On January 20, President Obama will inherit many challenges, among them the global AIDS epidemic.  He will also inherit the President’s Emergency Plan for AIDS Relief (PEPFAR), a program often cited as the hallmark of the Bush Administration’s otherwise contested international legacy, providing anti-retroviral therapy to an estimated 2 million people worldwide in its first five years. 

For Obama, PEPFAR presents both opportunities and challenges.  On one hand, the 2008 bill authorizes spending of up to $48 billion from 2009 through 2013, allowing dramatic increases in funding for treatment and care, orphans and vulnerable children and youth, and prevention of maternal-to-child transmission, among other programs. 

On the other, several controversial policies originally supported by the Bush Administration remain in place and unless fully addressed will continue to undermine efforts to stop the spread of HIV, by denying critical services to the most vulnerable, blocking effective integration of health services, and failing to effectively address the social and economic roots of this pandemic.   

The good news is: Some of these problems are remarkably easy to change at little if any cost.  By taking the following steps soon after inauguration, President Obama can initiate the change PEPFAR needs, ensuring we simultaneously save more lives and strengthen health systems while making the best possible use of scarce public dollars. 

Appoint a Global AIDS Coordinator who "gets it."  Throughout the campaign, Michelle Obama assured us that Barack Obama "gets it" regarding the problems faced by this country both here and abroad.  President Obama also needs to appoint a Global AIDS Coordinator who gets it.  For too long, PEPFAR has been driven by a highly medicalized approach to an epidemic fueled by gender, social and economic disparities and by stigma and discrimination.  A critical first step for the new Administration is to appoint a Coordinator who clearly understands these dynamics, who embraces both the public health and human rights dimensions of risk and disease and who recognizes that sex and sexuality are normal attributes of being human.  There is of course a need for excellence in delivery of medical services and a critical role for medical–as well as social science, public health, and human rights–experts to create and oversee effective programs.  But to end the epidemic we need to go beyond a medical model, and that means appointing a Global AIDS Coordinator who–no matter their background–can provide strategic vision from the top.

Talk about sex.  It’s time for "the talk."  President Obama must break the taboo perpetuated under PEPFAR and talk about the role of safer sex in prevention.  Today, unprotected sex is the single most important factor in the spread of HIV worldwide and is responsible for 80 percent of new infections in sub-Saharan Africa.  Unfortunately, current law still restricts prevention funding in ways that severely limit evidence-based and cost-effective approaches.  Talking about safer sex will help break the stalemate of the past several years.  Beyond real talk, however, President Obama also should immediately direct OGAC to support flexible interpretations of requirements in the law affecting spending on "abstinence and be faithful" programs, ensuring that these are component parts of comprehensive approaches to prevention and not ineffective stand-alone strategies.  We need to foster creative approaches that produce measurable outcomes-such as an increase in delay of sexual debut, reduction in the number of sexual partners, increases in the use of effective negotiation skills among couples, and correct and consistent condom use.  And we need to achieve these outcomes through a range of behavioral tools and interventions that fit the needs of the populations at risk.  Interpreting the law flexibly while working to rid the law of these restrictions altogether will make our prevention dollars go further.  These and other recommendations can be found in the transition document created by the Prevention Working Group of the Global AIDS Roundtable. 

To stop the spread of HIV, however, PEPFAR must go still further.  Funding should be available under PEPFAR to support programs that equip all individuals–young, old, male, female, married or unmarried–with the education, information, skills and methods necessary to engage in sexual relations only when these are truly consensual and mutually responsible.  We have to move beyond the formulaic "ABC" approach and away from the "abstinence versus condoms," debate as if either abstinence or condoms alone were sufficient to ensure healthy sexual lives. Instead, President Obama should make clear his administration’s support for synergistic strategies focused on achieving outcomes ranging from ending child marriage and reducing gender-based violence to increasing the number of people who use male and female condoms correctly and consistently-all as part of HIV prevention strategies.  Gender-disparities, violence, and lack of power in sexual relationships are the very drivers of this epidemic and by extension the keys to ultimate success in stopping the spread of HIV.  If we are serious about ending this epidemic, we have to to be serious about tackling these issues within and across prevention and treatment programs.  By talking the talk, and giving strong signals about his support for new, more effective approaches, President Obama will ensure accelerated success in the fight against AIDS.   

