Since its inception in 2003, the President’s Emergency Plan for AIDS Relief (PEPFAR) has saved millions of lives through providing anti-retroviral (ARV) treatment to people living with HIV/AIDS.  PEPFAR has been essential in moving overall coverage levels in African countries from near zero to a few countries reaching 80 percent coverage (e.g. Botswana) and several more reaching at least 50 percent of those in need (e.g. Zambia, Ethiopia).  However, the total need still substantially outstrips available treatment slots—with 6.6 million on ARVs but roughly 9 million people in immediate need of treatment still lacking access.

On November 8th, Secretary of State Hillary Clinton made a major speech on HIV announcing a shift is the U.S. global AIDS response based on new science. “Creating an AIDS-free generation,” she said, “has never been a policy priority for the United States government—until today.”  To reach that goal she laid out key interventions to be scaled up on top of the existing response, to turn the tide against HIV—among them ARV treatment to prevent new infections.

However, our analysis of publicly available PEPFAR operational plans shows that funding to AIDS treatment has actually fallen significantly since 2008 in both absolute dollars and as a portion of total budgets—just at a pivotal moment when investment could change the course of the epidemic.  Taking advantage of decreasing treatment costs (as discussed more fully below), PEPFAR is continuing to enroll new people on ARVs—expanding support to reach 3.2 million people as of last year. (See Note 1)  Yet, enacting Clinton’s policy directive will require ARV access to expand much faster.  In this context, reversing the decline in investments in treatment is critical—last year alone the funding could have paid for ARV access for nearly half a million more people.


ARVs Prevent HIV, Bend The Cost Curve Of The Epidemic

Breakthrough science has confirmed what has long been suggested: ARV treatment is HIV prevention. The recent NIH‐funded HPTNP 052 randomized control study demonstrated that people living with HIV who were on ARV treatment are 96 percent less likely to transmit HIV. This confirms the understanding that ART, by dramatically lowering viral load, is among the most effective modes of prevention (which has been the basis for virtually eliminating HIV transmission from mothers to children).  Indeed, studies in San Francisco, Taiwan, and Vancouver have shown that substantially expanded access to ART has helped lower the viral load of entire communities, which has been associated with reductions in new infections of as much as 50 percent, much of which is attributable to ARVs.

Marshalling this evidence, the Centers for Disease Control has modeled the potential impact of “accelerated treatment”—moving patients from care into treatment earlier and ensuring that pregnant women and people in serodiscordant couples (HIV+/HIV-) have ART access regardless of their CD4 count. Their models show that, in Kenya, this could reduce HIV incidence by 31 percent and offset the cost of care by up to 58 percent within five years.

This finding has the potential to revolutionize the global response to HIV and has major implications for the PEPFAR program.  Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases, wrote in Science in July, “The fact that treatment of HIV-infected adults is also prevention gives us the wherewithal, even in the absence of an effective vaccine, to begin to control and ultimately end the AIDS pandemic.”

Clear to all is that ARVs are not a stand-alone solution—but in combination with other proven prevention technologies from condoms to male circumcision to effective programs for most-at-risk populations, ARVs can be the missing link to end the crisis. Combining a conservative estimate of the impact of treatment on prevention with other proven interventions, experts at UNAIDS found that strategic scale up could avert 12.2 million new HIV infections, save 7.4 million lives and bend the cost-curve of the AIDS epidemic, significantly reducing financial needs by 2020.

ARV Investments Are Falling

Treatment funding under PEPFAR, however, is declining just as these breakthroughs make clear that ARV availability will be a key element in any global strategy to break the back of the HIV pandemic. Since 2008 PEPFAR funding for adult and pediatric treatment has declined significantly, both in absolute terms and as a portion of overall dollars. During the same period funding for the PEPFAR program overall has increased—though very modestly.

According to our analysis of the PEPFAR Operational Plans currently available through fiscal year 2010, the percentage of total PEPFAR funding going into the ARV procurement, adult and pediatric treatment services budget lines declined from an average of approximately 35 percent to 28 percent of the total PEPFAR funding. Absolute declines differed by country, with some countries experiencing essentially flat funding while others such as Namibia, Mozambique, Kenya, and Tanzania losing between 10 and 30 percent of their total treatment budgets by fiscal year 2010.


Costs Are Falling

PEPFAR has not made a public explanation of these specific declines, but available documents suggest that substantial efficiencies have been found, which explain how PEPFAR has been able to continue to scale up treatment in many countries. In her speech Secretary Clinton noted that the cost of adding a person to ARV treatment has fallen dramatically—data published just a year and a half ago showed costs at $436 per year, and in her speech Clinton announced this had dropped nearly a quarter to $335 per year.

This is based on a variety of factors. ARV prices have been driven down through purchase of generic medicines—with many regimens purchased in 2010 at less than half the cost they were in 2007.  ARV prices are now less than 40 percent of total treatment costs. In addition, PEPFAR has found savings through other areas, including switching from air to sea/land shipping of medicines, which saved $17 million in 2011.

Re-Investment Is Needed

Unfortunately, our analysis shows that only a small portion of these funds are being reinvested in treatment services. Implementing Secretary Clinton’s policy directive—and achieving the huge potential to halt both AIDS deaths and new HIV infections—will require dramatic scale up of the number of “treatment slots” being added each year. PEPFAR’s current target of “more than 4 million” by 2012 is clearly insufficient.

Part of accomplishing this lies in re-investing cost savings into ART programs. At today’s average costs 507,000 additional new people could have received access to ARV treatment last year with the estimated $170 million per year by which PEPFAR treatment budgets have been reduced. In a time of fiscal limitations this is an easy first step to a reinvigorated U.S. global AIDS response.


Note 1. As of last year, the US directly supported life-saving antiretroviral treatment for more than 3.2 million men, women and children, PEPFAR reports. In fiscal 2010, ARVs were provided to more than 600,000 HIV-positive pregnant women, preventing mother-to-child HIV transmission and allowing more than 114,000 infants to be born HIV-free. Taking into account U.S. contributions to the Global Fund to Prevent HIV/AIDS, Tuberculosis and Malaria, of the estimated 5.2 million total individuals in low- and middle-income countries who received treatment as of last year, nearly 4.7 million were supported through PEPFAR bilateral programs, the Global Fund, or both. (In absolute dollar terms, the U.S. is the largest single donor to the Global Fund, but other nations contribute higher percentages of their GDPs than the U.S. does, and the U.S. has fallen short of its stated targets for Global Fund contributions.)