Washington Watch

Global AIDS program: More money, new flaws

By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC

On July 30, President Bush signed a law revising and renewing the President's Emergency Plan for AIDS Relief (PEPFAR).1 In a deal reminiscent of the one that produced the original 2003 law, Bush and congressional conservatives agreed to more than triple the funding for the program in exchange for significant policy concessions from congressional progressives, particularly in the area of HIV prevention.2

The two sides agreed to authorize $48 billion over five years for HIV/AIDS, tuberculosis, and malaria — up from a total of $15 billion over the first five years of the program. If the new funding goals are met, the program's future impact should be even greater. The additional funding also is meant to help train at least 140,000 new health care workers and to help countries bolster their overtaxed health systems and better integrate HIV/ AIDS services.

The revised PEPFAR law eliminates or eases a series of spending requirements in the original law that hampered flexibility at the local level. One major change is in regard to treatment. The old law earmarked 55% of funding for treatment; the current law includes a similar earmark (50%) but allows the money to go toward care, as well as treatment. This change is critical to helping the ever-growing population living with HIV for long periods of time.

Another important change is in regard to prevention and PEPFAR's emphasis on abstinence promotion. Under the revised law, the global AIDS coordinator is required to develop a strategy to prevent the sexual transmission of HIV in which at least half of funding is directed to "activities promoting abstinence, delay of sexual debut, monogamy, fidelity and partner reduction" — which is to say, prevention activities other than those exclusively promoting condom use among sexually active people. This requirement only applies in countries with generalized epidemics, and not in those countries where HIV is more concentrated (among sex workers, for example).

This replaces a more restrictive earmark from the original PEPFAR law that required abstinence-until-marriage programs to receive at least one-third of all HIV prevention funds. Notably, that original earmark applied to all prevention funds — including those targeting the nonsexual transmission of HIV, such as mother-to-child — and in all countries regardless of the nature of their epidemics.

A major concession on the part of congressional progressives is that the new law avoids all mention of family planning or reproductive health services. The revised PEPFAR law explicitly promotes linkages between HIV prevention and treatment programs and a wide array of related services, from maternal and child health care to substance abuse services. An early draft of the bill included family planning programs in these efforts and encouraged them to provide referral or even provide PEPFAR-supported HIV prevention services on site. It also would have allowed PEPFAR to fund voluntary contraceptive services at HIV treatment sites for women seeking to delay or avoid pregnancy. The administration and congressional conservatives fought hard and vocally to eliminate these provisions, despite the fact that the administration itself already had taken steps to better integrate family planning and HIV prevention services.3

Remaining untouched from the 2003 law is a requirement that nongovernmental organizations wishing to receive PEPFAR funding take a pledge in opposition to prostitution. This provision is currently in litigation over its impact on U.S.-based organizations' free speech rights.

The new law also strengthens a "conscience" provision under PEPFAR, allowing organizations with a moral or religious objection to condom use to opt out of even providing information or referral about that option. Faith-based organizations, under both the original and the revised law, are given priority in receiving funding.

The new administration and Congress will have ample opportunities to fix the shortcomings of the revised law. Early in 2009, the president will appoint a new global AIDS coordinator who will be responsible for interpreting and writing guidance on the updated PEPFAR law.

If the administration cannot or will not address problems that emerge with the new law, Congress could make further adjustments to the law itself, as it did in several subtle but important ways with the 2003 law. Its most important decision, however, might be in regard to funding and whether it can fully fund PEPFAR in the face of the current fiscal crisis.


  1. P.L. 110-293, July 30, 2008.
  2. Cohen SA. U.S. global HIV prevention policy: Still time to get it right. Guttmacher Policy Review 2008; 11:2-6.
  3. U.S. Agency for International Development. Family Planning/HIV Integration: Technical Guidance for USAID-Supported Field Programs. September 2003. Accessed at www.usaid.gov/our_work.