No Good Deed Goes Unpunished

The Unintended Consequences of Washington's HIV/AIDS Programs

The George W. Bush administration increased annual U.S. assistance to Africa almost sixfold, from $1.3 billion in fiscal year 2001 to $7.3 billion in fiscal year 2009. One-time debt forgiveness and emergency humanitarian assistance contributed to this increase, but it was primarily driven by the President's Emergency Plan for AIDS Relief (PEPFAR), the United States' single largest continuing commitment to Africa. PEPFAR, which was originally expected to disburse some $15 billion over its first five years, actually spent $25 billion between 2003 and 2008. The program also kick-started a sharp increase in AIDS-related assistance worldwide and laid the foundation for the G-8's announcement, in 2005, that it would provide all those infected with HIV with access to life-saving antiretroviral (ARV) treatment.

This commitment will become staggeringly large. There are currently just over 33 million people infected with HIV, more than 22 million of whom are in sub-Saharan Africa. In 1998, only a few hundred thousand people with the virus received ARV treatment. By 2009, over four million were receiving treatment, with PEPFAR providing it for two million of them, according to the Kaiser Family Foundation. But UNAIDS, the Joint United Nations Program on HIV/AIDS, estimates that that year nearly ten million people needed treatment. If new infections continue to outpace AIDS-related deaths by 35 percent, as they did in 2009, this number will inevitably increase.

Because ARV therapy needs to be provided over a lifetime, treating HIV/AIDS patients is a serious long-term commitment. If universal treatment is to be achieved, some 30 million people worldwide will have to be kept on ARV treatment for three or four decades. Some countries may be able to shoulder the cost of such care for their own citizens, but those in sub-Saharan Africa -- the world's poorest region -- will not. If the United States continues to lead the international community in filling this "treatment gap," the magnitude of the commitment will steadily grow.

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