“Shackles” or “budget allocations”?

On March 30, the Institute of Medicine released a report called, “PEPFAR Implementation: Progress and Promise” which evaluates the initiative’s progress over the last three years. The interpretations of this report have been as mixed as those of the controversial initiative itself:

The New York Times focused on the IOM’s assertion that the fight against AIDS is “hampered” by certain restrictions in the plan, in particular:

1. the requirement that 33 percent of all prevention money be spent on teaching abstinence (and nearly 60% of all money for the prevention of sexual transmission)
2. that the FDA must approve AIDS drugs already approved by the WHO
3. that the program cannot sponsor clean needle exchange programs using taxpayers’ money.
   The article stresses IOM’s call for a more sustainable approach and less emergency response, and ends with the critical fact that at the half-way point of PEPFAR, the program has not met its goals.

The Boston Globe also focused on the obstacles to the US effort to fight AIDS, citing the funding restrictions and the report’s call for greater emphasis on prevention.

The Washington Post took a more positive slant, referring heavily to the reports statements that the program has made a “strong head start” and PEPFAR’s success at treating pregnant women, but also cites the report’s call for less prescriptive budgeting.

So does the IOM’s report “please almost everyone” as the Washington Post says?

Mark Dybul, who oversees the implementation of PEPFAR, was thrilled, welcoming the report as “an endorsement of our program”. In response to the critique on the prevention programs he said “There is no abstinence-only provision. I wish people would stop calling it that. It’s abstinence until marriage.”

According to the New York Times Dybul also disagreed with the report that PEPFAR should pay for clean needle programs. “Needle exchange just continues the condition” Dr. Dybul said. This, of course, contradicts with the Institute of Medicine’s recent review of the effectiveness of needle exchange, and the endorsement of needle exchange programs by the AMA, APHA, the American Academy of Pediatrics and numerous other groups.

While many PEPFAR critics were glad the report highlighted a need for a less “cookie cutter” approach to HIV prevention, tailoring responses to the epidemiology and emphasizing evidence-based approaches, others felt the report pitted prevention against treatment. Gregg Gonsalves said “If one needed more evidence that the pendulum has swung away from access to treatment and back towards the pre-2000 conventional wisdom that poor people can't be and shouldn't be treated with ARVs, the New York Times article today on PEPFAR just confirms” it.

The news coverage also gave little coverage of one of the major findings of the report – that more attention must be paid to factors making women and girls more vulnerable to HIV infection, and that PEPFAR must invest greater in efforts to improve their legal, economic, educational and social status. "We are making the overall recommendation to find ways to empower girls and women and to protect them from sexual harassment and sexual violence," the panel's chairman, Jaime Sepulveda of the University of California at San Francisco, told reporters.

This recommendation led many activists to call for passage of the PATHWAY bill re-introduced by Congresswoman Barbara Lee (D-CA) and Congressman Christopher Shays (R-CT) on March 27. The bill would require all HIV prevention programs funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) to address violence against women and would eliminate the earmark for abstinence-until-marriage programs (Read more).