An Enduring Obligation

On Wednesday, President George Bush signed into the law the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008. This extends PEPFAR – the President’s Emergency Plan for AIDS Relief – by five years and increases funding levels to just under $10 billion a year, with $8 billion earmarked for HIV/AIDS treatment, care and prevention in severely affected countries, most of them African.

The dollar amounts remain notional at this point.  The funds have been “authorized” in Washington-speak; they have not been “appropriated”. In other words, they are still whimsy.  They have not been added to the budgets of the relevant agencies. That will require more politics. Muddying those politics is the growing realization that the American taxpayer has acquired a long-term obligation.

This obligation, quite unprecedented, is to millions of Africans infected with HIV who are being kept alive with anti-retroviral (ARV) drugs the American taxpayer has purchased and must now expect to keep on purchasing.

AIDS is a chronic disease. There is no cure.  Stop treatment, patient dies. The Bush administration claims that some 1.7 million patients are currently receiving treatment under PEPFAR. Ethically, it would be hard for the US to walk away without some guarantee that treatment will continue on someone else’s dime. But whose?

To use another piece of local argot, PEPFAR has created an “entitlement” – an expenditure to which the recipient is “entitled” regardless of any other budget priorities. That, at least, is how Mead Over, an analyst at the mainstream Centre for Global Development in Washington, sees it

In the US, there are only two kinds of budget outlays, “entitlements” and “discretionary”. The former include the major social and corporate welfare programmes, but not defense. The latter, absent a healthy appetite for deficit spending or a war, is an ever-shrinking piece of the pie. Never before has the US granted an entitlement to a foreign party. This one promises to be costly.

Over has crunched the numbers, looking at the 15 PEPFAR “focus” countries, which include SA. There are a lot of variables.  How many new patients will PEPFAR and its extension bring onto treatment? Will the population of freshly infected in need of treatment continue to grow, or will incidence decline? By how much, either way? How quickly will patients need to move from relatively inexpensive first line ARV treatments to dearer second line regimens?

Over’s least costly scenario posits that the US will continue to fund treatment for around 18 per cent of those who need it in the focus countries – the current rate – while the number of new infections in each country will decline dramatically, by around 90 per cent annually. Price tag in constant 2006 dollars: $7.3 billion over the first term of the president inaugurated next January, $13.2 billion over his second term.

On the other hand, treat nearly everyone – 95 per cent of those in need – while incidence declines by a more realistic 5 per cent a year and, on Over’s reckoning, the costs balloon: $18.6 billion between 2009 and 2012, $37.3 billion between 2013 and 2016.

However you do the math, the open-ended commitment that ARV treatment implies will take money away from other things, very likely including prevention, care, training and improving health care systems, not to mention other development priorities.

Over himself is concerned not only about such crowding out; he fears the US will use the leverage it derives from having the power of life and death over African AIDS patients to demand geopolitical obedience from their governments.  Blackmail.

The Washington Post ran a piece last Saturday, “AIDS Funding Binds Longevity of Millions to US”.  The Web version triggered scores of angry comments.  Let ‘em die was the general thrust.  Millions of Americans live in terror of getting sick because there is no reliable safety net.  Commenters wanted to know why the $48 billion Congress had just authorized primarily for AIDS in Africa was not being spent to make medicine more affordable at home.

In crafting politically and economically sustainable approaches to HIV/AIDS, the dialogue between donors and recipients needs to get a lot deeper.

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