PEPFAR MythBusters: Episode Two

Yesterday, I blogged about how PEPFAR's Third Annual Report to Congress reveals that the United States is not doing as much on treatment in the 15 focus countries as many believed it was. I combated the myth that PEPFAR (the President's Emergency Plan for AIDS Relief) is providing treatment for 822,000 people.

Today, I combat another treatment myth—that generics account for 70% of PEPFAR's expenditure on anti-retroviral AIDS drugs. And I take issue with the argument that since the abstinence-until-marriage spending requirement is "only one-third of the prevention budget, it really isn't that big of a problem."

Myth: Generic drugs now make up 70% of the PEPFAR expenditure of ARVs (antiretroviral drugs).

Reality Check: In FY2006, generics accounted for 27% of the money spent by PEPFAR in the 15 focus countries on antiretroviral drugs.

Where did the myth come from? From unclear charts in a PEPFAR report in May of 2006.

In May 2006, PEPFAR released a report entitled Bringing Hope: Supplying Antiretroviral Drugs for HIV/AIDS Treatment. Figures on pages 9 and 10 indicate the percentage of "FDA-approved generic products" of total procurement in the focus countries. The figures show this number to be 70%. A footnote for the chart on page 9 says that "FY06 data represents a limited sample of four respondents." The larger chart on page 10 includes no such footnote, so anyone looking only at that chart (which is also easier to read for many people because it's a pie chart instead of a line graph) would not know that the 70% figure represented only four "respondents."

(It's not clear from the footnote or the surrounding text whether "respondents" means countries or programs in countries. However, a chart on page 10 of Bringing Hope, shows generic drugs percentages for three countries—Haiti, Nigeria, and Zambia—and these are the three countries that a November 2006 Boston Globe article reported as having 70% generics.)

Poorly footnoted figures aren't the only thing to blame for the confusion on generics numbers. There is also the issue of what the numbers are a percentage of. That is, what "total procurement" are we talking about? And that's a question I can't figure out the answer to based on the information in the reports. The figure that included 70% was based on a "total procurement" of the ARVs pot that was expected to be $279 million for FY06 (see page 1 of Bringing Hope). However, the numbers in the annual report (where the 27% generics number came from) indicate that PEPFAR spent $109.8 million in FY06 (fiscal year 2006) to procure ARVs.

While there are certainly questions to be answered about what that 70% figure really referred to, the fact of the matter is that for more than half a year advocates and the media praised PEPFAR for its major scaling up of generic drugs in the programs it is funding. The 2007 annual report to Congress shows that the "major scale-up" has not been very major. The U.S. is only spending 27% of its spending on antiretroviral drugs on generic drugs.

Myth: "Abstinence-until-marriage is only a third of the prevention budget so it's not that big of a problem."

Reality Check: As CHANGE (Center for Health and Gender Equity) has said for some time now, the question shouldn't be what percentage of the total prevention budget is going to abstinence-until-marriage programs but what percentage of the budget for the prevention of the sexual transmission of HIV is going to abstinence-until-marriage programs. Since 40% of the prevention budget in FY2006 went to preventing the non-sexual transmission of HIV (prevention of mother-to-child transmission and preventing the medical transmission of HIV), this is a crucial distinction.

In FY2006, one-third of the total prevention budget went to meeting the abstinence-until-marriage earmark and those programs represented 56% of the prevention of sexual transmission budget. Other programs to prevent the sexual transmission of HIV accounted for just 44% of the budget for the prevention of sexual transmission of HIV and just 27% of the total prevention budget.

PEPFAR refers to this other prevention of sexual transmission money as "Condoms and Related Prevention Activities," however this is a misnomer intended to mislead Congress, the media and members of the advocacy community. Footnote number 2 on page 38 of the annual report explains briefly what that category includes:

"Examples include mass media and community outreach programs to promote avoidance of or reduction of HIV risk behavior, community mobilization for HIV testing, and the social marketing or promotion of condoms, including work with high-risk groups such as injecting drug users, men who have sex with men, people in prostitution and their clients, and people living with HIV or AIDS."

So, the category "Condoms and Related Prevention Activities" actually includes a lot of programs that aren't condom education and distribution or even necessarily related to condoms. Also, the U.S. requires that …

"… [f]or programs that include a ‘C' component, information about the correct and consistent use of condoms must be coupled with information about abstinence as the only 100 percent effective method of eliminating risk of HIV infection; and the importance of HIV counseling and testing, partner reduction, and mutual faithfulness as methods of risk reduction."

(That's from the PEPFAR ABC Guidance.)

So, whereas it has been argued that the earmark is only one-third of prevention money, we see that when taken as a share of prevention of the sexual transmission of HIV (which is all abstinence-until-marriage is used for), abstinence-until-marriage programs (which are really abstinence-only-until-marriage programs) account for 56% of funding. Only 44% of the budget for prevention of the sexual transmission and 27% of the total prevention budget goes to non-abstinence-only-until-marriage responses to the sexual transmission of HIV even though sexual transmission accounts for 80% of all new HIV infections.

Intrigued by my reporting on the PEPFAR report to Congress? Check out for more information about PEPFAR. You can also visit for more of PEPFAR's public reports.

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