The Politics of PEPFAR: The President's Emergency Plan for AIDS Relief [Full Text]

In January 2003, President George W. Bush called for the United States to commit $15 billion over five years to address the international AIDS epidemic. More recently, in May, 2007, President Bush called for the reauthorization of the President’s Emergency Plan for AIDS Relief (PEPFAR) with a doubling of funding, asking Congress to authorize an additional $30 billion over the following five years. With such a large figure now before the Congress, the issue of U.S. leadership in the fight against the AIDS pandemic has taken on unprecedented—and very public—proportions.

The president's initial announcement in 2003 caught many people by surprise both for its unparalleled commitment of resources and for its timing, given how much of the administration's attention was focused on the impending war in Iraq at that time. The surprise was followed by excitement, tempered by skepticism. Excitement stemmed from the hope that the tragic scope of the AIDS epidemic and its potential impact on U.S. and global interests were finally being fully acknowledged. Some observers also felt that the initiative was in line with a broader definition of "security." Others interpreted the plan as a case of a major power moving beyond strict national interests to cooperatively address global humanitarian challenges. Furthermore, since the initiative enjoyed support from both parties in Congress and an unusual coalition of liberal and conservative NGOs, PEPFAR suggested a stronger domestic alliance supporting future U.S. humanitarian initiatives.

Skepticism came from a worry that the announcement was simply a short-term rhetorical effort to enhance America's image at a time that its use of military power was opposed by much of the international community. Many also questioned whether Congress would ever appropriate such a large sum, given other spending priorities and mounting budget deficits. Most crucially, some observers worried that program choices would be shaped more by economic calculations and moral agendas than best-practice medical guidelines.

Four years after PEPFAR's creation, both some excitement and some skepticism appear warranted, although not for all the same reasons that either the optimists or pessimists predicted. On the plus side, the initiative has enjoyed sustained political and fiscal support from both the administration and Congress and is starting to show impressive results in prevention and treatment. On the other hand, the optimists' hopes of redefining security and seeing the United States act multilaterally to address global issues have receded. In addition, skeptics' fears that U.S. economic interests and conservative Christian views would heavily influence administration programs have been borne out. Thus, the optimists won the war but lost most of the battles.

An interim assessment of PEPFAR shows that major humanitarian initiatives can be developed in today's political environment, but that actual programs will be more influenced by international and domestic calculations than by pure humanitarian considerations. With such disputes over details, establishing a long-term liberal-conservative coalition broadly supporting humanitarian objectives appears unlikely.

AN OVERVIEW OF PEPFAR'S ORIGINS AND ACTIONS

Although unprecedented in its scale and scope, President Bush's 2003 announcement was not the first U.S., or even the first Bush administration, action on the international AIDS pandemic. The magnitude of the AIDS crisis became apparent to U.S. officials in the 1980s, and small amounts of funding were soon allocated to efforts to address it. In 1996, the United States supported the creation of a UN program to coordinate global AIDS efforts. In subsequent years, Clinton administration officials gave the need to combat AIDS increased rhetorical prominence. U.S. programs increased, but overall funding remained low. For example, a 2000 bill signed by President Clinton authorized only $150 million to be administered by the World Bank and $300 million for bilateral programs.

In the spring of 2001, UN secretary-general Kofi Annan put new pressure on world governments by proposing the creation of a Global Fund to Fight AIDS, Tuberculosis, and Malaria. On May 27, 2001, President Bush announced that the United States would make a founding contribution of $200 million to the fund and pledged to add more if the programs proved effective. At the time, administration officials pressed the UN to spend most of its money on prevention rather than treatment. In one extreme attempt to justify this focus, the United States Agency for International Development (USAID) administrator Andrew Natsios argued that sending antiretrovirals to African countries would be ineffective due to their lack of trained doctors, limited infrastructure, and the inability of Africans to follow a complicated treatment regimen because of their insufficient knowledge of clocks. The U.S. focus on prevention continued with Bush's June 2002 announcement of a new $500 million U.S. initiative aimed at the reduction of mother-to-child transmission of HIV. This initiative was an impressive increase over past U.S. funding levels, but it avoided addressing the crucial, and controversial, issue of prevention of sexual transmission.

