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PEPFAR Critics Get the Knives Out

There is a report from the Center for Public Integrity that suggests that less than 5% of PEPFAR money for ARV therapy–less than $15 million–in 2004 and 2005 was spent on generic drugs, despite the fact the Bush Administration has put into place an expedited FDA approval process for generics. As part of this series, the Center is also reporting how it took Freedom of Information Act requests and a lawsuit to get at this and other data. One of the other bits of disturbing news in this reporting is that:

the proportion of money in focus countries going for prevention has fallen by more than a third over the first three years of the program, from 34 percent of the total PEPFAR budget in 2004 to 22 percent this year.

Another likely controversial bit in the piece is the following on unqualified faith-based groups getting PEPFAR money:

Critics say that some PEPFAR-funded groups lack the know-how to run HIV programs. In one instance, a politically well-connected U.S. faith-based group, Children’s AIDS Fund (CAF), was found by an expert panel of reviewers to be “not suitable” for PEPFAR funds, according to published reports. But this finding was overruled by the then head of USAID, and the group was awarded a $10 million grant anyway to run abstinence-centered programs in Uganda, Zambia and South Africa. The president of CAF, Anita Smith, a longtime vigorous promoter of abstinence programs, has been the co-chairwoman of President Bush’s Advisory Council on HIV/AIDS.

Having heard Mark Dybul recently defend PEPFAR against the charge that ARV therapy money is only going for generics, I’m worried that this is true. I’m also a little suspicious that this center has a particular axe to grind against the Bush Administration’s approach. While I agree that an ideology-based program could be very bad, and the piece provides some additional anecdotal evidence of pressure to focus on abstinence in the field, discussions I’ve had with some folks suggest that programs in the field are pragmatic and are willing to countenance the use of condoms as part of a mixed prevention strategy. It’s not clear that a purely condom-based program will work on its own, since people tend not to use them all the time. While the piece cites Thailand’s experience, particularly in the prostitution sector, the nature of the epidemic with more broad-based diffusion of the disease, is very different.

I certainly don’t want to be an apologist for a program that doesn’t work, but I also worry that we have to look at this with less than a jaundiced eye. If the data ultimately show PEPFAR is not working or is skewed in the ways this report describes, I will concede I’m wrong. In the meantime, I think this piece needs to be complemented by better information. To the extent that the Administration has withheld information that could demonstrate that these charges are untrue or missing the point, they are doing themselves a disservice by dragging their feet on FOIA requests.

POSTSCRIPT: Here is a recent November 2006 Boston Globe piece which suggests that the Center for Public Integrity folks may not be right for long…

Based on the first three months of this fiscal year, 70 percent of antiretroviral drugs bought in Nigeria, Haiti, and Zambia are expected to be generic. Last year, just 11 percent of AIDS drugs in the program’s 15 countries were generics. The figures for this fiscal year will not be available until January, but senior US officials predict substantial increases in generics across the program.

Dybul said 14 of 15 countries in the program now were buying generic drugs. Officials declined to name the country that was not because of sensitive negotiations underway to purchase generics there.

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