Remove legal and policy restrictions that increase stigma and discrimination against already-marginalized groups.  In many countries around the world, including Vietnam, Russia, Georgia and China, injection drug use is the primary driver of HIV/AIDS.  In virtually every setting, stigma and discrimination further isolate injecting drug users, dramatically increasing their vulnerability to HIV infection, conditions that have sometimes been perpetuated by our own policies.  For example, the United States has refused to fund–and has lobbied other governments to eliminate support for–"harm reduction" efforts such as needle exchange programs for drug users.  Overwhelming evidence shows that such programs are the most effective way to stop the spread of HIV in this population.  Indeed, most experts agree that scaling up needle and syringe exchange is essential to arresting the epidemic.  Preparations are now underway for an international meeting in early spring at which US support for evidence-based approaches to harm reduction will send a critical signal regarding a new era in U.S. policy.  Some advocates, however, fear the new Administration won’t have time to affect the outcome and that the U.S. position will therefore default to that of the current administration.  Both Obama and his transition teams need to ensure their views on this are heard now so the U.S. government does the right thing this spring and beyond.   

Likewise, the President must act swiftly to mitigate the effects of the prostitution pledge, which has resulted in loss of funding for some of the most successful programs working to improve the health and human rights of sex workers, among the most marginalized groups in any society.  U.S. global AIDS law requires recipients of PEPFAR funding to have a policy opposing prostitution.  In August 2008, a federal court found it unconstitutional to compel groups to adopt the U.S. government’s position.  It also determined that existing guidelines did not provide for exercise of free speech rights including the right not to have a position at all.  Ultimately, this part of the global AIDS law should be struck.  More immediately, however, President Obama should instruct USAID and HHS to immediately revise their guidelines as applied to both domestic and foreign NGOs to comply with the Court ruling and allow for the most effective groups to partner with the United States in the fight against AIDS.  

Integrate essential services.  In 2005 and 2006, during several trips to Kenya, Nigeria, Tanzania and Uganda, it was clear to me that PEPFAR was actively if quietly discouraging integration of HIV prevention with primary reproductive health programs on the ground, including maternal health and family planning services.  This made no sense: For one thing, the roles of sexual and maternal-to-child transmission in the epidemic make clear HIV *is* a sexual and reproductive health issue.  In sub-Saharan Africa, for example, women make up the majority of those infected.  Indeed, complications of pregnancy, labor, and unsafe abortion are rivaled only by AIDS-related illnesses as a cause of death among women ages 15 to 49 in many countries in the region.  The indivisible rights of women–whether HIV-positive or negative–to make decisions about whether, when, and with whom to have children; to access HIV prevention, family planning, maternal and child health and related services; to be able to plan their pregnancies; and to ensure they are able to practice protected sex are fundamental to ending the AIDS epidemic.  Yet these conditions do not exist in part because access to services has deteriorated during years of US restrictions on funding for strengthening this most basic aspect of health systems.  PEPFAR’s previously unofficial policy of discouraging or providing anemic support for integration was recently made worse by new guidance prohibiting the purchase by PEPFAR of contraceptive supplies.  President Obama can remove these obstacles by calling for immediate elimination of this guidance, and instructing OGAC to promote wherever necessary the integration of relevant HIV and AIDS services with broader reproductive and sexual health services.  For these and other reasons, he must also strike the global gag rule and restore funding for the United Nations Population Fund.  

Create a climate of constructive questioning, critique and creativity.  There is no disputing that the United States made an unprecedented commitment to global health by creating PEPFAR and has saved many lives under this program.  However, for much of the past 5 years, critiquing PEPFAR has been seen as tantamount to being unpatriotic.  The reality is that any program that allocates huge sums of money–whether $15 billion or $50 billion–will have positive and negative aspects.  Vigorous and open debate are necessary for the evolution of effective laws and policies and for ensuring accountability for the billions of taxpayer dollars being spent.  President-elect Obama has promised–and has already begun to walk the talk on–a culture of transparency in government.  The new Coordinator should foster a similar culture of transparency, debate and review in the next phase of PEPFAR, including voices from a wide range of civil society actors, whether funded by PEPFAR or not.  In doing so, we can work together to achieve the shared goal of ending the AIDS epidemic.

President Obama must take action on these issues soon after inauguration.  Time is of the essence because 2010 country operating plans for PEPFAR funding are already being drafted and must be approved by early summer. Country missions can use greater flexibility to make great progress on prevention using the next round of funding. These are by no means the only course corrections necessary to fulfill the ultimate vision of PEPFAR–ending the AIDS epidemic.  But each of these steps can be taken by President Obama early in his Administration, at little cost but with huge gains politically, financially, and ultimately measured in millions more lives saved.