US Funding for HIV/AIDS The PEPFAR Program

1. US Funding for HIV/AIDSThe PEPFAR Program

2. “PEPFAR”: the President’s Emergency Plan for AIDS Relief • Proposed $15 billion over 5 years. Funding first approved in 2004. • All USG HIV/AIDS money is “PEPFAR” money. • Focus on scaling up treatment, prevention and care in 15 countries. • Includes funding for research, the contribution to the Global Fund, and spending in more than 100 countries.

3. Federal Funding for HIV/AIDS: FY 2003 – FY 2007 Source: Kaiser Family Foundation * Figure includes unused funding carried over from FY 2004

4. Focus Countries • 15 Focus countries: Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia • 5 “Focus-light” countries: Zimbabwe, Malawi, Russia, India, and Cambodia

5. Examples of Country Spending Levels • Focus countries • South Africa: $148,187,427 • Cote d’Ivoire: $44,375,766 • Vietnam: $27,575,000 • Focus-light countries • Russia: $12,920,000 • Cambodia: $14,300,000 • Non-focus country • Georgia: $1,100,000 All figures from U.S. State Dept., Office of the Global AIDS Coordinator and USAID, FY 2005

6. Concerns with PEPFAR Areas of Concern: • Earmark for “Abstinence until Marriage” programs • Prostitution pledge requirement Areas of Potential: • Earmark for Palliative Care • Support for substitution therapy (such as methadone) • Legal reforms, such as inheritance rights

10. PEPFAR and “Abstinence Until Marriage” The US Government Accounting Office found: • Ambiguities in the ABC guidance have led to uncertainty in implementation • The spending requirements can limit “efforts to design prevention programs that are integrated and responsive to local prevention needs.” • Some countries have cut prevention funds in certain areas

11. Prostitution Pledge Requirement US Law: • Prohibits funds from being spent on activities that “promote or advocate the legalization or practice of prostitution and sex trafficking.” • Provides that “no funds made available to carry out this Act… may be used to provide assistance to any group or organization that does not have a policy explicitly opposing prostitution and sex trafficking.”

12. Grounds for Lawsuit The OSI/AOSI lawsuit charges that the “pledge requirement”: • Violates the First Amendment by forcing private organizations to adopt the government’s ideology and by restricting what they can say and do with their private funding; and • Is unconstitutionally vague, which allows for arbitrary application and violates the First Amendment as well as the due process clause of the Fifth Amendment.

13. The Court’s Decision • The judge issued a preliminary injunction against the enforcement of the pledge requirement • “The organizations… seek to cooperate with the Government in furtherance of a shared purpose: combating the devastating consequences of the HIV/AIDS pandemic. They seek to do so, however, without forfeiting the critical role they play in stimulating public discourse on controversial themes… The Policy Requirement, to the extent it prevents NGOs from speaking openly on such questions with their private funds, contravenes our national commitment to open debate and our First Amendment values.” • The court’s decision applies directly only to AOSI and Pathfinder, but it could impact many other organizations.

14. AIDS Action Alan Guttmacher Institute American Foundation for AIDS Research American Humanist Association Center for Health and Gender Equity Center for Reproductive Rights Center for Women Policy Studies Community HIV/AIDS Mobilization Project Feminist Majority Foundation Gay Men’s Health Crisis Global AIDS Alliance Human Rights Center, University of California, Berkeley Human Rights Watch Interaction Institute of Human Rights at Emory University International Planned Parenthood Federation, Western Hemisphere Region International Women’s Health Coalition Physicians for Human Rights Planned Parenthood Federation of America, Inc. Population Action International Population Council Religious Consultation on Population, Reproductive Health and Ethics Sexuality Information and Education Counsel of the U.S. Other US NGOs In Support of the Lawsuit

15. Palliative Care 15% of PEPFAR funding must be used for palliative care. • The State Department uses a very broad definition of palliative care • Increasing opiod availability is part of the PEPFAR program, but does not appear to be a focus • TB/HIV co-infection is included as part of palliative care

16. Harm Reduction • US can’t fund needle exchange, but can fund wrap-around activities. USAID policy “expressly permits USAID implementing partners to cooperate with other donors and governments that fund activities not permitted with USAID funds (such as the purchase of needles), provided that USAID funds are segregated and coded for separately.” -- USAID Communication to US Congress, February 15, 2005 • US can fund substitution therapy, such as methadone. Substance abuse programs may include behavioral models or medication-assisted treatment, or a combination of the two, and should also include case management and counseling services. Medication-assisted treatment that uses methadone, buprenorphine or naltrexone, is an effective option for treatment of heroin dependence. -- US Office of the Global AIDS Coordinator, HIV Prevention among Drug Users Guidance #1: Injection Heroin Use, March 2006

17. Engaging with PEPFAR • Engage at country level • Feed country level insights into DC advocacy • Insist that USG not over-reach on legal requirements • Choose messages carefully. Frame requests in terms of meeting prevention, care and treatment goals • Decide: • When does the OSI name help or hurt? • Do we have something unique to contribute? • Conflict between implementer and advocate?

18. Advocacy Examples • Monitoring • Public Health Watch • • OSISA • Informing policy guidance • Commenting on new guidelines for Prevention Among IDUs • • Commissioning research on substitution therapy to inform • scale-up • Cultivating new leadership on OSI issues • • Center for Strategic and International Studies • • Physicians for Human Rights • Changing legal requirements • • Prostitution Pledge Lawsuit • • Advocacy through Open Society Policy Center