Spending is less than promised, but more people receive medical treatment and care
A new advertising campaign puts forward an image of a president who appears to be half Barack Obama and half George W. Bush. The attention-catching photo introduces this question:
"Who's better on AIDS?” it asks.
Promoted on the Internet and on posters in Washington, the campaign is sponsored by the AIDS Healthcare Foundation, an advocacy group that also provides medical treatment and HIV testing in 26 countries. The organization is upset that Obama didn't appear at the International AIDS Conference held in Washington from July 22 to 27 -- the first time it took place in the U.S. in more than 20 years. Another reason? Obama has asked Congress to cut spending for fighting HIV and AIDS.
We thought this was an excellent opportunity to review Obama's one AIDS-related promise on the Obameter. As a candidate, he said he would provide at least $50 billion by 2013 for the global fight against HIV and AIDS. He also made a series of related pledges:
- at least double the number of HIV-positive people on treatment
- continue to provide treatments to one-third of all those HIV-positive people who desperately need them
- pay a fair share of The Global Fund to Fight AIDS, Tuberculosis and Malaria
- expand existing programs to help millions of children orphaned and made vulnerable by AIDS
- prevent violence against women and girls
- increase the number of health care workers by at least one million
We'll take these in order.
Most of the administration's spending on HIV and AIDS comes from a program called the President's Emergency Plan for AIDS Relief, or PEPFAR for short. There are different ways to count Obama's commitment here -- budget requests, the amount obligated, or actual spending. Suffice to say that the administration spent an average of $5.5 billion per year on direct HIV and AIDS programs between 2009 and 2011, and is on pace to spend about $5.1 in 2012. That accounts for slightly more than $21.6 billion in four years.
The administration also spent about $4.4 billion through annual donations to The Global Fund to Fight AIDS, Tuberculosis and Malaria. This is an international fund that gets money from governments and private donors, such as the Bill and Melinda Gates Foundation. The Global Fund pays for testing, antiretroviral drug treatment and basic care for children orphaned by HIV and AIDS.
That puts U.S. spending on HIV and AIDS abroad at about $26 billion, still short of the $50 billion figure mentioned in Obama's campaign promise.
The AIDS Healthcare Foundation complains the administration is cutting back on global HIV and AIDS money, and in one way this is true: Obama asked for about $4.5 billion for the 2013 PEPFAR budget, a 10.7 percent decrease from average level of spending in the last four years.
Less money doesn't mean fewer people treated, though. By lowering the costs of antiretroviral drugs and their distribution, the federal government has more than doubled the number of HIV-positive people receiving treatment -- fulfilling one part of Obama's promise -- even as spending has remained flat.
It's also worth noting that the U.S. has increased its annual contribution to The Global Fund to Fight AIDS, Tuberculosis and Malaria by about $300 million, with a request for another $350 million.
What about providing treatment to at least a third of those desperately in need? This is an area where the president far exceeded his goals. The United Nations Programme on HIV/AIDS -- usually abbreviated to UNAIDS -- says 54 percent of HIV-positive people in low- and middle-income countries, or about 8 million people, receive treatment today.
Another part of Obama's pledge: The U.S. should pay its "fair share” of financial contributions to The Global Fund to Fight AIDS, Tuberculosis and Malaria.
There isn't one definition of of a donor's "fair share,” but a 2012 report by the Henry J. Kaiser Family Foundation and UNAIDS sheds some light on the issue. Depending on which measure you use, the U.S. was either first or sixth in the world in giving money equal to its wealth, relative to other countries in 2011. Either way, the U.S. is the biggest donor to The Global Fund, accounting for 32 percent of the fund's total contributions in 2011. That's a higher proportion of the total contributions than any year since 2007.
Obama's promise mentioned children who become orphaned because of HIV and AIDS. In 2009, the United Nations Children's Fund estimated that 15 million children worldwide had lost one or both parents to AIDS. About 10 percent of PEPFAR money goes to orphans and other children affected by HIV and AIDS. We couldn't find any sign of a major expansion, but children are already a "huge part” of the U.S. strategy for HIV and AIDS, said Christine Lubinski, vice president for global health at the Infectious Diseases Society of America and HIV Medicine Association.
Preventing sexual violence, such as rape and female circumcision, was part of the Obama campaign pledge because the government estimates "the risk of HIV among women who have experienced (sexual) violence may be up to three times higher than among those who have not.” Under PEPFAR, the U.S. increased spending on programs that try to reduce sexual violence against women in 28 countries from $38 million to $57 million. The U.S. also launched a pilot program for preventing and understanding sexual violence in three countries -- Mozambique, Tanzania and the Democratic Republic of Congo -- which cost another $48 million.