Within the administration, support for increased funding of AIDS programs came from a number of cabinet members, top aides, and President Bush himself, who came to see it as a moral matter but feared that the money would not be effectively spent. Congress saw mounting support from both liberal Democrats, who had long pushed for greater action, and key Republicans. Senate Majority Leader Bill Frist, a doctor who had been on medical missions to Africa, and Senator Jesse Helms, a former sharp critic of most U.S. foreign aid programs, were particularly crucial players. The liberal-conservative alliance in Congress was mirrored by the mix of NGOs active on the issue. These ran the gamut from traditionally liberal humanitarian and medically focused groups to conservative religious groups that argued that Christians had a responsibility to assist the sick. Claiming that Bush moved forward on AIDS funding only to placate his Christian conservative base would be an overstatement; encouraging data on Uganda's prevention programs and sharp decreases in antiretroviral prices were certainly at least as important. Still, in the words of the rock star and AIDS activist Bono, "The administration isn’t afraid of rock stars and student activists—they are used to us. But they are nervous of soccer moms and church folk. Now when soccer moms and church folk start hanging around with rock stars and activists, then they really start paying attention."¹ The stage was therefore set for President Bush's January 2003 announcement:

The Emergency Plan for AIDS Relief—a work of mercy beyond all current international efforts to help the people of Africa. This comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS. I ask the Congress to commit $15 billion over the next five years, including nearly $10 billion in new money, to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean. This nation can lead the world in sparing innocent people from a plague of nature.²

The $15 billion commitment included $5 billion for existing bilateral programs throughout the world, $1 billion for the UN fund ($200 million per year), and $9 billion for new programs in fourteen target countries in Africa and the Caribbean. The announcement contained several noteworthy points. First, Bush established specific numeric targets for prevention, treatment, and care before any of the program's details were established. Second, prevention would now be expanded to programs addressing sexual transmission, following the model of Uganda's highly regarded ABC program: Abstinence, Be faithful to your partner, use a Condom. Finally, the biggest change was in the administration's position on funding treatment. Ultimately, treatment would come to represent roughly half of all PEPFAR spending.

In May 2003, Congress passed the necessary authorizing legislation. The legislation largely followed President Bush's original outline, but added three important provisions. On the House floor an amendment passed, supported by considerable administration lobbying, requiring that at least a third of all prevention funds be spent to promote sexual abstinence. A second amendment allowed faith-based groups to reject strategies they considered objectionable, such as condom distribution. Third, the law authorized, but did not require, up to $1 billion per year for the Global Fund, five times what the president had favored. The legislation stipulated that the exact amount of U.S. contributions could not comprise more than a third of the total contributions to the fund for any given year.

Little funding was dispersed in the first year of the plan as a new bureaucracy and ties to groups in Africa were developed. By the spring of 2007, however, the administration was able to provide impressive numbers in its third annual report. Overall U.S. budget authorizations to combat international AIDS were $2.3 billion in FY2004, $2.6 billion in FY2005, $3.2 billion in FY2006, $4.5 billion in FY2007, and are projected to be $5.4 billion in FY2008. Thus, the administration, with some prodding from Congress, which increased early funding levels, appears on track to exceed its goal of $15 billion in five years by roughly $3 billion.

Prevention funding has supported outreach activities to over 60 million people. An estimated 100,000 infant HIV infections have been prevented by mother to-child-transmission programs. The true efficacy of programs focused on sexual transmission is harder to assess, since the programs are more diffuse, but the administration argues they can achieve the goal of preventing 7 million infections.

Antiretroviral treatment has been provided to 822,000 people in the targeted countries, and another 165,000 people worldwide. There is, however, controversy over how the United States reached these figures. Almost half of the recipients included in U.S. figures were actually receiving treatment through the Global Fund, and thus were only indirectly funded by the United States. The figures also include both patients directly receiving U.S.-funded medication and those receiving treatment after countries received funds for general "system strengthening." The manager of Botswana's treatment program called the U.S. figures "a gross misrepresentation of the facts," and several Botswanan officials have said that not a single Botswanan is receiving treatment as a direct result of U.S. funding.³ Even using administration figures, the program is behind in reaching its target of 2 million recipients, in part because of the slow approval of using PEPFAR funding to buy generic drugs and in part because of significant logistical barriers to care in some countries.

Overall, PEPFAR's first years have far exceeded the expectations of its critics: funding has been sustained, programs are rapidly expanding, and prevention and treatment figures show huge increases over pre-2003 numbers. On the other hand, PEPFAR has not reached all of its bold goals, and disputes on several policy issues have generated much controversy.

