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Paradigm shift needed to remedy PEPFAR’s shortcomings

The election of Barack Obama, and larger Democratic majorities in both chambers of Congress, has generated much discussion about how America will re-engage the world. One of the questions people are asking is how U.S. policy on assistance to curb the spread of HIV in countries most affected by the epidemic will change.
While the successes of the President’s Emergency Plan for AIDS Relief (PEPFAR) in the areas of treatment and care have been widely touted, there remain significant shortcomings in the area of prevention. For example, under PEPFAR spending on prevention efforts was limited to a maximum of 20 percent of the overall funding, of which 33 percent were earmarked for the ideologically motivated abstinence-until-marriage programs.  Despite the overwhelming evidence that abstinence-until-marriage programs are ineffective at preventing the transmission of HIV, they remain the cornerstone of the prevention policy. 
As the U.S. response to the global HIV/AIDS epidemic transitions from an emergency framework, with its disproportionate emphasis on care and treatment and funding channeled through large-scale, multinational organizations, to one with an eye towards sustainability, sound approaches are needed to support this shift. This would include a greater balance among the prevention, care and treatments needs, and supporting evidence-based, not ideologically motivated strategies.  Moreover, from the outset, PEPFAR has been guided by a disease-specific medical model in lieu of a broader human rights framework and public health approach. Ending the epidemic requires going beyond the medical model currently driving the U.S. global HIV/AIDS response, and understanding the social complexities – gender inequalities, social and economic disparities and stigma and discrimination– which drive the global HIV/AIDS epidemic. 
Such thinking is slowly emerging during the sunset of the current administration with a new initiative called the Partnership for an HIV-Free Generation. This program links the private sector with the public sector and non-governmental organizations to generate innovative prevention strategies and seeks to reduce the spread of HIV in the population 10-24 years of age by 50% over the next 5 years in the countries where it is being implemented. Partners contributing to HIV-Free Generation build on “PEPFAR’s technical and programmatic capacity with the expertise of the private sector in messaging, branding, new technologies and real-time market research to promote and maintain behavior change.”[i] 
The Pamoja Mtanni PC multiplayer video game created by Warner Bros. Interactive Entertainment is an example of a new, interactive strategy being used to engage youth through HIV-Free Generation. The game seeks to be culturally relevant to Kenyan youth by presenting land and cityscapes to mirror the reality in Kenya and using voiceovers done by pop icons. The game promotes an understanding of behavior changes related to preventing HIV, including delaying initiation of and/or abstaining from sexual activity, increasing correct and consistent condom use and increasing uptake of HIV counseling and testing.
The reauthorization of PEPFAR in August 2008 outlined many of the statutory changes which will modify the landscape of PEPFAR’s impact, but many of the details remain to be created through guidance from the Office of the Global AIDS Coordinator (OGAC). Many global HIV/AIDS advocates are seeking new leadership for the U.S. global AIDS response, someone who can usher in innovative concepts to HIV prevention. The Sexuality Information and Education Council of the United States and the International Women’s Health Coalition drafted a letter, signed by 55 colleague organizations calling for new leadership at OGAC. The global HIV/AIDS pandemic can no longer suffer a leader who can not challenge the failings of ideological agenda set by the current administration.
Bill Smith, vice president for public policy with the Sexuality Information and Education Council of the United States weighed in on the future of PEPFAR and OGAC : “The shortcomings of the PEPFAR reauthorization, particularly in the area of prevention, require new leadership to oversee the changes needed at the implementation level. These range from clarification of guidance to putting in place evidence-based programs. The state of the global HIV/AIDS epidemic can not tolerate more of the same– we need someone who will guide the paradigm shift with innovative thinking and integrity.”

[i]  “Premier Global Companies, U.S. Government Launch Unprecedented Partnership for an HIV-Free Generation: The U.S. President’s Emergency Plan for AIDS Relief Announces Public-Private Partnership for Global HIV Prevention for Youth”, Partnership for an HIV-Free Generation, accessed 15 January 2009,