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On the occasion of World AIDS Day, President Bush’s has written an op-ed in today’s Washington Post vaunting his President's Emergency Plan for AIDS Relief (PEPFAR), telling Congress that AIDS patients supported by PEPFAR “cannot be abandoned” and pleading for continued expansion of treatment access.  Astonishingly, except for a reference to hypothetical future vaccines, the Op-Ed has not one word about HIV prevention.

Given our fiscal crisis, we cannot do everything.  If we accept that AIDS patients currently on treatment have an entitlement to continued support, President Bush’s call to scale-up treatment likely means less money for the rest of PEPFAR’s mandate – which is to prevent infection so that fewer people will need treatment in the future.  If Congress followed the former president’s guidance, it would increase treatment funding and drastically cut financing for HIV prevention. Is this what he has in mind?

From the start, PEPFAR has over-emphasized treatment at the expense of prevention (for numbers, see my working paper, Treatment Failure: The Ballooning Entitlement Burden of U.S. Global AIDS Treatment Spending and What to Do About It). Like many of President Bush’s programs (on the domestic front, think the unfunded Medicare drug program) PEPFAR gratified those who benefited directly and immediately while creating massive problems for others to deal with in the future.

One would think that a “conservative” administration would be prudent, sacrificing in the current period in order to make a better future.  I would vote for such an agenda, especially in a time of prosperity.  But by placing all its emphasis on treatment expansion, without tying the rate of expansion to prevention success, President Bush created the AIDS dilemma we face today: every additional patient placed on U.S.-funded treatment expects U.S. support for the rest of his life. Meanwhile, new infections, and thus the future need for U.S. support, continually outpace the numbers of people placed on treatment.

U.S. foreign assistance should focus on helping poor countries to help themselves.  With PEPFAR, our assistance instead fuels the accumulation of millions of AIDS patients who are unable to support their own medical treatment, requiring lifelong assistance from the United States for their very survival.  Instead of an AIDS program focused on prevention, which would have both protected and empowered the people of affected countries, PEPFAR has engendered increased dependence on the United States.