AIDS AS A SECURITY ISSUE

In the first years of the epidemic, AIDS was largely thought of as a medical problem. As the scope and impact of the disease became more clear, discussions centered on AIDS as a social and economic challenge for certain countries. Beginning in the late 1990s, the terms of discussion shifted once more, notably in the academic literature and within government circles, and some began to describe the epidemic as a security issue.

By 1999, key members of the Clinton administration were committed to putting AIDS on the security agenda. Their efforts led to an unprecedented discussion of the issue in the UN Security Council in January 2000. There and elsewhere supporters made the case that the epidemic's impact on social systems, economies, governing capacities, militaries, and peacekeeping operations meant that it posed a real threat to both citizens and institutions. Some also used the emerging idea of "human security" to argue that because AIDS would affect the core individual right of life, it should be seen as a security concern. In July 2000, the Security Council passed Resolution 1308, which declared that action was necessary before the AIDS pandemic could further threaten world security, and President Clinton announced that AIDS would now be treated as a threat to U.S. national security.

Intriguingly, as AIDS gained prominence on the U.S. agenda, President Bush moved away from the formula of AIDS as a security problem. China, India, and Russia—three strategically important countries that analysts suggest might be shaken by the second wave of the pandemic—were not included among the countries targeted for the most U.S. aid. AIDS received only passing mention in Bush's landmark 2002 National Security Strategy of the United States of America. More importantly, none of his major speeches on the issue include the word "security." Instead, his justifications for action repeated themes enunciated in January 2003:

We have a chance to achieve a more compassionate world for every citizen. America believes deeply that everybody has worth, everybody matters, everybody was created by the Almighty, and we're going to act on that belief and we'll act on that passion.⁴

In Bush's eyes, AIDS relief is tied to a religious obligation to help the suffering because all humans are God's creations. He also frequently ties AIDS relief to a legacy of compassionate U.S. policies, such as the Marshall Plan, the Berlin Airlift, and the Peace Corps.

Bush's move away from security arguments is in line with the fact that few Americans ever fully accepted their validity. As long as the epidemic remains centered in Africa, the average American considers the economic and security risks too small and too remote to be of concern. The broader concept of human security also is not widely accepted outside of academic or UN circles. In coming years, the U.S. government is unlikely to revive the security argument, and any attempt to do so may be seen as politicizing a moral issue.

The president's reframing of AIDS relief as a non-security, and thus more optional, issue may have significant future implications. Positioning PEPFAR as part of a U.S. moral tradition is likely to have rhetorical appeal to future administrations, but that does not guarantee continued funding and attention. It is less certain whether the religious arguments will be utilized by others in the future. So far, AIDS funding has withstood competition from the war on terrorism and the need to aid tsunami and Hurricane Katrina victims, but future funding is far from guaranteed under presidents who might stake less of their personal political capital and moral commitment on the issue.

BILATERAL VERSUS GLOBAL ACTION

Almost as soon as President Bush announced the major U.S. initiative, observers began to question what relationship the bilateral program would have with the recently created UN Global Fund. Bush was careful to announce plans for ongoing donations to the fund, and he also noted that U.S. Secretary of Health and Human Services Tommy Thompson would chair the fund's board. Similarly, UN officials expressed the view that the programs were complementary, not adversarial.

Despite the surface accord, clear signs of friction quickly emerged. On the very day of the president's program announcement, Anil Soni, an adviser to the fund's executive director, commented that the United States' "taking a unilateral approach" could hamper care for victims.⁵ Subsequently, Ambassador Stephen Lewis, the UN secretary-general's special envoy for HIV/AIDS in Africa, became a frequent and blunt critic of U.S. funding priorities and prevention strategies. While top UN officials pressed for large increases in U.S. support for the fund, Bush administration officials questioned the fund's management and effectiveness. Questions in these areas were even included in PEPFAR's formal reports to Congress. Bush's budget requests repeatedly targeted only $200 million annually for the fund, and despite the fact that in several years Congress more than doubled the president’s request, U.S. contributions to the fund were still less than 10 percent of total U.S. spending on AIDS.

