantities of antiretroviral drugs and supported day-to-day medical care for more than 1.4 million people whose survival depends on continued treatment.

"It is the first time I can think of where we have foreign aid treating a chronic disease," said Michael H. Merson, director of Duke University's Global Health Institute and a former head of the World Health Organization's AIDS office. "It's a challenge to take this on. I think the questions it raises are going to be important ones for the future."

Once started, AIDS therapy must continue indefinitely, because stopping it can rapidly lead to death. As a consequence, international health experts and medical ethicists say it would be immoral to withdraw the financial assistance that pays for the therapy unless someone else steps in to replace it.

Although all governments and organizations supporting AIDS patients overseas have made an implied open-ended commitment, it looms largest for the United States, which provides about 40 percent of global AIDS assistance. Few experts say they think the needy countries now getting help from the United States will be able to fend for themselves anytime soon.

"We've never really been confronted with this in the international health arena," said Paul De Lay, a physician formerly with the U.S. Agency for International Development who is now with UNAIDS, a United Nations program in Geneva.

The President's Emergency Plan for AIDS Relief (PEPFAR), a surprise announcement in the 2003 State of the Union address, has spent about $19 billion in the last five years. The president sought to double it to $30 billion in a bill reauthorizing it for another five years, but Congress trumped him, sending him a larger bill that when it passed on Thursday authorized the spending of $48 billion -- $39 billion for AIDS and the rest for other diseases.

The money is provided to governments, charitable organizations and academic medical centers to buy drugs and equipment, train workers and run programs. By the administration's estimates, PEPFAR in five years has provided antiretroviral drug therapy for 1.4 million people; treatment for 1 million infected women during pregnancy so they are less likely to transmit the virus to their babies; care for nearly 3 million AIDS orphans; and 33 million counseling-and-testing sessions.

Although Bush's initiative enjoys support in both parties and has been praised around the world, some policy experts say the implications of its open-ended commitment have been largely ignored. A few view PEPFAR as essentially an open-ended "entitlement program" for citizens of other countries.

One person with that view is Mead Over, a former World Bank economist who is now at the Center for Global Development, a Washington think tank. He fears that if PEPFAR's commitments grow, as they are likely to, they will squeeze out funding for other, equally important, foreign aid.

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