Monday, March 9, 2009

Is PEPFAR Really So Great?

Dr. Joia Mukherjee, the medical director for Partners in Health, writes in the Boston Globe today about the need to fully fund the new, expanded PEPFAR, the big anti-AIDS program pioneered by President Bush. While I agree that an investment of that scale makes sense, it's not clear to me that PEPFAR, as currently conceived, is the best vehicle to do this. Couldn’t we find a better way to spend $48 billion on improving the health of Africans?

A few points:
1. This idea that PEPFAR has put 2.1 million Africans on “life-saving drugs” is simply not true. The program’s numbers, and those of most similar programs, are notoriously tricky. In addition, the best meta-analysis says that half of all Africans put on antiretroviral drugs have fallen out of those programs after 2 years. Many, if not most, are dead. And let's not forget that ARVs, though miraculous, are not cures.
2. The other, oft-cited stats are inputs, not outputs. Money spent, audiences supposedly reached, etc, are flimsy measures of success. New HIV infections are falling in some African countries, but there's no obvious relationship between PEPFAR money and falling infection rates. Perhaps the steepest drop since PEPFAR began came in Zimbabwe, which is not a PEPFAR country. Many of the biggest PEPFAR recipients, meanwhile, have not done nearly as well. Wasn’t Bush’s goal to “turn the tide” on the AIDS epidemic? Has this happened? (My take on PEPFAR last year
3. There's meager evidence that PEPFAR has succeeded at preventing many new infections. Bush deserves real credit for getting the politics, and money, rolling toward widespread treatment. But in prevention programs, PEPFAR got stuck in distracting debates about condoms vs. abstinence.
4. The focus on treating people with AIDS has, no doubt inadvertantly, drained energy and money away from other similarly worthy goals. As my book project co-author Daniel Halperin wrote in the New York Times last year, as AIDS funding has skyrocketed, vital efforts on clean water, breastfeeding and family planning have stagnated or worse. Some PEPFAR money has spilled into basic health, most famously in Rwanda, but if basic health is the goal, is this program the best way to pursue it?

Now for some suggestions:
1. If we are going to put $48 billion into PEPFAR, let’s spend it much better, with a renewed emphasis on prevention programs that work. That means expanded services for male circumcision, much more effort to break up sexual networks by promoting partner reduction. Obviously the push for wider, more accessible treatment remains vital.
2. If we’re serious about saving African lives and improving African health, let’s invest intelligently in African health systems, not merely buy AIDS drugs, or send over expensive U.S. doctors, or build clinics focusing on a single disease. Let’s help build medical schools, and even better, nursing schools. Let’s work harder on medical system brain drain. And let’s make real investments in making drinking water clean, encouraging breastfeeding and making modern contraceptives (and not only condoms) easily available for everyone.

If we do these things, we’ll save and improve a lot more lives, no matter what the budget ends up being.

What do you think? Hit “Comments” below.


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