Among those interested in AIDS policy, a fierce debate has raged over whether UN or U.S. programs are preferable. Some support for the UN arises out of baseline anti-U.S. and pro-multilateral sentiments, but fund supporters raise several other points. In a world with finite resources to combat the surging epidemic, they argue that pooling funds and knowledge is critical. Also, the UN has existing institutional ties and a decent reputation in most countries. Working through a multilateral forum also decreases the chance that the political interests or moral preferences of any one country will dominate decisions. Finally, the fund's money is disbursed through grants to local groups, so more of the money goes directly to citizens of targeted countries, rather than to large international NGOs. Supporters of working through the fund also suggest that the United States would benefit from both the perception that it is the leader of a multilateral effort and from sharing the financial burden of AIDS activism.

Those who favor channeling most or all of the money through bilateral programs counter that UN agencies are not the right vehicle for a major health program. There are also long-standing questions about the UN's financial practices and supervision of those receiving grants. Conversely, U.S. programs could be guided by professionals with years of experience in health management. They also would have a single central bureaucracy facilitating tight monitoring of dispersed funds. Furthermore, a U.S. program could be fully guided by U.S. interests and perspectives, better enabling it to hold together a supportive domestic coalition.

Of course, decisions between multilateral and bilateral programs are not made entirely based on theoretical benefits and pitfalls. In this case, the fund's performance to date has borne out many of the worries expressed by its critics, and therefore has decreased the likelihood of multilateral efforts in the future. Even those generally in favor of the fund have been sharply critical of its slow disbursement of money. The fund also suffered problems of financial accountability, and had to suspend grants in Ukraine in January 2004 and Uganda in August 2005 due to reports of mismanagement. The fund has also been unable to rally major international financial support. Although the United States has committed the vast majority of its money to bilateral efforts, it has provided close to 30 percent of the fund's contributions in most years. The fund is so short of money that it has only provisionally accepted certain grant applications, with the hope that new funds will become available. The combination of slow disbursements, suspended programs, and limited funding of new grants has left the UN far behind its goal of treating 3 million patients by 2005.

Even had the fund not stumbled, the United States was unlikely to funnel the majority of its money through the UN. Although it has historically been a global leader of human rights and humanitarian action, the United States often has been hesitant to commit to multilateral initiatives. America's tendency toward unilateralism was reinforced by President Bush's worldview, but it was not created by this administration and will surely not end with it. Therefore, while some observers may prefer that U.S. humanitarian actions, and AIDS programs specifically, be channeled through the UN, they are likely wasting their efforts and possibly missing any chance they might have to shape U.S. bilateral programs.

FACTORING IN ECONOMIC INTERESTS

While international AIDS programs are generally described in humanitarian terms, they are also big business. The contract to oversee the distribution of U.S. assistance is worth hundreds of millions of dollars. Increased spending on prevention means major new orders for condom producers. Most important, Bush's new emphasis on treatment has huge implications for the pharmaceutical industry. One early indicator of the issue's importance was the creation of two lobby groups, the Corporate Council on Africa's Task Force on AIDS and the Coalition for AIDS Relief in Africa, which brought together major pharmaceutical companies, such as Bristol-Myers Squibb, Abbott Laboratories, Pfizer, and others, to lobby Congress in support of PEPFAR funding.

At PEPFAR's start, the administration held that its funds could only be spent on name-brand drugs, to protect patent rights and assure quality. President Bush did maintain a Clinton-era policy that allowed companies in such countries as India and Brazil to make generic versions of U.S.-patented drugs, but stipulated that these companies were not to export those drugs. He also sent an interesting signal on the issue by appointing the former chairman of Eli Lilly and Company, Randall Tobias, who had no specific experience on AIDS or African politics, as U.S. Global AIDS Coordinator. While traveling in South Africa in 2004, Tobias commented about generics: "Maybe these drugs are safe and effective. Maybe these drugs are, in fact, exact duplicates of research-based drugs. Maybe they aren’t. Nobody really knows."⁶

Others, however, argued strongly that these generics were indeed safe, given that they had been approved by the World Health Organization’s (WHO) prequalification program and were being distributed by several governments, international NGOs, and groups financed by the UN fund. They also argued that generics should be a crucial part of any major treatment strategy because their cost was only a third or less of U.S. brands. Furthermore, patient compliance with drug regimens could be increased by using three-in-one combination pills that were not available from any U.S. manufacturer at the time.