Nobody we interviewed could provide us with an exact number on health care workers involved in HIV and AIDS across the world, or much that has increased under Obama. The White House does have a goal of expanding the number of health care workers by 140,000 by 2014.
So, who is better on AIDS, Bush or Obama? Lubinski said Obama has been far stronger on domestic programs, something we didn't rate here. On the global fight, Bush showed greater personal commitment to the cause, but Obama spent about as much money on HIV and AIDS programs, in spite of the recession he inherited.
"It's not really fair to hold the president accountable in a rigid way. The floor fell out with the economy,” Lubinski said. "I think overall, it's been a plus.”
Taken together, Obama isn't spending as much as he said he would on HIV and AIDS abroad, but he has delivered on many of the outcomes that matter. We rate this a Compromise.
Interview with Christine Lubinski, vice president for global health at the Infectious Diseases Society of America and HIV Medicine Association, July 26, 2012
Interview with Dr. Daniel Kuritzkes, member of the Infectious Diseases Society of America's Global Health Policy Scientific Advisory Committee, July 25, 2012
Email interview with Mahesh Mahalingam, spokesman for the United Nations Programme on HIV/AIDS, July 25, 2012
United States Agency for International Development, Congressional Budget Justification
World Health Organization, The strategic use of antiretrovirals to help end the HIV epidemic, 2012
Congressional Research Services, The Global Fund to Fight AIDS, Tuberculosis,
and Malaria: Issues for Congress and U.S. Contributions from FY 2001 to FY 2013, May 15, 2012
U.S. State Department, Remarks by Secretary of State Hillary Clinton, International AIDS Conference, July 23, 2012
The Global Fund to Fight AIDS, Tuberculosis and Malaria, Fighting AIDS
U.S. President's Emergency Plan for AIDS Relief, PEPFAR: Addressing gender and HIV/AIDS, 2011
U.S. President's Emergency Plan for AIDS Relief, United States Support for the Global Fund, A Key Vehicle for Meeting Shared Responsibility, 2012
U.S. President's Emergency Plan for AIDS Relief, Using Science to Save Lives: Latest PEPFAR Results, 2012
U.S. President's Emergency Plan for AIDS Relief, Executive Summary of PEPFAR strategy, December 2009
U.S. President's Emergency Plan for AIDS Relief, Total number of individuals reached (on Antiretroviral Treatment FY2005-FY2008), accessed on the Internet Archive Wayback Machine, May 27, 2010
BarackObama.com, Barack Obama: Fighting HIV/AIDS Worldwide, 2008
Government Printing Office, State Department and other international programs, Fiscal Year 2013
The Global Fund, Donor governments
State Department, Progress on Achieving an AIDS-Free Generation, July 23, 2012
The White House, Fact Sheet: HIV/AIDS Prevention, July 21, 2012
The White House, Fact Sheet: The Global AIDS Epidemic, July 21, 2012
ChangeAIDSObama.org, AIDS Healthcare Foundation, AHF: Obama appears to be M.I.A. for D.C. International AIDS Conference, July 7, 2012
Project Vote Smart, Remarks by the President on World AIDS Day, Dec. 2, 2011
The Huffington Post, AIDS 2012: Measuring progress by lives saved, July 19, 2012
Goal moved back a year
On the eve of World AIDS Day on Dec. 1, 2009, several White House officials, including Secretary of State Hillary Rodham Clinton, made public remarks to highlight the efforts of the Obama administration on HIV/AIDS issues. Clinton talked about the progress U.S. contributions have made toward global health, and others highlighted some of the initiatives the White House has undertaken on AIDS this year.
So it seemed like a good time to check in on the one HIV/AIDS campaign promise we have in our database, Obama's promise that he would provide at least $50 billion by 2013 for the global fight against HIV/AIDS.
That commitment, along with Obama's many public pronouncements and votes in support of the global campaign against AIDS, convinced many global AIDS activists that the country had elected the right man to take the global AIDS fight to a higher level.
In late 2008, with Bush still in office, then-Sen. Obama co-sponsored a reauthorization of the President's Emergency Plan for Aids Relief (PEPFAR) initiated by President Bush in 2004, which called for $48 billion for global AIDs relief over the next 5 years. So this one seemed like an easy layup if Obama simply stuck to that plan.
But Obama's proposed 2010 budget, unveiled early this year, was very disappointing to many in the global AIDS community. It called for only a small increase in global AIDS funding, including $6.7 billion for PEPFAR (just $165 million more than this year). Global AIDS advocates said the budget would have had to increase by $1 billion to stay on course with Obama's pledge.
