Princeton Lyman and Stephen Wittels of the Council on Foreign Relations have written a thoughtful article in the July/August issue of Foreign Affairs (No Good Deed Goes Unpunished: The Unintended Consequences of Washington’s HIV/AIDS Programs). Far less sensationalist than the NYTimes reporting in May, this in-depth analysis explores the paradox that US commitments supporting HIV treatment have lessened American policy leverage over the countries which receive this sort of aid. While not intuitive, the argument is compelling: since ARV treatment is meant to be for life, the US is making an implicit humanitaritan commitment when it pays for treatment – this commitment, by ethical standards, is irreversible, thus reducing Washington’s ability to use aid as an instrument of influence.
Through PEPFAR, the US has spent $25 billion on AIDS-related assistance worldwide from 2003 to 2008. Since 2009, 2 million people have been enrolled for ARV treatment through PEPFAR; global need is estimated at 10 million. In this same year, 45% of the total PEPFAR budget was spent on treatment; the US has committed to increasing access to treatment to 4 million by 2014. The cost of treatment, while declining on an individual basis, will continue to grow as enrollments increase and second line treatments are used more frequently to treat more advanced stages of the disease.
The analysis reveals the Obama administration’s difficult conundrum: in an era of budget cuts and austerity measures, international aid is unlikely to be increased by any significant measure. At the same time, the ethical commitment that has been made through PEPFAR will become costlier as treatment is maintained and enrollments increase. With an aid “pie” of roughly the same size, treatment costs will consume an ever larger % of overall funding flows, decreasing funds available for other development assistance. Lyman and Wittels, with their leverage argument, point out that this implies more funds tied up in assistance that creates little influence, thereby leaving less monies available for aid that does influence (part of Secretary Clinton’s “twin pillars” soft-power strategy).
Read Mead Over’s excellent analysis of the same. Make sure and read Brook Baker’s counter-argument in the comments section, which importantly point out that treatment and prevention are not mutually exclusive.