Pressure to change U.S. policy came from a host of players. AIDS activists argued that the president's comments on human dignity would ring hollow if the United States did not take every action possible to increase treatment numbers. Representatives of the European Union’s drug regulatory authority refused to attend a U.S.-led conference on generic medications as a symbolic protest against administration policy. U.S.-based service providers, who hoped to buy drugs at the lowest available price, also pushed for policy change. In May 2004, the administration altered its policy to permit PEPFAR funding of generics, but only once they had U.S. Food and Drug Administration (FDA) approval through an expedited review process.

Even the revised policy came under fire. Critics argued that requiring FDA approval was redundant, since the drugs had WHO prequalification, and would only serve to slow delivery of drugs. They believed the requirement was a political move designed to reassert U.S. independence and to maintain profits for U.S. companies. The administration maintained that careful approval procedures would guarantee medical quality. Ultimately, no generics completed the FDA process until January 2005, so PEPFAR funds were not used to purchase a significant number of generics until the end of 2005. By 2007, thirty—four generics had been approved, but only 27 percent of PEPFAR-funded purchases in 2006 were of generics.

Overall, the generic drug issue is one of the few examples of a U.S. administration partly reversing policy in a way that put humanitarian objectives above U.S economic gains. This issue was unusual for having a particularly strong coalition of actors pushing for change, directly comparable U.S. and foreign products, and a situation in which lives potentially hung in the balance. In most cases, one or more of those conditions will not exist. Therefore, future humanitarian policies are more likely to resemble President Bush's original plan, which would have quietly pumped billions of dollars into U.S. corporations.

IDEOLOGICAL DISPUTES OVER IMPLEMENTATION

On several fronts, the conservative lean of PEPFAR programs threatens both programmatic success and America's global image. There are both smaller issues in dispute and larger controversies over the roles of abstinence, condom distribution, and faith-based programs.

Among the smaller issues is that of AIDS prevention through needle exchange. By law, the U.S. government does not fund programs that exchange used needles for clean ones. The argument against needle exchanges is that they support or encourage drug use. Others argue that drug use would occur in any case, so needle exchanges simply prevent further HIV transmissions. To date, this policy has not been a major factor in U.S. international AIDS programs because drug use is not a major source of infections in Africa; however, it could grow in importance as the epidemic moves to such places as Russia and China, where needles are a significant source of infection.

A second issue is restrictive U.S. rules regarding abortion. The Mexico City Policy announced by President Reagan in 1984 required nongovernmental organizations to agree as a condition of their receipt of federal funds that they would neither perform nor actively promote abortion as a method of family planning in other nations. This policy was rescinded by the Clinton administration, but Bush restored the policy in a memorandum dated January 21, 2001. As PEPFAR legislation was moving through Congress, he announced that this rule would be relaxed for groups fighting AIDS, as long as they kept AIDS funds separate from other funds. Still, in August 2003 the administration terminated funding for a well-regarded AIDS program run by a consortium of seven groups because one group had worked with the UN Population Fund, which in turn had worked with the Chinese government, which allegedly promotes abortion.

A third policy that has triggered debate is a legislative requirement prohibiting funding of any group that does not have an explicit written policy opposing prostitution and sex trafficking. Three U.S.-based NGOs filed lawsuits against USAID, arguing that compelling the pledge was a violation of free speech. In June 2006, two district courts ruled in favor of the NGOs, but the rulings have been challenged at the appellate level, and would not apply to groups based outside the United States. International opposition to the policy was highlighted by the UN fund's refusal to enact a pledge and by the Brazilian government's refusal of $40 million in U.S. assistance because it felt that the requirement would further stigmatize sex workers and make it difficult to provide AIDS information to an important target group. Since most countries cannot afford such a loss of U.S. dollars, however, they are forced to pledge or to scale back certain programs.

Much greater controversy has surrounded U.S. implementation of the Abstinence, Be faithful, use Condoms prevention strategy. There is a broad consensus among public health officials that all three elements are essential to reducing HIV incidence, but the U.S. weighting of programs toward those promoting A and B over C is sharply contested. PEPFAR requires that at least 33 percent of all funds spent on prevention from 2006 forward go to abstinence and fidelity programs. This number is somewhat deceptive because mother-to-child transmission, blood safety, and safe medical use programs are also included under prevention, so programs to stop sexual transmission receive only just over 50 percent of all prevention funds. Therefore, the Office of the U.S. Global AIDS Coordinator (OGAC) in March 2005 directed country teams to spend 66 percent of their prevention funds for the interruption of sexual transmission on A and B activities. The remaining sexual transmission funds cover testing programs, condom distribution, and other activities. Country teams can apply for an exemption to the 33 percent rule, but overall funding across PEPFAR's focus countries must meet the target, so a waiver for one country requires compensatory increases by others. Additionally, all programs that discuss condom use must discuss abstinence, but abstinence programs are not required to discuss condoms. Therefore, of the 61 million people reached in PEPFAR-supported outreach programs, over 40 million were in programs promoting only abstinence and/or being faithful.

