US Global AIDS Policy: Emergency Course Correction Required

December 1, 2009, marks President Obama’s first World AIDS Day in the White House and the first World AIDS Day for the newly elected Congress. The time is right for a frank assessment of his first year in the fight against global AIDS as President. This analysis focuses on the funding and policy decisions the Administration has made since taking office in January 2009, and assesses the human impact of those decisions.

The AIDS pandemic continues to ravage the developing world, shattering communities, undermining development, and reversing macroeconomic growth. On November 9 2009, the World Health Organization launched its first ever study on women and health, concluding that HIV is the leading cause of death worldwide for women in their reproductive years.1 33 million people worldwide are living with HIV, and 2.1 million AIDS deaths occurred in 2008 alone.

However, the AIDS response is beginning to show signs of real progress: the most recent AIDS Epidemic Update published by UNAIDS reveals that steadily increasing AIDS funding has resulted in real but fragile gains. For example, in Kenya, AIDS-related deaths have fallen 29% since 2002 and rates of HIV infection are falling in other countries as well, including the Dominican Republic and Tanzania. HIV mortality rates have decreased in sub Saharan Africa by 18% since 2004.2 In some places where community-wide HIV treatment coverage has been achieved, non-HIV related mortality rates overall are also decreasing, with maternal mortality falling, and significantly more children are surviving.

These seeds of success are in significant part due to U.S. investment by both the Bush Administration and, importantly, by the Congress, which increased investments for PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund) when the budget requests of the Bush Administration budget were anemic.

But President Obama’s first budget request to Congress, for fiscal year (FY) 2010, essentially froze spending for global AIDS at FY2009 levels. Initial information about his likely FY2011 budget request for global AIDS indicates the Administration plans to continue to flat-line funding for life saving programs—at the very same time those programs are beginning to show population-level impact. Without continued funding increases in the near term the positive public health gains beginning to emerge will likely evaporate. The global community could revert to little more than running in place in response to the global AIDS crisis, rather than making real progress in ending the pandemic and achieving a
sustainable global response to the greatest public health challenge of our generation.

This report card gives President Obama a “D+” for his first year as president. This assessment contrasts his one-year record to the promises he made to get elected, and takes into account the areas where some progress has been made, particularly on HIV prevention and support for integration of reproductive health and HIV prevention and treatment. It also takes into account pre-existing broad bipartisan support established during the Bush Administration for increased U.S. investment to fight AIDS. But one year is early in any Administration; President Obama still has the potential to carry forward a bold agenda on global AIDS.

President Obama could earn an “A” if he seizes this opportunity and if he
crafts a budget request for FY2011 that puts U.S. investments in global AIDS back on track—and includes prominent support for a bold HIV treatment target to be achieved by 2013. There is urgent need for course correction by U.S. leadership in fight against AIDS.

President Obama’s Global AIDS Promises

As a Presidential candidate and as a Senator, President Obama made bold commitments to tackle global AIDS, and followed through on those promises with legislation passed just before the 2008 Presidential election. For example, on World AIDS Day in 2007, Senator Obama pledged to “provide $50 billion by 2013 to fight the pandemic, and contribute our fair share to the Global Fund.”

He also pledged to “at least double the number of HIV-positive people on treatment.”5 As a Senator he backed this pledge with legislation that would authorize $48 billion in spending for PEPFAR by 2013; this legislation was signed into law by President Bush in 2008, just months before Obama was elected President.

Obama’s global AIDS platform was coupled with a public commitment to double foreign assistance in order to combat poverty that increases vulnerability to HIV infection and AIDS-related death.

Since taking office, however, President Obama has failed to keep these promises—despite tremendous potential.

After one year in office we can assess in four critical areas the performance of the Administration:

1) U.S. global AIDS funding levels;

2) U.S.-supported HIV treatment scale up efforts;

3) effective HIV prevention; and

4) linkages between AIDS programs and U.S. global health programs supporting primary health care in developing countries.

