For every one million people put on treatment, 2.5 million are getting infected. So why has Congress ensured that the $48 billion PEPFAR reauthorization legislation, passed by the Senate of July 16, privileges treatment and care over prevention? In this second of an HIV/AIDS monitor series of posts we look into some key issues around prevention in the reauthorization bill.The PEPFAR program itself reports that new infections far outpace the world's ability to provide treatment and care and that prevention is the best approach to respond to HIV/AIDS. Despite that, OGAC reports prevention still accounts for only 21 percent of their spending. The HIV/AIDS Monitor report "New PEPFAR Data: The Numbers Behind the Stories" has shown spending on program areas across countries has been influenced by the earmarks and another HIV/AIDS Monitor report shows that ratios of spending on prevention, treatment and care are very similar across countries despite differences in epidemiology and country context. While the reauthorization bill reduces some of the restrictions placed on prevention, it falls short of internalizing the learning from the past five years: that prevention is critical for the fight against HIV/AIDS and that prevention approaches need to be determined in country specific realities and strategies and not by the political and ideological maneuverings of congress.In terms of progress, the reauthorization bill introduces the option for countries to choose not to focus on abstinence and 'faithfulness' programs (as long as they submit a formal justification why they have not). The bill also at least pays lip service to the need for evidence and local context to be critical concerns for decisions about prevention. It also makes modest recognition of the need to work with vulnerable groups such as men having sex with men, sex workers, and the particular needs of women and girls. Many questions remain though about whether the US approach to working with these groups is based on the best known science to prevention or on ideology, and the issue remains that even a weakened restriction is a restriction that may hamper the effectiveness of what funding the reauthorization bill does allow towards prevention.By putting in place an earmark requiring more than half of funding be devoted to treatment and care, the bill limits country teams ability to expand prevention efforts. This doesn't mean that Congress should put into place a prevention earmark. Previous research done by the HIV/AIDS Monitor has argued that for HIV/AIDS aid to be effective, national governments and stakeholders, with donors aligned and harmonized behind them, need to be the stewards of a national response making the judgments ideally based on the facts on the ground about what response is most appropriate in their country. Their hands should not be tied by the arguments and ideology of politicians in Washington. PEPFAR funding needs to be structured in such a way that it is flexible to meet specific country needs. It is difficult enough to determine these needs and the most effective strategies at a country level and quite impossible to do it at a global level. For PEPFAR legislation, this means not only taking out earmarks, but also removing harmful restrictions, such as the reauthorization bill's emphasis on abstinence and 'faithfulness' over other activities to prevent sexual HIV transmission, maintenance (and even expansion) of the "conscience clause," and undermining effective prevention efforts among sex-workers through the anti-prostitution pledge. These restrictions limit the ability of programs to design the most needed and evidence-based interventions and to reach some of the groups most vulnerable to the epidemic. In a 2006 report from the GAO 17 out of 20 country teams reported that fulfilling Office of the U.S. Global AIDS Coordinator's guidance on the spending requirement for abstinence programs presented challenges to their ability to respond to local prevention needs. More on these issues and related issues is being examined in more detail by the HIV/AID Monitor work in progress.The conscience clause states that groups receiving funding do not have to take an approach to prevention, treatment and care that they find morally objectionable, and preference in funding decisions cannot be given (or taken) based on these objections. The anti-prostitution pledge is a pledge that all recipients of funding have to take that says they will not work to support or advocate for legalization of sex work, often criticized for leading to criminalization of sex workers and marginalizing from prevention programs. For an example of how USAID has advised on both of these see here. While the PEFAR program and its partners have claimed successes in terms of rolling out treatment that has saved millions of lives, most everyone admits there is much more work to be done on prevention. If we want to avoid maintaining an ever growing supply of people to treat and care for in the future, Washington needs to exhibit its leadership by stepping back and allowing those on the front lines of the global fight to lead on the decisions for preventing the continued spread of the disease.
