In a report released last week, the Joint United Nations Program on HIV/AIDS (UNAIDS) downgraded its estimate of the number of people living with HIV/AIDS from 39.5 million to 33.2 million. While improvements in data collection—which critics say should have been made long ago—account for most of the change, the UN report also suggests that global HIV prevalence has "leveled off and that the number of new infections [has] fallen,” partly as a result of HIV-prevention programs. Has President Bush’s AIDS policy made a significant difference? That is less clear. 

In his January 2003 State of the Union address, Bush called on Congress to commit $15 billion over five years to combat HIV/AIDS in Africa and the Caribbean—more money than any nation had ever pledged to spend fighting one disease. His proposal, known as the President’s Emergency Plan for AIDS Relief, or “PEPFAR,” was certainly ambitious. It promised to prevent 7 million new AIDS infections, treat at least 2 million people, and, in Bush’s words, “provide humane care for millions.” The initiative enjoyed broad bipartisan support and even won praise from Bob Geldof, the Irish musician-activist. “You’ll think I’m off my trolley when I say this, but the Bush administration is the most radical—in a positive sense—in its approach to Africa since Kennedy,” Geldof told The Guardian in May 2003.

While the number of people living with HIV/AIDS may be less than originally estimated, it is still increasing. Originally conceived as an emergency measure, PEPFAR must respond to this long-term reality.

Nearly five years later, however, there is no real consensus on PEPFAR’s record. There is little question that it has increased awareness of the global battle against HIV/AIDS. Indeed, it initially prompted a wave of similar commitments from other Western leaders, including Britain’s Tony Blair and France’s Jacques Chirac. It also may have fueled popular support in the United States for HIV/AIDS relief: in 2006, 60 percent of Americans told the Kaiser Family Foundation that the United States had a responsibility to help fight HIV/AIDS in developing countries, up from 44 percent in 2002.

But in a practical sense, PEPFAR has been less effective. As of March 2007, it had not even come halfway to meeting any of its benchmarks for success. A report issued that month by the Institute of Medicine notes that each of the initiative’s 15 focus countries still face “enormous challenges in controlling [the] epidemic.” According to the UNAIDS report, prevalence rates in sub-Saharan Africa are “stabilizing,” yet the number of people infected with HIV/AIDS continues to grow. While the rate of new infections may be declining, the UN’s figures suggest it has been doing so since the late 1990s; it’s not clear how much impact PEPFAR or other HIV/AIDS programs have made.

PEPFAR suffers, too, from a number of logistical problems. Critics claim the aid money is too heavily conditioned; that the program is over-reliant on outside contractors and insensitive to local priorities. Activist groups such as Human Rights Watch insist that PEPFAR’s “33 percent rule,” which stipulates that 33 percent of all funding be spent on initiatives promoting abstinence or sexual fidelity, has drained resources from other, more important prevention methods.

On the other hand, as U.S. Global AIDS Coordinator Mark Dybul recently noted, PEPFAR has accomplished a great deal in a remarkably short period of time. When the plan launched, only 50,000 people in all of sub-Saharan Africa had access to antiretroviral treatments; today, over 1 million do. Public education campaigns, school curricula, and other preventative programs have reached an estimated 140 million people (although more data is still needed to assess their effectiveness). Compared to other large HIV/AIDS initiatives, PEPFAR’s performance appears strong: a 2007 Center for Global Development report found that PEPFAR bested the World Bank and the UN-backed Global Fund to Fight AIDS, Tuberculosis and Malaria in channeling aid money into on-the-ground initiatives in Zambia, Uganda, and Mozambique.

PEPFAR is far from perfect, as even its most ardent champions recognize. Its initial focus on working through a few well-placed service providers, while making treatment delivery more efficient in the short-run, may have unintentionally eliminated the impetus—and the resources—for recipient countries to develop their own health infrastructures. In hindsight, too, the program’s heavy focus on treatment meant that prevention got too short shrift. Over the short term, providing enhanced and more readily available treatments has allowed AIDS patients to live longer. But down the line, the financial costs of longer treatment periods and more expensive second- and third-line drugs will be unsustainable for many developing countries. More attention needs to be paid to implementing and assessing the effectiveness of preventative measures.

To their credit, Bush administration officials have shown a willingness to adapt. They made “The Power of Partnerships” the theme for the upcoming World AIDS Day (December 1st) and reaffirmed their commitment to working with multilateral partners such as the UN-backed Global Fund. They have also expressed a willingness to clarify PEPFAR’s goals to complement (rather than replicate) the efforts of other agencies. Five years in, the PEPFAR benchmarks have been amended to reflect, in Dybul’s words, “the need for increased focus on prevention.” Dybul says that in 2008 PEPFAR financing for prevention will nearly double, from $7 million to $12 million, with more modest increases in funding for treatment ($2 million to $2.5 million) and care ($10 million to $12 million). 

For while the number of people living with HIV/AIDS may be less than originally estimated, it is still increasing—and it will likely increase even more as improvements in the quality and availability of antiretroviral treatments allow patients to live longer. Originally conceived as an emergency measure, PEPFAR must respond to these long-term realities.

Karen Porter is an editorial assistant at THE AMERICAN and a research assistant at the American Enterprise Institute.