AIDS and Aid: Rethinking PEPFAR

December 14, 2009
This week on the Global Prosperity Wonkcast, I'm joined by Nandini Oomman, director of the Center's HIV/AIDS Monitor. Our conversation focuses on the new 5-year strategy laid out earlier this month by Ambassador Eric Goosby, the new U.S. global AIDS coordinator and head of PEPFAR (the President's Emergency Plan for AIDS Relief).Nandini praises the evidence-based framework PEPFAR has laid out and its move towards much greater openness and transparency. She stresses that the challenge ahead will be in designing concrete plans that implement the strategy effectively and measure its impacts.Nandini brings to the table a wealth of experience, dating back to the late 1980s, when she worked on the front lines of the battle against HIV/AIDS in India. On the Wonkcast, she tells me how she moved from educating sex workers in Mumbai about HIV to studying global HIV/AIDS policy. That journey started when her organization hosted a US Congressman, who wanted to see the realities of AIDS & sex work in India up close."I felt there was such a distance between the woman we were addressing and this wonderful Congressman, and I wanted to travel that distance to find out what decisions were made at the top that allowed money to flow down and prevention programs for health to work."Money earmarked specifically for HIV/AIDS represents a significant chunk of total foreign assistance (roughly 5-10% of the $125 billion official development assistance in recent years), and the United States provides around two-thirds of the AIDS money, around $5 billion in 2007 alone.Nandini explains that four out of every five dollars the United States spends internationally on AIDS is channeled through U.S. bilateral agreements, while the remainder goes through multilateral organizations such as the World Bank and the Global Fund for AIDS, Tuberculosis, and Malaria.PEPFAR is the main channel for U.S. bilateral spending on the disease, and Nandini gives listeners a brief history of PEPFAR and its approach. She says the program has always strived for clear results. "When PEPFAR was established, the administration thought very strategically about how they could demonstrate success... and I think they realized that to make this a success, they had to have very strong metrics."In the first five years of its existence, PEPFAR exceeded its target of getting 2 million people with HIV on treatment. The challenge now, Nandini explains, is making PEPFAR's work sustainable, in particular by stepping up prevention efforts, since for every two people who are placed on treatment, five people become newly infected."The difficulty in defining success in prevention is great, because how do you count something that didn't happen?" she tells me.For those who are interested, this is an area where CGD has been doing some pioneering work: senior fellow Mead Over is investigating the possibility of designing a Cash on Delivery program that would offer clear incentives for governments to prevent new HIV infections. I'll be interviewing Mead in an upcoming Wonkcast.Listen to the Wonkcast to hear the interview. Have something to add to our discussion? Ideas for future interviews? Post a comment below. If you use iTunes, you can subscribe to get new episodes delivered straight to your computer every week.


CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.