HIV/AIDS is the scourge of the developing world. An estimated 8,000 people die from AIDS every day. In sub-Saharan Africa there are countries where two out of every five residents are HIV-positive, and the ensuing loss of working-age adults to AIDS threatens progress toward greater political stability and economic prosperity. Too few people recognize that the United States is playing the leading role in fighting—and winning—the war on HIV/AIDS.

January 2006 marks the third anniversary of President Bush’s announcement of a comprehensive program to fight HIV/AIDS. In his 2003 State of the Union address, Bush pledged $15 billion over five years—far in excess of any other donor—to fight the AIDS pandemic globally. Despite the significant funding level of the program and the domestic security concerns of the post-9/11 period, the President’s Emergency Plan for AIDS Relief (PEPFAR) earned rapid bipartisan support in the House and the Senate. Randall Tobias, a former pharmaceutical company executive, was quickly confirmed as the U.S. Global AIDS Coordinator with the rank of ambassador. By early 2004, new money had already begun reaching the people and programs that needed it.

The plan is the largest contribution from any nation in history to combat a single disease around the world. With its concentration on 15 “focus countries”—12 in sub-Saharan Africa, plus Guyana, Haiti, and Vietnam—and programs elsewhere, the plan encompasses clinical, educational, social, and developmental work to help prevent the spread of HIV; care for persons infected or affected by the virus; and treatment for AIDS sufferers. Among other things, funds procure anti-retroviral drugs, lab equipment, and condoms; train and hire medical professionals; renovate clinics and other facilities; and create and expand programs on sexual abstinence, being faithful to one partner, and general HIV/AIDS awareness.

The plan is remarkable for both its scope and its effectiveness: The restoration of health—and hope—to so many has been dramatic. After PEPFAR’s first full year of implementation, an estimated 250,000 people had begun receiving life-extending anti-retroviral treatment. In addition, the plan has drastically increased the number of HIV-negative babies born to HIV-positive mothers and has educated many people, young and old, to embrace less risky behaviors.

We have learned a great deal from these successes. PEPFAR’s use of existing institutions, centralized funding and planning mechanisms, clear targets, and focus on partnership with each country supported by the program constitutes a model for effective and efficient development assistance.


Use of Existing Institutions

The use of existing institutions is a particular strength of the emergency plan. Rather than create a new bureaucratic apparatus, a conscious decision was made to use existing U.S. embassies and appropriate U.S. government agencies’ offices abroad. In places that already had ongoing HIV/AIDS programs, the infusion of PEPFAR money—in some cases increasing funding levels tenfold—vastly increased their effectiveness. In most PEPFAR focus countries, the lion’s share of HIV/AIDS assistance goes through the U.S. Agency for International Development (USAID), which boasts the most experience in providing assistance and a proven apparatus for providing funding, and the Centers for Disease Control and Prevention (CDC), which has the lead in clinical matters.


Centralized Planning and Funding

Once the overall annual budget has received congressional approval, all money for PEPFAR programs is controlled by Ambassador Tobias’s office. For a specific country to obtain money for HIV/AIDS programs, its U.S. embassy must convene a committee to determine how the money should be spent. Each U.S. agency representative must then make a case for programs and funding to that committee. This is a tremendous improvement over traditional budget planning, where decisions on projects and funding levels are often made in Washington with minimal local input from U.S. ambassadors and embassy staff and without interagency coordination.

Traditionally, Congress complains that U.S. assistance money is often spent without regard to the broader context of policy needs and priorities. The structure of PEPFAR, however, ensures a unified policy direction under the ambassador in each country. Because Congress has seen to it that PEPFAR both addresses clear clinical needs and is coordinated with overall U.S policy, support for the plan on Capitol Hill continues to be bipartisan and enthusiastic.


Targets, Set and Met

Too frequently, results in development assistance programs are defined by the total expenditure of the allocated funds by the end of the fiscal year. By contrast, from the beginning, PEPFAR had specific global targets—two million persons to receive treatment, seven million HIV infections to be averted, and care and support for ten million persons infected and affected by the disease—as well as country-specific goals. Every PEPFAR-funded effort must demonstrate, both to the in-country team and to Tobias’s office in Washington, that it will help reach the plan’s targets in a clear and quantifiable way.

Both the centralization of the process under the U.S. ambassador in each PEPFAR country and the adherence to meeting specific targets have led to striking developments in the field: Any element of the U.S. government under an ambassador’s direction is now empowered to play a role in the fight against HIV/AIDS. Although USAID and CDC generally have the lead, the Peace Corps, embassy public affairs offices, small grants programs, and defense attaché’s offices are able to garner support if they can make a solid case to their colleagues that their projects will help meet PEPFAR targets.



In every PEPFAR focus country, U.S. efforts are carefully calibrated and coordinated with the work and planning of host governments and local authorities. This commitment to partnership helps ensure that assistance projects are complementary rather than duplicative. It also represents a critical departure from the patronizing attitude of many traditional assistance programs, where other countries’ officials are told by outside “experts” what their problems are. Treating other countries respectfully in the fight against HIV/AIDS has helped improve the quality of bilateral dialogues with the United States on AIDS and other issues.

Careful attention is also being paid to strengthening indigenous nongovernmental and faith-based organizations, rather than relying exclusively on U.S. or third-country contractors and consultants. Although it is hoped that the emergency plan will continue after its initial five-year period, it is evident to all that successful in-country institutions will be needed to carry on the fight in the long term.

Americans’ optimistic, can-do attitudes cannot replace local indifference—for example, when senior host government officials act in ways that we find irrational or insupportable (challenging the scientific dogma that HIV causes AIDS or advocating ineffective folk cures for the virus). One can only hope that, in the longer term, nongovernmental activism and clear evidence of the “Lazarus effect” (the dramatic improvement in the health of AIDS patients brought about by anti-retroviral therapy) will have an impact on some of the more reticent and skeptical foreign leaders.


Future Directions: Transformational Diplomacy

In establishing the emergency plan, President Bush made it abundantly clear that fighting HIV/AIDS is a priority of the United States. Secretaries of State Colin Powell and Condoleezza Rice strongly echo that sentiment. During both her Senate confirmation testimony and her first meeting with State Department employees as secretary, Rice introduced her vision of “transformational diplomacy”: a call to U.S. diplomats to “develop new skills, and rise to new challenges” and to be “partners with those around the world who share our values and want to improve their lives.” She has specifically cited work on HIV/AIDS as an example of transformational diplomacy in practice.

Secretary Rice’s emphasis on new types of diplomatic activity is a positive development both at home and abroad. The PEPFAR model—in which our ambassador controls the process in each nation, new bureaucratic mechanisms are avoided, and genuine partnerships are built with recipient nations—offers great effectiveness in implementation, great relevance to overall policy, high levels of political and social support at home, and more-enduring relations with other countries. Although the lessons of the PEPFAR model cannot be used in every instance, we can better serve U.S. interests by applying them whenever possible.

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