Eran Bendavid, an infectious diseases and health policy fellow at Stanford University, and Jayanta Bhattacharya, associate professor of medicine at Stanford, used data compiled by UNAIDS to examine HIV/AIDS data in sub-Saharan Africa (Chase, Bloomberg, 4/6). They examined the period prior to PEPFAR's launch -- 1997 to 2002 -- and the period during PEPFAR's implementation -- from 2004 to 2007. The researchers compared HIV/AIDS-related mortality and prevalence among residents of 12 PEPFAR focus countries with residents of 29 other sub-Saharan African countries that did not receive PEPFAR funds (Steenhuysen, Reuters, 4/6). The PEPFAR countries examined were Botswana, Cote d'Ivoire, Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda and Zambia. The researchers did not include Guyana, Haiti and Vietnam -- three non-African countries receiving PEPFAR funds -- in their analysis (Bloomberg, 4/6).
According to the study, both the countries receiving and those not receiving PEPFAR funding had similar HIV/AIDS-related mortality rates during the period prior to PEPFAR's launch. After the target countries began receiving PEPFAR funds, the researchers found that mortality rates decreased by about 10.5% in the PEPFAR countries, compared with the non-focus countries. The researchers also estimated that the program helped prevent about 1.1 million AIDS-related deaths (Reuters, 4/6). According to the New York Times, antiretroviral treatment provision accounts for about half of PEPFAR funding (McNeil, New York Times, 4/6). The study also found that PEPFAR's cost per death averted was $2,450 between 2004 and 2007.
According to Bendavid, the study demonstrates that PEPFAR has allocated "a lot on treatment and treatment has worked" (Bloomberg, 4/6). Mark Dybul, former U.S. Global AIDS Coordinator and PEPFAR administrator, said that it is "great news that even in the first three years [of PEPFAR], the American people supported the saving of more than a million lives" (Dinan, Washington Times, 4/7). Peter Piot, former executive director of UNAIDS, added that the program "is changing the course of the AIDS epidemic." Piot said, "People are not dying. That is spectacular." However, he added, "The irony -- and it is a positive irony -- is that the more people are staying alive, the higher the percentage" of people living with HIV will be. According to Bendavid, any increase in HIV prevalence "probably reflects the decreasing death rate and may have several public health spillover benefits." For example, HIV-positive adults who live longer lives "may be able to support their children and dependent elderly family members, reducing the burden of orphans and elderly care" (Bloomberg, 4/6).
Despite the study's promising findings, challenges remain for reducing HIV/AIDS prevalence in high-burden countries, the researchers said. For example, as increased treatment distribution allows more HIV-positive people to live longer, the cost of providing treatment to the affected population will increase. According to the study authors, "The gap between the available funds and those needed will continue to increase unless the incidence of HIV in Africa is substantially reduced" by "striking the right balance between treatment and prevention."
According to the authors, about 20% of PEPFAR funding was allocated to prevention under the Bush administration, with about one-third earmarked for abstinence-only efforts (Reuters, 4/6). When Congress reauthorized the program in 2008, the abstinence provision was removed. Bendavid said that the challenge will be to make prevention a "serious component of the program in the next five years" (Bloomberg, 4/6). Smita Baruah, government relations director for the Global Health Council, said that although PEPFAR initially focused on treatment, it should now expand its focus to prevention. She said, "As you move from emergency to sustainability, it's not going to work just to treat your way out of the infection. You now need to figure out how do we prevent new infections" (Washington Times, 4/7). According to Bendavid, "You need to reduce the number of new people infected by at least as many as the number of people you're keeping alive" (Bloomberg, 4/6).