- The Washington Times - Wednesday, February 20, 2013

A U.S. program that has generated hopes around the world that the AIDS pandemic can be defeated should start “relinquishing” more control to its partner countries, according to an independent evaluation prepared for Congress.

The President’s Emergency Plan for AIDS Relief (PEPFAR), created by President George W. Bush in 2003, has been “a lifeline” to dozens of countries in their fight against HIV/AIDS, said authors of the Institute of Medicine report released Wednesday by the National Academy of Sciences.

“PEPFAR has achieved — and in some cases surpassed — its initial ambitious aims,” the report says. “That success has in effect ‘reset’ the baseline and shifted global expectations for what can be achieved in partner countries.”

The 10-year-old program, which is up for reauthorization this year, should prepare for yet another transition, said Dr. Robert E. Black, chairman of the Institute of Medicine evaluation committee that produced the 659-page report.

When PEPFAR started, it was described as an “emergency response” that flooded countries with funds for HIV prevention, HIV testing and antiretroviral drugs for people living with HIV. The U.S. effort then shifted to helping countries build up their own health care systems, train medical personnel and expand care and support to orphaned children and communities.

Now the effort toward “country ownership” of the AIDS battle should continue on an even larger scale, Dr. Black said.

“As the HIV response becomes more country-driven,” he wrote, PEPFAR, like other outside donors, “will need to focus its contribution on national efforts, rather than direct provision of services and attribution of results.”

This “will require relinquishing some control” over how PEPFAR-funded programs are run, added Dr. Black.

Mr. Bush’s AIDS fight initially was funded at $15 billion over five years and was renewed in 2008 with $39 billion.

Serra Sippel, president of the Center for Health and Gender Equity, said she supported the idea of country “ownership,” but hoped PEPFAR officials would not end up telling their partners, “Now, OK, you take it from here.”

Key concerns are making sure that women with HIV get treatment and family-planning products, such as female condoms that prevent both unintended pregnancy and disease. “When [female condoms] are made available, women do want them,” she said.

Another concern is the program’s anti-prostitution provision, which bars funding to promote or advocate for sex work or sex trafficking. “The policy is just discriminatory and undermines public health” and “we need to get rid of that” oath, Ms. Sippel said, noting that the Supreme Court is scheduled to hear a legal challenge to the policy in April.

With new advances in the global fight against HIV, President Obama and his administration, notably former Secretary of State Hillary Rodham Clinton, have called for an AIDS-free generation.

In an article in The Lancet, released online Wednesday, Dr. Black urged PEPFAR to put particular stress on “reduction of sexual transmission” of HIV, a position shared by Dr. Dawn K. Smith, a member of the Institute of Medicine evaluation committee.

Sexual transmission is the way in which “most new HIV infections are occurring,” said Dr. Smith, a federal specialist on HIV prevention.

Prevention efforts should be tailored for a nation’s populations, she said, citing the risks posed by commercial sex workers; men who have sex with men; and young, sexually active heterosexual adults as examples.

Proven prevention methods, she added, include giving antiretroviral drugs to certain high-risk people to prevent their acquisition of HIV; ensuring that HIV-positive individuals are on antiretroviral drugs to reduce the likelihood they will transmit the virus; and voluntary male circumcision.