PEPFAR is history: Difference between revisions

The '''President's Emergency Plan For AIDS Relief''' ('''PEPFAR''') is a United States governmental initiative to address the global HIV epidemic and help save the lives of those suffering from the disease. Launched by U.S. President George W. Bush in 2003, PEPFAR has provided more than $85 billion in cumulative funding for HIV/AIDS treatment, prevention, and research since its inception, making it the largest global health program focused on a single disease in history.

PEPFAR has begun providing money (United States tax dollars) for male circumcision programs.<ref>{{REFweb

  |last=The White House

  |first=

  |date=2010-10-01

  |title=World AIDS Day at the White House

  |url=http://www.youtube.com/watch?v=60uUA0uGOkc#t=22m38s

  |accessdate=2011-04-10

}}</ref> Focus countries have been invited to request program funding to increase access to the procedure.  

PEPFAR ignominiously ended the provision of non-therapeutic circumcision of boys under age 15 in November 2019 due to significant abuses and complications.

==FACT SHEET: The Beginning of the End of AIDS 2011 ==

  |Text=PEPFAR is leading the world in support for a rapid expansion of voluntary medical male circumcision. In the past few years, research has proven that this low-cost procedure reduces the risk of female-to-male transmission by more than 60 percent—and the benefit is life-long.  Approximately one million male circumcisions for HIV prevention have been done in recent years, with the United States providing the support for three-quarters of them. Building on this, over the next two years, PEPFAR will support more than 4.7 million voluntary medical male circumcisions in Eastern and Southern Africa.

Note that the 60% is a relative risk reduction (absolute risk reduction 1.31%) during 18 months - not life-long.<ref name="boyle2011">{{BoyleGJ HillG 2011}}</ref>

  |quote=The Ministry of Health, supported principally by UNICEF and PEPFAR, is currently working to introduce and scale up neonatal circumcision.

Point of Interest: In recent studies, HIV transmission was found to be more prevalent in circumcised males in Swaziland. The drive to circumcise the majority of Swazi men continues none the less.<ref>{{REFjournal

  |quote=As Table 14.10 shows, the relationship between HIV prevalence and circumcision status is not in the expected direction. Circumcised men have a slightly higher HIV infection rate than men who are not circumcised (22 percent compared with 20 percent

From the PEPFAR Blueprint: Creating an AIDS-free Generation (emphasis added):<REF>{{REFweb

  |Text=Action Step: Increase the number of males who are circumcised for the prevention of HIV....

From a blog.AIDS.gov entry by Jeffrey S. Crowley, {{MPH}}, Director, Office of National AIDS Policy dated 26 May 2011:<ref>{{REFweb

  |Text=Last week, I wrote about my attendance at the PEPFAR annual meeting in South Africa, the country that has more people living with HIV (over 5 million) than any other country in the world.  After this meeting, I visited the neighboring country of Swaziland, which has the unwelcome distinction of having the highest HIV and TB prevalence rates in the world.

The United States Ambassador to Swaziland, the Honorable Earl Irving, was an incredible host.  I attended a large reception at the Ambassador’s residence with the Honorable Minister of Health, Benedict Xaba and other Swazi leaders working on HIV, as well as representatives from PEPFAR, Peace Corps, CDC, USAID, DoD, and private American institutions, including Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP) project.   Another evening, the Ambassador hosted a dinner with leaders from the Swazi Cabinet, the Ministry of Health and the national AIDS commission. I participated in a handover ceremony where the Ambassador ceremoniously transferred nine vehicles from PEPFAR to the government of Swaziland that will support their HIV work in the field. Through this event I also had  the opportunity to meet His Excellency the Right Honorable  Prime Minister of Swaziland.

A major focus of PEPFAR’s work is to assist the Swazi government’s plan to scale up adult male circumcision.  This lowers the risk that men will acquire HIV infection and research models indicate that if the country can get up to 80% of its adult men circumcised, they could observe a substantial decline in HIV transmission.  I visited one of several mobile sites that enabled Swaziland and PEPFAR to quickly expand access to circumcision.

Boyle & Hill (2011) established conclusively that the randomized controlled trials had disabling methodological and statistical flaws that invalidated their findings,<ref name="boyle2011" /> therefore the PEPFAR VMMC program is based on false information. Van Howe & (2011) correctly forecast that institution of a circumcision program would increase the number of HIV infections.<ref>{{REFjournal

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}}</ref> PEPFAR, however, paid no attention to these warnings and continued to promote the harmful VMMC program.

  |Text=Our review found that CDC did not always monitor recipients’ use of President’s Emergency Plan for AIDS Relief (PEPFAR) funds in accordance with departmental and other Federal requirements. CDC implements PEPFAR, working with ministries of health and other public health partners to combat HIV/AIDS by strengthening health systems and building sustainable HIV/AIDS programs in more than 75 countries in Africa, Asia, Central and South America, and the Caribbean. HHS receives PEPFAR funds from the Department of State through a memorandum of agreement.