PEPFAR strategy documents and administration officials defend the A and B focus with the argument that abstinence is the only guaranteed way to prevent sexual infection. They point to evidence from Uganda and elsewhere that sexual practices were altered and infection rates fell once the government began promoting the A and B parts of the ABC strategy. Critics, on the other hand, suggest that such a large focus on abstinence and fidelity is unwise. Data from a study conducted by Ugandan scientists in collaboration with Columbia and Johns Hopkins universities shows that the effect of educational messages in Uganda seems to have peaked. More broadly, the Center for Health and Gender Equity reports that a survey of the available literature suggests that "abstinence-only programs have high rates of failure in terms of both infection and other adverse outcomes, such as unintended pregnancy."⁷

Additionally, fears that the 33 percent rule makes it difficult to tailor programs to local circumstances and that the money going to abstinence programs crowds out funding for other programs have been confirmed by recent studies. In a 2006 U.S. Government Accountability Office (GAO) study, seventeen of the twenty country teams required to meet the A and B spending requirements reported that meeting the requirement "challenges their ability to develop interventions that are responsive to local epidemiology and social norms."⁸ In 2005 ten of these countries were granted exemptions. The remaining seven had to reduce such programs as condom distribution and services for commercial sex workers in order to meet the requirements. A legislatively required 2007 Institute of Medicine report similarly noted problems caused by the abstinence requirement. A second area of controversy involves condom distribution. PEPFAR has increased both funding for condoms and the number of condoms distributed per year but targets only specific high-risk populations, such as commercial sex workers and their clients, sero-discordant couples, men who have sex with men, substance abusers, and mobile male populations. Distribution outlets are placed near areas where high-risk behavior takes place, so that the general population receives a clear message that avoiding risk is the best means of preventing infection. Additionally, specific rules prohibit using funds to discuss condom use with in-school youth under fourteen, to distribute condoms in school settings, or to establish marketing campaigns that target youth and encourage condom use as a primary preventive strategy.

The problem with targeting only high-risk populations is twofold. First, reports from targeted countries indicate that condom users are now becoming stigmatized as promiscuous and irresponsibly pro-sex. In societies that have long avoided open discussions of sexual topics, policies that encourage negative views of those who take steps to protect themselves could lead to more misinformation, unsafe sexual practices, and more infections. Second, in countries whose adult infection rates run as high as 20 or 30 percent, the argument that any sexually active person is not at high risk lacks credibility. More specifically, programs that focus condoms only on high-risk groups miss others, such as sexually active single youth and married women, who remain at significant risk if their husbands have other sexual partners.

A third major point of debate has been the role of faith-based organizations. In 2006, 23 percent of all PEPFAR partners were faith-based. The administration argues that these organizations are the only established institutions providing aid in many rural areas. President Bush also feels that, in both domestic and international settings, faith-based groups should not be discriminated against based on their organizing principles. Administration critics point out that there now appears to be reverse discrimination, with faith-based groups favored over secular ones. Country teams do not reserve specific funding for faith-based groups, but they do write grants specifically designed for groups with a faith-based approach. Additionally, the administration has set aside $200 million for grants under the New Partners Initiative, and many of the new partners are faith-based. In several cases, major funds have gone to religious groups with little or no experience in either AIDS programs or Africa more broadly.

A fall 2004 grant to the Children's AIDS Fund, a Washington-based group that promotes abstinence education, serves as a good example of the controversy. The expert committee that reviewed the request judged that it was "not suitable for funding."⁹ Despite this recommendation, USAID's Natsios approved the project, in part because the Children's AIDS Fund has ties with the Uganda Youth Forum, which is led by Janet Museveni, the first lady of Uganda and an evangelical Christian. This relationship suggests that the United States is not simply pushing its religious and moral values on the rest of the world. In fact, there has been a major rise of local evangelical Christian groups in many parts of Africa. Even in Uganda, though, there is some sharp opposition to faith-based groups, because many groups openly acknowledge that they push their religious beliefs while they distribute education and assistance.