In the spring, the administration changed the game a bit, announcing a new, wide-ranging initiative on global health. It would put the United States on a path to provide $63 billion over six years (2009 to 2014) for global health programs. The White House said 70 percent of that money would go toward HIV/AIDS, but the initiative would also include efforts to address such critical needs such as child health, family planning and neglected tropical diseases.
White House officials say Obama's plan keeps him on course, that 70 percent of that health funding by 2014 comes to $51 billion for global AIDS relief.
But that's a year later than promised, some AIDS activists say.
The Global AIDS Alliance put out a report saying the new timeline would have "devastating health consequences." As a result of the new plan, the alliance claimed, one million people around the world will not receive treatment for AIDS.
"Many people could die because of that change of the game," said the group's executive director, Dr. Paul Zeitz.
The Global AIDS Alliance gave Obama a D+ on his first World AIDS Day report card. Obama's budget essentially froze spending for global AIDS at 2009 levels, the group said, and as a result, "the global community could revert to little more than running in place in response to the global AIDS crisis, rather than making real progress in ending the pandemic and achieving a sustainable global response to the greatest public health challenge of our generation."
An August letter from Eric Goosby, the administration's global AIDS coordinator, to American ambassadors gave some global AIDS activists further pause.
"The landscape around us is changing, with the need to balance a broad portfolio of global challenges at a time of financial crisis," Goosby wrote. "As a result, we need to plan for the next stage of PEPFAR's development in this context and cannot assume the dramatic funding growth of PEPFAR's early years will be repeated."
In an interview with Global Health Magazine , published on Nov. 5, 2009, Goosby was asked how he was going to continue to add people on treatment and expand prevention efforts when some believe the Obama administration will flat-fund global AIDS for the next several years.
"We are in an economic crisis," Goosby said. "The reality is that a flat or slightly rising PEPFAR allocation is what we are looking at for at least two years, maybe longer."
The White House contends that its global health initiative meets the AIDS pledge Obama made during the campaign, and that while that plans stretches into the 2014 fiscal year, it still meets his pledge because the 2014 fiscal year begins in 2013. But we're not buying that.
An extra year has clearly been added, according to the reauthorization bill for PEPFAR.
And consider the president's remarks on World AIDS Day in 2007: "As part of my comprehensive national HIV/AIDS strategy, we'll provide $50 billion by 2013 to fight the pandemic, and contribute our fair share to the Global Fund. ... I"ll expand the President's Emergency Plan for AIDS Relief by $1 billion a year in new money over the next five years so we can reach more people in places like Southeast Asia, India, and Eastern Europe, where the pandemic is growing."
Let's review where he stands: Obama did not increase PEPFAR by $1 billion in the proposed 2010 budget (just $165 million), and all signs indicate that PEPFAR funding may remain fairly flat for the next couple of years. Some may argue that pushing the deadline from 2013 to 2014 isn't a big deal. But Obama promised to do it by 2013, so we believe he's moving the goalposts on this one to make his promise more achievable. The facts show that the administration is already falling behind in meeting the promise and will continue to do so in the next few years. If there's a surge in money in the future, we'll revisit this item, but for now we rate the promise Stalled.
Global AIDS Alliance, Press release: President Obama's World AIDS Day Report Card , Nov. 30, 2009
Global AIDS Alliance, Press release: Fact Sheet on President Obama's Four Broken Campaign Promises , May 12, 2009
Global AIDS Alliance, Press release: GAA Calls on President Obama to Act on Reality of AIDS , Nov. 30, 2009
United States President's Emergency Plan for AIDS Relief Web site, PEPFAR Five-Year Strategy
U.S. Department of State Web site, "Remarks on the Administration's Efforts on HIV/AIDS by Hillary Rodham Clinton, Eisenhower Executive Office Building," Nov. 30, 2009
White House Web site, Statement by the President on Global Health Initiative , May 5, 2009
Time, "Is Obama Scaling Back Bush's AIDS Initiative?" by Amy Sullivan, Dec. 2, 2009
Washington Post, "Slowed funding threatens AIDS fight, group says," by Karin Brulliard, Nov. 6, 2009
Obama Campaign Web site, World AIDS Day Statement by Obama , Nov. 30, 2007
Global Health Magazine, Q & A with Ambassador Goosby , Nov. 5, 2009
Office of Management and Budget, Obama Administration's Proposed 2010 Budget, Department of State and Other International Programs
U.S. Department of State Web site, Press release: "U.S. President's Emergency Plan for AIDS Relief Launches Five-Year Strategy," Dec. 1, 2009
Interview with Christine Lubinski, vice president for global health at the Infectious Diseases Society of America, Dec. 3, 2009
Interview with Dr. Paul Zeitz, executive director of the Global AIDS Alliance, Dec. 3, 2009