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This is a joint posting with David Wendt

Does the new AIDS bill constitute recognition that AIDS treatment has become a de facto "entitlement"? If so, will AIDS continue to be exceptional in this respect -- or will Americans and the citizens of other relatively rich countries increasingly be willing to accept that the recipients of their assistance are "entitled" to its continuation.

The US congress passed last week and has sent to President Bush for signature the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act (H.R. 5501). This bill extends the US commitment to treat foreign AIDS patients by doubling the time period (from 5 years since 2003 to 10 years) and increases the target number of patients to be enrolled in treatment from 1.73 now to 2 or more million in five years.

David Brown's article in Saturday’s Washington Post draws on my recent working paper and other sources to make the case that that extending the duration of the nation's commitment to the 1.73 million whose care is now supported by the US was the only ethical option given the unavailability of other sources of support for these people and the fact that they would have died without continued support for their treatment. For Congress to have denied those patients the funds to support the continuation of their treatment would have entailed grave reputational risks for any American politicians associated with the denial. Although the 1.73 million whose lifeline was extended had no legal claim to the extension of their support, the fact that they are identifiable individuals rather than statistical abstractions, the degree to which they were at risk and the fact that their deaths from absence of US funding would be attributed to the actions of specific American politicians all seemed to combine to give them a claim on American tax revenue that exceeds that of many other groups. As just one striking example, the US congress has not yet seen fit to grant an entitlement to health services for the 47 million Americans without health insurance.

But Congress went beyond simply recognizing the "entitlement" of these 1.73 million to five more years of treatment. In the 2003 PEPFAR bill, the target for treatment was loosely based on a calculation of need for treatment. In the reauthorization bill Congress did not create a target for how many people would be treated at all. Instead there is a formula for calculating the treatment target in the future. The formula sets a floor for treatment of 2 million people. Then it says that target will increase by the percentage that total annual funding for PEPFAR increases over the 2008 amount (so if the annual PEPFAR budget is twice the 2008 budget, the target will be 4 million). It then goes on to say the target will also increase by the same percentage that the cost of treatment per person decreases. So if treatment costs fell by one quarter by 2013 and the annual budget for global HIV/AIDS spending tripled (to around 15 billion dollars a year in 2013), the target number of people on treatment in 2013 would be 7.5 million. And the lives of all of these people would hinge on another renewal of PEPFAR authorization.

So assuming Congress understands that it is creating entitlements, it seems so far to be remarkably willing to do so - at least for AIDS patients in the 15 PEPFAR focus countries. In the next months when the matter of AIDS spending is taken up by Congress's appropriations committees, we will see how the US legislature interprets and follows through on the commitments contained in this reauthorization. If so, advocates of other types of assistance to the poorest countries must ask what they can do to convert their programs into similarly compelling entitlement. One answer might be to emulate PEPFAR's remarkable success at putting human faces on its success and at counting their number.