The exact impact of PEPFAR's choices on abstinence, condoms, faith-based agencies, and other issues is difficult to measure, but shaping programs to hit funding targets and ideological goals is not a recipe for maximal medical success. In politics, though, perceptions often matter as much as hard facts. Many observers view U.S. programs as employing leverage to spread conservative moral and religious views. In PEPFAR's early days, tense meetings occurred between U.S. officials and leaders in Mozambique, who perceived U.S. policies as arrogant and neocolonial. Stephen Lewis and other UN officials blamed U.S. policy for a shortfall of condoms in Uganda. Top U.S. officials are aggressively booed and heckled at international AIDS conferences. Administration policy choices have reconfirmed global views of the United States as a unilateral power imposing its views on others. If the administration saw AIDS programs as a way to improve the country's world image, they have failed miserably.

INTO THE FUTURE

Overall, PEPFAR remains a historically unparalleled effort. Now that programs are established and generic drugs can be purchased with PEPFAR funds, its practical impact should continue to grow. The way that PEPFAR has been justified and implemented allows certain conclusions to be drawn about its future and the future of other humanitarian aid programs. First, President Bush's shift in rhetoric away from security and toward humanitarian justifications for AIDS relief is likely to be applied to future AIDS and other humanitarian programs, increasing the chance that they will be cut in the future if other interests become more pressing. Second, the United States will preferentially fund bilateral rather than multilateral efforts for the foreseeable future. Third, economic interests remain a prime factor in U.S. aid programs, but can occasionally be superseded by humanitarian goals. Finally, the conservative Christian influence on AIDS policy will continue to make U.S. programs a target for international criticism.

Collectively these lessons also explain why the hope of building a long-term liberal-conservative coalition supporting future humanitarian objectives has been dashed. When the conservatives became interested in what previously had been a liberal issue, they took programmatic control. This left liberals in the awkward position of being on the outside of decisions but unable to be too critical because President Bush was providing far more funding and attention to the AIDS issue than any previous president. Whether liberal groups and legislators would have been so supportive of PEPFAR in 2003 had they known what policies would be implemented by 2007 is an interesting question.

Bush's call for the extension of PEPFAR beyond 2008 was again met with bipartisan and NGO praise, but many supportive statements now included sharp follow-up comments on the need to change contentious program details. Even before his announcement, members of the House of Representatives had fired the first shot of this battle by submitting legislation to end the AB funding requirements. PEPFAR will likely be reauthorized since it has proven successful and retains possible political benefits in helping America's global image and giving President Bush a humanitarian legacy to point to, but political disputes over implementation will intensify. PEPFAR is a public health program, but it is also a political program. International and domestic political pressures will continue to mix with, and at times outweigh, best practice standards of care in shaping PEPFAR programs and other U.S. global health and humanitarian initiatives.

1. Bono, as quoted in Sheryl Gay Stolberg, "The World: A Calling to Heal; Getting Religion on AIDS," New York Times, February 2, 2003.

2. "State of the Union, 2003"; available at www.whitehouse.gov/news/releases/2003/01/20030128-19.html.

3. Segolame Ramotlhwa, as quoted in Craig Timberg, "Botswana's Gains Against AIDS Put U.S. Claims to Test," Washington Post, July 1, 2005.

4. "President Discusses the Fight Against Global and Domestic HIV/AIDS," January 31, 2003; available at www.whitehouse.gov/news/releases/2003/01/20030131-4.html.

5. Anil Soni, as quoted in Mike Allen and Paul Blustein, "Unlikely Allies Influenced Bush to Shift Course on AIDS Relief," Washington Post, January 30, 2003.

6. Randall Tobias, as quoted in Nina Siegal, "No Experience Necessary: A Profile of Bush's AIDS Czar," Progressive 68, no. 11 (November 2004), p. 33.

7. Center for Health and Gender Equity, Debunking the Myths in the U.S. Global AIDS Strategy: An Evidence-Based Analysis, March 2004, p. 8.

8. United States Government Accountability Office (GAO), Global Health Spending Requirement Presents Challenges for Allocating Prevention Funding under the President's Plan for AIDS Relief, April 2006, GAO-06-395, p. 36.

9. David Brown, "Group Awarded AIDS Grant Despite Negative Appraisal," Washington Post, February 16, 2005