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July 2008
Volume 18, Number 7
U.S. Global AIDS Program Expands

Congress has passed a 5-year, $48 billion expansion of the U.S. global HIV/AIDS initiative known as the President’s Emergency Fund for AIDS Relief (PEPFAR).

The new legislation targets $5 billion for malaria and $4 billion for tuberculosis (TB). The broader focus makes a lot of sense, noted HIV Medicine Association (HIVMA) board member Eric Goosby, MD, CEO and chief medical officer of Pangaea Global AIDS Foundation and Professor of Clinical Medicine at UCSF Global Health Science Department of Medicine, because, “It’s often the same patient who gets all three diseases.” Making the funds available for malaria and TB can also help to build a country’s public health infrastructure, he added. “You have a huge influx of resources coming into a country. Since that country can decide to use these resources for TB and malaria, it’s going to benefit the larger population that’s not (HIV-)infected as well, hopefully, all boats rise.”

As significant as what the new version of PEPFAR includes is what it leaves out. It strikes down the long-standing ban on travel to the United States for those living with HIV. HIVMA has long argued against the ban, which has no medical basis, stigmatizes those with HIV, and has kept the International AIDS Society’s major biannual meeting out of the United States.

“For many of us, this ban has been an embarrassment,” said HIVMA Vice Chair Michael S. Saag, MD, FIDSA, director of the Center for AIDS Research at the University of Alabama at Birmingham. Dr. Saag was in close contact with the office of Alabama Senator Jeff Sessions (R), who led objections to lifting the ban. Dr. Saag and others were instrumental in persuading Sen. Sessions to drop his objection, and Sen. Sessions on the Senate floor praised Dr. Saag’s work in Zambia and elsewhere.

Also conspicuous in their absence are many of the earmarks and restrictions that restricted how countries may spend PEPFAR funds. Requirements have been relaxed on spending fixed percentages on antiretroviral drugs and prevention programs emphasizing sexual abstinence. “Flexibility is absolutely required because of the dramatic differences in need from one country to another, and even within a country from one setting to another,” Dr. Saag said. According to Dr. Goosby, relaxing these restrictions also will encourage countries to take ownership of the programs.

The enlarged PEPFAR program includes funding to strengthen health systems and the health care workforce, including a goal to train at least 140,000 new health care workers. Dr. Goosby is helping to implement HIV/AIDS programs in several countries currently receiving PEPFAR funding and has first-hand knowledge of the severity of the health care workforce crisis in many developing countries affected by HIV/AIDS.  In many countries more physicians are needed, but in the meantime, he said, “Diagnosis and treatment decisions need to be shifted from exclusively an MD decision  to an RN or NP in consultation with a physician. Without the midlevel provider expansion of role,it won’t work.”

Also included in the PEPFAR package are resources for monitoring, evaluation, and operational research. These funds will help to establish what interventions and methods of delivery work best in individual settings.

HIVMA has written several letters to Congress regarding this legislation, which can be found on in the “Public Policy” section of the HIVMA website,, under “Global.” 
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