President’s Emergency Plan for AIDS Relief (PEPFAR):
Mailman School of Public Health Faculty Address Criticisms, Accomplishments, and Future Directions in New England Journal of Medicine Perspective

July 30, 2008 -- A commentary published in the July 30 on-line edition of the New England Journal of Medicine by Wafaa El-Sadr, MD, MPH, professor of clinical medicine and epidemiology and director of the International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University’s Mailman School of Public Health, and David Hoos, MD, MPH, assistant professor of clinical epidemiology at the Mailman School and an ICAP director, provides their perspectives on the criticisms, accomplishments, and possible future directions of the President’s Emergency Plan for AIDS Relief (PEPFAR), one of the largest international health-assistance programs in history. Launched in 2004 to combat the global HIV epidemic, the program was recently reauthorized for an additional five years and its funding more than tripled to $48 billion.

In the commentary titled “The President’s Emergency Plan for AIDS Relief – Is the Emergency Over?,” Drs. El-Sadr and Hoos describe the criticisms raised about PEPFAR since its inception. They include PEPFAR has focused on HIV/AIDS treatment while most previous efforts had emphasized prevention. In addition, infrastructure and systems within target countries would not be able to deliver treatment. PEPFAR also has been criticized for being too narrowly focused on a single disease and for utilizing a single donor-driven structure and strategy.

Despite these criticisms, Drs. El-Sadr and Hoos point to a number of significant accomplishments. As of March 2008, 1.6 million people were receiving treatment through PEPFAR-supported programs – a 10-fold expansion of access to treatment in less than five years. One of PEPFAR’s largest implementing partners, ICAP currently supports HIV/AIDS programs in 14 resource-limited countries, primarily in sub-Saharan Africa, that are providing HIV services to more than 508,000 people, including life-saving antiretroviral therapy to more than 232,000 people.

Drs. El-Sadr and Hoos cite other potential PEPFAR accomplishments that extend beyond its support for HIV programs, particularly its potential benefits to wider health systems. They argue that some of the systems established in support of HIV programs can form the foundation for systems to help address other chronic conditions that are often neglected in resource-limited countries.

According to Drs. El-Sadr and Hoos, PEPFAR’s future direction revolves around the debate over whether the program should be transformed from an emergency plan focused on HIV prevention and treatment to one that focuses on strengthening health care systems in general, and addresses social and economic factors that play a key role in fueling the epidemic.

The authors write, “The key choice for PEPFAR at the crossroads is between a “pull” strategy and a “push” strategy: Will a continued singular focus on HIV “pull” other components of national healthcare systems forward, so that they become more responsive to other health threats and can catalyze the necessary changes in social norms and policy? Or will a “push” strategy that is focused primarily on strengthening healthcare systems and tackling fundamental issues that define societal vulnerabilities to disease be more effective in achieving both HIV-specific and broader health and social goals?”

Given that only 37 percent of the people in need of treatment in the 15 PEPFAR focus countries are receiving such treatment, Drs. El-Sadr and Hoos believe PEPFAR’s key challenge will be “to maintain its sense of urgency and its razor-sharp focus on results,” while working towards strengthening systems in general. They conclude, “The advances have been dramatic, but much remains to be done.”

With more than 700 employees worldwide, ICAP currently supports 523 health care facilities and 319 laboratories providing HIV services. ICAP-supported sites have provided HIV counseling and testing services to more than 258,000 pregnant women. For more information, visit the ICAP website at www.columbia-icap.org.

To access the paper, visit www.nejm.org.

About the Mailman School of Public Health
The only accredited school of public health in New York City, and among the first in the nation, Columbia University's Mailman School of Public Health provides instruction and research opportunities to more than 1000 graduate students in pursuit of masters and doctoral degrees. Its students and more than 300 multi-disciplinary faculty engage in research and service in the city, nation, and around the world, concentrating on biostatistics, environmental health sciences, epidemiology, health policy and management, population and family health, and sociomedical sciences. www.mailman.hs.columbia.edu