  |Text=Through its Global HIV/AIDS Program, CDC implemented the President's Emergency Plan for AIDS Relief (PEPFAR), working with ministries of health and other in-country partners to combat HIV/AIDS by strengthening health systems and building sustainable HIV/AIDS programs in more than 75 countries. Through a 5-year cooperative agreement, CDC awarded PEPFAR funds totaling $20.6 million to the Republic of Namibia, Ministry of Health and Social Services (the Ministry) for the budget period September 30, 2009, through September 29, 2010.

  |Text=The President's Emergency Plan for AIDS Relief (PEPFAR) program authorized $78 billion from 2003 through 2014 in support of international programs for prevention, treatment, and care to combat HIV/AIDS, tuberculosis, and malaria. OIG examined the funds spent through this program in a 2011 report focusing on whether the Centers for Disease Control and Prevention's (CDC) oversight met departmental and Federal regulations. OIG found that while CDC performed some oversight of recipients' fund use, most of the award files did not include all required documents or evidence to demonstrate that CDC performed required monitoring. Because of these concerns, OIG expanded its audits internationally to include CDC's monitoring of PEPFAR funds by offices in other countries as well as audits of recipient organizations abroad. OIG issued two audits on Namibia, one in 2012 and another in 2013, and has an additional eight audits conducted there and in South Africa and Vietnam that are near completion." OIG is also planning seven more audits of PEPFAR grantees in Ethiopia and Zambia for FY 2013.

Garenne & Matthews (2019) reported that there is little difference in the incidence of HIV infection between circumcised men and intact men in Zambia. The authors stated that the "effectiveness of VMMC could therefore be seriously questioned."<ref name="garrenne2019">{{REFjournal

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[[George C. Denniston]], {{MD}}, {{MPH}}, the president of [[Doctors Opposing Circumcision (D.O.C.)| Doctors Opposing Circumcision]], in a letter to Ambassador Deborah L. Birx, {{MD}}, {{MPH}}, dated 29 June 2020, the head of the President’s Emergency Plan for AIDS Relief (PEPFAR),  has called on PEPFAR to suspend the provision of male [[circumcision]] because it is ineffective and may increase the reception of HIV infection due to the loss of [[Immunological and protective function of the foreskin| immunological protections]] of the [[foreskin]], and to focus on the provision of anti-retroviral therapy and condoms.<ref name="denniston2020">{{REFdocument

  |publisher=Doctors Opposing Circumcision

Campaigns to circumcise millions of boys and men to reduce HIV transmission are

to properly consider the economic determinants of HIV prevalence. This critical

solution” to African HIV epidemics has more to do with cultural imperialism than with

[[David Gisselquist]] (2021) reported that "circumcising men to reduce their risk to get HIV from sex" was an error.

<blockquote>In 2007, WHO and UNAIDS recommended “male circumcision should be recognized as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men.” Subsequently, WHO and UNAIDS endorsed programs to circumcise 20 million men in 14 countries in sub-Saharan Africa during 2008-15.[34] After 11.7 million circumcisions were reported through 2015, UNAIDS set a new target to circumcise another 25 million men in 15 countries during 2016-20. Through 2017, the US government supported more than 80% of these circumcisions.

WHO’s and UNAIDS’ recommendation was based on three studies in Africa that reported circumcised men were less likely to get HIV than intact men. But what happened in those studies? In two of the studies, men who reported no sexual risks (no partners or 100% condom use) got HIV at rates more than half as fast as the rates for men who reported any unprotected sex. The third study did not report men’s sexual risks. One study tested most wives, but has not said if the wives of men getting new infections during the study were known to be HIV-positive or HIV-negative.

But criticizing these studies – how they were badly managed and reported<ref name="boyle2011" /> – does not get to the heart of the problem with circumcising millions of men to prevent HIV. Insofar as sex is a risk, men already have multiple options to protect themselves. And because there is overwhelming evidence bloodborne risks – most likely in medical settings – drive Africa’s epidemics (Chapter 6), it is irresponsible to put millions of men at risk for HIV and other bad outcomes from unnecessary operations.<ref>{{REFbook

[[George Hill]], CFI, ATR, acting for Doctors Opposing Circumcision, wrote to Deborah L. Birx on 28 January 2021 regarding her lack of action and to transmit a copy of the article by Fish et al. (2020).<ref name="hill2021">{{REFdocument

  |publisher=Doctors Opposing Circumcision

The United States Department of State on 10 February 2021, announced a "temporary pause" in the development of Country Operational Plans and Regional Operational Plans, which it said was caused by the COVID-19 pandemic. The Department of State affirmed that "HIV prevention and treatment services" would continue, but made no mention of male circumcision or VMMC.<ref name="state2021">{{REFweb

  |last=Foregen Staff

  |publisher=Foregen