Storm Clouds and Silver Lining around US Funding for AIDS

Next week some 20,000 AIDS activists, practitioners and researchers from around the world will pour into Washington, DC to discuss new research and technologies at the International AIDS Conference (IAC). Meanwhile, fifteen blocks away on Capitol Hill, US policy makers will be grappling with policy issues that could have a significant impact on billions of dollars in global HIV/AIDS funding, of which the United States is by far the largest provider.

This dynamic isn’t lost on the AIDS community.  The president of the International AIDS Society and International AIDS Conference co-chair, Dr. Elly Katabira of Uganda, recently said that he will use the conference to thank the United States for its contributions:“We want the world to know how we appreciate the contribution of the American people. We know that we haven’t been going to the US for the last 22 years, but in spite of that the US is still the leading contributor to the struggle against the epidemic,” he said.With the theme “Turning the Tide Together,” this year’s conference is sure to exude a renewed sense of optimism concerning the epidemic. This is justified given new technologies and promising research.  But these advances were largely made possible because of an unprecedented ramp-up in public funds over the past decade – in 2010 more than half of all global AIDS funding came from the United States – and that funding seems likely to decline in the years ahead. A report from the Kaiser Family Foundation found that global resources dedicated to fighting AIDS fell for the first time last year.While the United States is only one of many players in the global fight against AIDS, it has consistently been the leading force in funding and scientific expertise. At least four big issues will impact US support for the global response to the epidemic over the coming year:1)     FY2013 Budget - President Obama’s FY2013 request for the President’s Emergency Plan for AIDS Relief (PEPFAR) was $6.4 billion, a 3 percent decrease from the year before and the lowest level since FY2008.  While the House and Senate’s State and Foreign Ops committees both came in a little higher, funding was still flat-lined and there’s a strong chance that the bill will not be taken up by either chamber before the end of the year. Bottom line for FY2013: the US budget for HIV/AIDS will likely be flat or decrease, the start of a trend that’s expected to continue in coming years.2)     Upcoming Election  – The US Congress and Administration face a tough election in November and there isn’t much appetite to put HIV/AIDS on the political agenda. While it’s unclear who will be in the White House, the composition of Congress will undoubtedly change and many of those who drummed up support for PEPFAR in 2003 and 2008 will be gone.  Following the recent demise of President Obama’s Global Health Initiative, the fate of PEPFAR and other global health programs will remain in the hands of the State Department, which may not be run by someone as supportive of global health issues as Secretary Clinton.3)     Sequestration – The looming, automatic, across-the-board spending cuts that will be triggered under sequestration in January 2013 could significantly impact the future of US funding levels for AIDS. The Congressional Budget Office estimates that the international affairs budget will drop about 8 percent in FY13. It’s unclear how much those cuts will come from PEPFAR’s budget, but it’s unlikely that AIDS funding will remain untouched and advocates fear that the human impact of sequestration would be devastating. Avoiding sequestration will likely be a major focus of the post-election lame duck session at the end of the year.4)     PEPFAR Reauthorization – The law authorizing PEPFAR will be considered for reauthorization in 2013 at a time when fiscal concerns that have already put pressure on its budget are likely to be heightened. Although it seems likely that the program will be reauthorized given its longstanding bipartisan support, Congress may decide to authorize (and eventually appropriate) less than in the past. The outcome will depend, in part, on the composition of Congress and on who occupies the White House in 2013.These storm clouds over AIDS funding could turn out to have a silver lining if austerity creates pressures to improve the global response to AIDS in ways that make it more effective and efficient. Participants in this year’s AIDS conference should keep in mind that continued high levels of funding are uncertain at best and discuss new ways to get the most value for money in AIDS programming.To kick off the conversation I’ll offer two ideas from my colleagues here at CGD:  Connie Veillette and John Norris from the Center for American Progress suggest accelerating cost-sharing arrangements with upper middle-income recipients of PEPFAR to foster country ownership and transfer financial responsibility to recipient countries.  And Mead Over proposes substantially strengthening incentives for prevention to achieve an AIDS transition in part through innovative approaches to aid financing and delivery (learn more in his recent book and brief).Check back here in the coming months as we continue to monitor these big issues on the US policy landscape, and assess their impact on the global response to AIDS.