US Funding for Global AIDS:

Despite repeated public commitments to expand funding for successful global AIDS programs, the first budget request to Congress prepared by President Obama, for FY2010, would essentially flat-fund U.S. global AIDS investments—this budget request would not even keep pace with the estimated rate of global medical inflation (4-10% for 2009).

Specifically, President Obama requested a slight increase in bilateral AIDS funding, but requested a cut of the same amount for the Global Fund. At the country level, flatlining in Washington is translating into actual budget cuts in many programs, sending shock waves through communities and calling into question the sincerity of the Administration’s commitment to reaching the coverage levels promised under the 2008 Lantos-Hyde Act, which passed with overwhelming bipartisan support and was cosponsored by then-Senators Obama,
Clinton, and Biden. Administration officials have signaled that they will likely request the same in FY2011 as 2010—a roughly 2 percent increase.

These budget requests contrast starkly with the funding trajectory required to conform with the Lantos-Hyde Act spending levels President Obama promised to reach (see graph and text box in original publication).

US Commitment to Treatment Scale-Up:

Worldwide, roughly 10 million of the 33 million people who are HIV
positive face death in the next two years if they do not initiate treatment urgently. Of those 10 million, approximately 60 percent still lack treatment access. The Lantos-Hyde Act committed the U.S. to continue an ambitious scale-up of AIDS treatment through 2013, expanding access as funding increased and the cost of HIV treatment fell. As the graph below shows, the number of people living with HIV on treatment has historically tracked directly to the funding available. The impact of AIDS funding as a result of the last budget prepared by the lame duck Bush Administration, for FY2009, will be announced shortly and will likely include reaching about an addition 1 million people on AIDS treatment—or 3 million total.

Increasing resources could enable President Obama to make good on his campaign promise to double the number of people on AIDS treatment—to 6 million people by 2013.9 However, the Obama Administration’s flat-lined funding for global AIDS undermines his commitment to fund the U.S. fair share of the AIDS treatment burden.

Already, reports are emerging of clinic waiting lists rapidly expanding, and clinics being forced to turn away patients due to lack of promised funding. Dr. Peter Mugyenyi, the director of one of Uganda’s leading AIDS clinics recently stated, “Soon we fear the carnage of AIDS will once again surge and the obvious success we have seen of PEPFAR may begin to be reversed.”10 Access to life-saving therapies has revolutionized the AIDS response in developing countries, resulting in millions of lives saved.

Simultaneously, HIV prevention has been strengthened and become more accessible to vulnerable communities—decreased stigma brought about by treatment access means more people are willing to know their HIV status. In addition, epidemiologists predict that expansion of AIDS treatment will directly avert infections as people and populations
become less infectious.

Finally, the rapid scale up of chronic disease management in the most impoverished parts of the world has laid the groundwork for scaling up overall public health service delivery—creating important opportunities to strengthen reproductive health, decrease maternal, newborn and child mortality, and address other community health priorities.12 WHO’s improved adult HIV treatment guidelines—released today—endorse the use of less toxic antiretroviral therapy, and the initiation of treatment at an earlier stage of HIV infection.

Rapid implementation of these guidelines will dramatically improve the impact and durability of the treatment response—but will be impossible unless President Obama and the Congress keep their AIDS funding promises.

US Commitment to Effective, Comprehensive HIV Prevention:

As a candidate, President Obama promised to break away from the Bush Administration’s ideologically-driven HIV prevention programs that disregarded science and evidence, and that required PEPFAR recipient countries to scale up abstinence-only-until-marriage prevention programs despite evidence that they were ineffective.

Admirably, by rescinding the Global Gag Rule, President Obama ended restrictions on U.S. funding for organizations that provide family planning services and that are often the first responders for women in the fight against HIV. He also re-instated funding to the United Nations Population Fund, a UN agency that provides critical support for sexual and reproductive health care, including HIV and AIDS, throughout the world.

