PEPFAR: Beware of Americans Bearing Gifts

Feeling at first a little disgruntled that my editor here at RH Reality Check had asked if I could write about the effect of PEPFAR on other donor countries (what does US policy have to do with Europe, and why do I have to write about the USA, I wondered), I contacted European experts for their thoughts on PEPFAR. I'm glad I did — it turns out PEPFAR has deep and lasting impacts on both other donor nations and, obviously, on its target countries. My interviewees' comments are worth quoting in full.

This from a spokesperson at the International Planned Parenthood Federation's Central Office in London:

"PEPFAR's impact on the policy or programs of other donors is difficult to ascertain. There were very real concerns that other donors might downscale their efforts or pull out of countries in receipt of PEPFAR funding, which many feared would severely undermine the response to HIV and AIDS because of PEPFAR's dangerous ideological restrictions on working in critical areas or with certain groups and individuals. If anything, what has happened is that more progressive donors, including European donors, have changed their focus in PEPFAR countries and are concentrating their efforts on areas, particularly in HIV prevention, where PEPFAR has put serious limitations on the use of funds for evidence based programming, e.g. needle exchange, comprehensive HIV prevention including condoms, working with vulnerable groups such as sex workers or injecting drug users. These donors had always worked in these areas and have just increased their work, almost as a counter-balance to the in-built gaps in PEPFAR.

"The inherent danger is that if donor harmonization does not happen at country level, creating parallel systems, as PEPFAR does, severely undermines efforts to maintain a comprehensive approach to HIV programming. Due to the sheer level of money being committed at country level by PEPFAR it has managed to influence country level decisions on how to use HIV funds in spite of other donors."

Neil Datta, who runs the European Parliamentary Forum On Population and Development in Brussels, takes a harder line:

"PEPFAR has very little if any impact in Europe – it is people in developing countries who will suffer. European donors are all moving in a direction of harmonizing their aid in accordance with internationally agreed principles, such as the Paris Declaration on Aid Effectiveness, where aid should be based on these five principles:

1. OWNERSHIP: Developing countries will exercise effective leadership over their development policies and strategies, and will coordinate development actions;

2. ALIGNMENT: Donor countries will base their overall support on recipient countries' national development strategies, institutions, and procedures;

3. HARMONIZATION: Donor countries will work so that their actions are more harmonized, transparent, and collectively effective;

4. MANAGING FOR RESULTS: All countries will manage resources and improve decision-making for results; and,

5. MUTUAL ACCOUNTABILITY: Donor and developing countries pledge that they will be mutually accountable for development results.

"The abstinence-only earmarked funding in PEPFAR goes against modern principles of effective aid. The developing countries have not asked for American abstinence funding, abstinence-only approaches have no effect in the developing world where a significant percentage (in some cases up to one third) of sexual initiation among young girls is coerced or forced and abstinence-only approaches are in themselves disempowering of vulnerable groups, thus undermining other donors' efforts. Finally, the earmarked funding for abstinence-only programs casts in a negative light the otherwise noble and important efforts of PEPFAR, for example, in making a significant contribution to malaria eradication and providing HIV/AIDS treatment."

Chris McCafferty MP, and Chair of The UK All Party Parliamentary Group on Population, Reproductive Health And Development, describes PEPFAR as giving HIV and AIDS organizations two choices.

"They can either continue the work they are doing which they know is right and working. Or they can take the [PEPFAR] funding and not do that work. The regulations that PEPFAR imposes on recipients of its funds inhibits a fair assessment of what relevant organizations are achieving, and is detrimental to existing evidence based programs and projects."

Health systems expert David Daniels, who is a Director at YozuMannion Ltd, argues: "[Donors] have a duty to maintain their promise and commitment to providing ARVs. We have to continue doing that. But if you don't support preventive work, the conclusion is obvious. The spread of HIV and AIDS will increase, especially within the poorest communities around the globe. Yes we need lots of money to tackle HIV and AIDS, but that money can't be restrictive and ignore prevention."

Steve Cockburn, Co-ordinator of the STOP AIDS Campaign, the campaigning arm of the UK Consortium On AIDS & International Development, picks up on the actual amounts of money being talked about. "If Congress does agree to an increase to 50 billion for PEPFAR, and that money is delivered correctly then it would be a dramatic contribution. But the fairly unanimous feeling amongst HIV and AIDS organization in the UK is that current PEPFAR funds are – to an extent – being wasted. There is evidence at country level that PEPFAR funding is having a detrimental effect in its current prohibitive state."

The USA remains an important international donor, if nothing else for the sheer scale of its contributions. However, the strategies that currently guide the US's contribution through PEPFAR remain more political than practical, and more prescriptive than empowering. PEPFAR was and remains an opportunity for vital interventions. In its current state that intervention is severely compromised.

See all of RH Reality Check's extensive PEPFAR coverage.

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  • invalid-0

    A really serious downside of providing money on the sheer scale that PEPFAR does is that it massively distorts incentives in the countries it seeks to help. The best and the brightest get sucked into PEPFAR programmes. Because the US will not give money to other goverments directly, this means that smart people get winkled out of government, further undermining the capacity of countries to take charge of their own problems.

    In addition, people get sucked towards AIDS from other health and development priorities which in many countries, especially in West Africa and Asia, are greatly more pressing than HIV.

    The 2003 PEPFAR manifesto openly declares that it will try and bend international institutions to the will of the Bush administration, and they’ve been true to their word. There’s been huge pressure on UNOCD and others to support the administration on harm reduction, for example. European donors have for the most part stood firm, but these battles waste time, energy and money, and undermine the already weak will of many developing countries to spend money on drug injectors, the sex industry and gay men. The influence of PEPFAR is so great that many of us think it should be renamed.