The re-authorization of the President's Emergency Plan for AIDS Relief (PEPFAR) has been getting into the news here in Washington as policy debates over by how much to increase its funding, what gets included or not in the legislation, and when it will even come up for a vote. In the midst of all of this, the Annual Report of the Program to Congress has been released.
As the chart below demonstrates (left click on it to enlarge), funding for HIV/AIDS treatment accounts for the largest proportion of the dollars spent in the program (47%), followed by total care funding services (including counseling and testing). HIV prevention constitutes 21% of the current budget allocations - 12% for prevention activities aimed at sexual transmission.
Some of the prevention highlights from the overview of the report:
In the 15 PEPFAR focus countries, home to approximately half of the world’s HIV-infected persons...infant mortality has declined in 12 of the 15 focus countries since 1987; in most of them, the decline has been very substantial. This is a major achievement for these nations and one that should be expected to reflect an overall improvement in health...
Yet ...few of these countries have experienced significant improvements in life expectancy. Tragically, seven of the 15 have actually seen life expectancy drop, and those declines have been especially dramatic in Botswana, Mozambique, Namibia, and South Africa - the four focus countries in southern Africa, where HIV prevalence is the highest in the world...
In many regions, 50 percent or more of hospitalizations are due to HIV/AIDS...
Of the countless developments taking place in the global fight against the pandemic, perhaps the most important in recent years is the growing number of nations in which there is clear evidence of declining HIV prevalence as a result of changes in sexual behavior...
Another key trend in HIV/AIDS is the growing importance of HIV-discordant regular partnerships, in which one partner is living with HIV and the other is not, as a means of transmission....Many HIV-discordant couples do not know their HIV status. Several studies in Africa have shown that provision of voluntary counseling and testing for couples reduces HIV transmission by 56 percent and that consistent condom use in discordant couples is associated with an 80 percent reduction in HIV transmission. However, the rate of condom usage in regular partnerships is very low — in Uganda, it rose from 0 percent in the early 1990s to 1.9 percent in the late 1990s. Despite massive provision of condoms by the USG and others, increasing usage has proved difficult, even when couples know their HIV status. A promising new prevention approach is safe male circumcision, which lowers transmission rates where the man is the HIV-negative partner. Discordant couples represent an extremely important opportunity for prevention, so further innovation is needed to address this vulnerable population. This could include the use of antiretroviral treatment — as pre-exposure prophylaxis for the HIV-negative partner, or to reduce the level of HIV, and therefore the transmission rate, in the HIV-positive partner...
For all populations, multiple concurrent partnerships remain a significant challenge. While, on average, Africans have numbers of life-time partners comparable to Americans or Europeans, in certain areas multiple concurrent partnerships are common, and this practice promotes more rapid spread of HIV. The challenges of multiple concurrent partnerships parallel those of discordant couples. Data show that decreases in partnerships could have a significant impact on HIV transmission, and this issue will continue to be a key focus for PEPFAR in the coming year...
One of the central themes of PEPFAR programming over the past year has been “Knowing Your Epidemic” - understanding where, why and in whom infections are occurring, both in terms of geography and in terms of vulnerable populations, and tailoring programs accordingly. An HIV prevention program in Vietnam, where the epidemic is largely concentrated among injecting drug users and people in prostitution and their clients, must have a very different approach from a prevention program in Uganda, where most infections occur through sexual partnerships in the general population (and, increasingly, within discordant couples).
But regardless of the key factors in transmission, in the absence of an effective vaccine and microbicide - and in 2007 the global community experienced setbacks in identifying either - behavior change will remain the keystone of success. Even with the new advances in prevention related to male circumcision, behavior change — and maintenance of behavior change — is essential. [All emphasis added.]
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