Inter Press Service - June 22, 2009
Servaas van den Bosch interviews THOMAS WALSH, PEPFAR coordinator

At the annual HIV/AIDS Implementer's Meeting in Windhoek, Namibia, held Jun. 10-14, global AIDS coordinator of the President's Emergency Fund for Aids Relief (PEPFAR), Tom Walsh looked for a way to cut costs in Southern Africa and still keep the pressing commitment to the two million HIV-positive Southern Africans for whom PEPFAR is financing antiretroviral (ARV) treatment.

IPS: In 2008, the U.S. Congress approved an increase in PEPFAR funding from $15 billion in the period from 2004 to 2008 to $48 billion in the period from 2009 to 2013. That translates to almost $10 billion a year. However, the budget for 2010 stays stagnant at $6.1 billion. Why?

Thomas Walsh: The global financial crisis is affecting our budget. Although there's a $165 million increase to $6.1 billion for 2010, we will definitely not be able to grow as exponentially as before.

Anyone we put on antiretroviral treatment will stay on. But otherwise, we don't yet really know what the impact of this is until we finish the calculations.

We might have to be more selective. In that case, orphans and vulnerable children (OVCs) living with HIV/AIDS will be a first priority. We also will have to work more efficiently.

IPS: Where do you intend to cut costs?

TW: A lot of money can be saved by governments and partner organisations that receive PEPFAR funds, for instance through cutting overheads, but also by changing national policies.

It's unnecessary that every medical intervention, such as prescribing ARVs, involves a physician with a relatively high salary. A lot of work can be done by nurses or trained community members.

Or, take for example South Africa's law that prohibits the registration of generic ARVs. If such laws are overturned, drug procurement will become much cheaper. Since PEPFAR funds many of these activities directly or indirectly, it will save us money.

IPS: PEPFAR has been criticised for its emphasis on abstinence and faithfulness. Has this approach failed in Southern Africa?

TW: I don't think you can argue that abstinence is not effective against infection or that married men shouldn't be faithful. It's obvious that having multiple partners is a catalyst for spreading HIV. It's really necessary to reign in that kind of behaviour.

Condoms can be effective, but they are only 90 percent effective.

The 2008 Act [Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorisation Act of 2008] that governs the second phase of PEPFAR requires us to spend up to a third of our budget for prevention on promoting abstinence and faithfulness.

But we have also realised that we need to be more flexible in this approach. Epidemics vary per country, and in some places better results are reached with providing condoms on a wide scale.

What we will not do is hand out condoms to learners under the age of 14. We don't think that's for us. But there are other organisations that do this.

IPS: What Is PEPFAR's budget for prevention, and how is it calculated?

TW: Prevention is 29 percent of our total budget. Universal access to treatment is great, but it means more people with HIV/AIDS will keep on living.

Moreover, the reservoir of chronically-ill people requiring treatment is constantly fuelled by the extremely high rates of HIV infection in the SADC [Southern African Development Community] region. It's obvious that the costs for the health systems will become unbearable at some point.

IPS: Why is PEPFAR present in some SADC countries and almost absent in others that are equally or more affected by HIV?

TW: We have realised that, epidemiologically speaking, this doesn't make sense. In Lesotho and Swaziland, PEPFAR was absent because of a lack of US personnel on the ground. In Zimbabwe, I figure there was too much political uncertainty.

PEPFAR is moving to a different way of operating where we sign comprehensive frameworks with existing and new partners. These include agreements on good governance, policy reform and financial commitments.

Malawi and Swaziland have just signed one. Lesotho will follow soon and Zimbabwe's power-sharing agreement has also made it eligible for assistance.

IPS: Organisations that receive PEPFAR funding have to publicly denounce prostitution. Why?

TW: It's because the US government does not want to fund organisations that promote the legalisation of prostitution. It doesn't mean recipients can't address the needs of commercial sex-worker populations when it comes to HIV/AIDS. They can and they should.

The pledge is part of the law that governs us, but I agree it's controversial. Is it enforced by PEPFAR? Let me say this, we cannot give you money without that signature on the dotted line, but there is no further inquiry from our side.

IPS: What have been PEPFAR's key successes in Southern Africa?

TW: In the past five years, we exceeded our targets, put 2.1 million people on ARVs and provided support for ten million infected and affected people, including OVCs, mostly in Africa.

The president has granted an extension until 2014, but after that anything is possible. We need to focus now on strengthening healthcare systems, not just dropping pills on parachutes in peoples' waiting open mouths. That also means that it's unacceptable if health budgets of countries that we support stay stagnant.

It will not be easy to turn this pandemic around, modifying human behaviour never is, and some cultural practices have been around a lot longer than AIDS.

*****

+ AFRICA: Global Financial Crisis Leads to HIV Budget Cuts

+ MOZAMBIQUE: Scant Progress With Paediatric HIV

+ LESOTHO: Cultural Beliefs Threaten Prevention of Mother-Child HIV Transmission

+ SOUTH AFRICA: Bringing HIV Testing Where It's Needed

090622
IP090609

Copyright © 2009 - Inter Press Service. All rights reserved. Reproduced with permission. Reproduction of this article (other than one copy for personal reference) must be cleared through the Inter Press Service, IPS-ONLINE, World Desk via Panisperna 207 00184 Rome, Italy. Email: info@ips.org  http://www.ips.org

AEGiS is a 501(c)3, not-for-profit, tax-exempt, educational corporation. AEGiS is made possible through unrestricted funding from the National Library of Medicine, AIDS Walk of Orange County, and donations from users like you.

Always watch for outdated information. This article first appeared in 2009. This material is designed to support, not replace, the relationship that exists between you and your doctor.

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 2009. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content. .