Access to comprehensive reproductive health care services provides life- saving information and services to prevent the sexual transmission of HIV as well as unintended pregnancy. Since taking office, the Obama Administration has clearly stated its commitment to addressing the linkages between reproductive health and HIV and AIDS in the fight to prevent sexual transmission of HIV and vertical transmission of HIV from mothers to their children—which was underscored in the newest policy guidance provided by PEPFAR headquarters to country teams.

However, PEPFAR has not produced country guidance that clearly directs countries toward funding comprehensive HIV prevention services. In
addition, countries that do not spend the majority of funding for sexual prevention activities on “abstinence-only-until-marriage” and “being faithful” programming are still required to explain those decisions. In fact, this so-called “soft earmark” is now associated with an essential PEPFAR indicator that all countries must report to PEPFAR headquarters on—the numbers of people reached with “interventions that are primarily focused on abstinence and/or being-faithful.”

In addition, President Obama has pledged to lift restrictions on funding needle exchange programs in the U.S. and overseas. However, for PEPFAR programs those restrictions would not require a change in U.S. law—only a change in PEPFAR policy guidance to countries. Nevertheless the Administration has not authorized that change.

US Committment to Expanding Global Health Investments:

President Obama pledged to expand investments in global health programs as a feature of U.S. foreign policy. Investments in reproductive, maternal, newborn and child health, neglected tropical diseases, and other health priorities are much needed and would bolster the health of people living with HIV around the world. In May 2009, the White House announced a “Global Health Initiative.”

The details of this six-year program remain vague, however a coalition of leading US-based global health organizations point out that the current $63 billion price tag touted by the White House will not be sufficient to reach the goals envisioned—instead an estimated $95 billion over six years would be needed.16 Lantos-Hyde Act spending for AIDS, tuberculosis and malaria programs is pledged at $48 billion over five years; a $63 billion health initiative over six years means significant increases in other health priorities would have to come at the expense of infectious disease investments—or not at all.

With AIDS as the number one killer of women of reproductive age around the world, tackling maternal mortality and child health requires expansion of HIV treatment and prevention programs and simultaneous expansion of other women’s health priorities.


In his first year in office, President Obama has all but failed to fulfill his commitments to wage an aggressive battle against global AIDS. Signs of policy shifts toward science-based prevention are most welcome, as is the President’s progress on lifting of the ban on people living with HIV traveling or immigrating to the U.S. However, this cannot mask the failure—so far—to chart a course that fully funds the U.S. response against global AIDS and ensures policy changes that were promised, are kept. Leading up to the State of the Union and the release of the FY2011 budget in February 2010, President Obama should take the following steps in order to make the urgent course correction needed:

* Fulfill promises on funding: This means not flat-funding AIDS in FY2011 but instead increasing funding to $7.25 billion for PEPFAR and $2 billion for the Global Fund. This would put the President back on track reaching the Congressional Lantos-Hyde Act authorization of $48 billion for AIDS, tuberculosis, and malaria by 2013—including $39 billion for HIV. In addition to bilateral aid, the Administration should also support the establishment of a tax on currency transactions for health, a straightforward way to raise substantial new resources, and a move that was recently endorsed by several G8 country governments. Finally, the Obama Administration should help ensure that U.S. funding is truly additional, by supporting liberalization of IMF macroeconomic policies.

* Set a goal to double the number of people on treatment to 6 million by 2013: The Bush lame-duck budget will have financed an expansion to nearly 3 million people on treatment by this year. Doubling treatment coverage to 6 million is possible—and would put the U.S. on track to treat roughly one-third of those in need under new WHO guidelines announced today.

* Real support to evidence-based prevention: The Administration should launch a full review of its prevention portfolio and eliminate funding for prevention programs that are not evidence based, such as abstinence-only programs. It should immediately issue new guidance to all programs focused on science and evidence. It must also lift the policy barriers to proven health interventions such as syringe exchange.