Healy Thompson is Senior Associate for Advocacy and Outreach for the Center for Health and Gender Equity (CHANGE).

PEPFAR (the President's Emergency Plan for AIDS Relief) is no stranger to criticism. However, most of the focus of the criticism to date has been PEPFAR's requirement that one-third of prevention money be spent on abstinence-until-marriage programs.

Other than some initial criticism about not buying generic AIDS medications, the global AIDS advocacy community has mostly praised PEPFAR on its treatment efforts. (PEPFAR's goal of "supporting treatment for 2 million people in 15 focus countries by 2008" has been seen as a crucial step in gaining universal access to treatment by 2010.) Reports that PEPFAR is on-target to reach 2 million people by 2008 (treating 822,000 by the end of 2006) and that it has scaled-up its use of generic drugs have increased that praise lately.

However, PEPFAR's third annual report to Congress (The Power of Partnerships: Third Annual Report to Congress) reveals that we need to reconsider most of the advocacy community's assumptions about the scale of PEPFAR's treatment efforts.

Today I use the report to combat the myth that PEPFAR is treating 822,000 people. Tomorrow, I will blog on the myth that PEPFAR is using 70% generic drugs and the myth that abstinence-until-marriage programs account for only one-third of the prevention budget so they're really not that big of a problem.

Myth: PEPFAR is treating 822,000 people in the 15 focus countries. (Part I)

Reality Check: PEPFAR is supporting treatment for 822,000 people in the 15 focus countries if you use a very broad definition of "support."

PEFPAR has two categories of support: "upstream systems-strengthening" and "downstream site-specific". Upstream support "includes those supported through contributions to national, regional, and local activities such as training, laboratory support, monitoring and evaluation, logistics and distribution systems, protocol and curriculum development" (footnote 2 on page 60 of the annual report). Downstream support "refers to … instances where the Emergency Plan [PEPFAR] is providing all or part of the necessary components for quality services at the point at which services are delivered."

293,700 of the 822,000 people that the United States is "supporting" treatment for are receiving only upstream support. In other words, more than 35% of the people we're claiming to support treatment for are receiving no more than systems-strengthening support from the United States. The other 528,300 people receive all or part of the necessary components of treatment ("essential services, training, commodities, infrastructure") from PEPFAR. The annual report does not report how many are receiving all vs. how many are receiving part of the necessary components; however, we can be sure that the United States is not providing the full costs of treatment for those 528,300 people.

In a setting in which multiple players are providing treatment support (national governments and the Global Fund to fight AIDS, TB, and Malaria in addition to PEPFAR, for instance), it makes sense that PEPFAR would not pay for the full costs of treatment for any given patient. However, since the goal of treating 2 million people in the 15 focus countries by 2008 was designed to significantly increase access to treatment, PEPFAR should be responsible for the full costs of treatment for 2 million people. So, if PEPFAR is paying for 50% of the treatment for 100 people, it should report that as 50 people on treatment, not 100 people.

Myth: PEPFAR is treating 822,000 people in the 15 focus countries. (Part II)

Reality Check: PEPFAR may be counting the Global Fund's treatment numbers in the 15 focus countries (418,000) as its own since the United States is a 30% contributor to the Global Fund.

A confusing section of the treatment part of the annual report talks about the treatment numbers for the Global Fund. Pages 64 and 65 say, "The Emergency Plan is the largest contributor to the Global Fund, providing approximately 30 percent of all resources to date. The Global Fund has reported support for 770,000 people globally as of the end of 2006; strikingly, 418,000 of those were reported in PEPFAR focus countries." There is a figure on page 64 (figure 2.5) that is headed "Treatment: People Receiving ARV Treatment with Support from the President's Emergency Plan for AIDS Relief in Focus Countries through FY 2006." It has two boxes; one reads "PEPFAR and Global Fund Joint Support = 418,000" and the other reads "Global Fund Focus Country Results = 418,000." Below those two boxes is a third box that says "Combined Total = 822,000." To the left of the two boxes is text that reads, "Includes those programs receiving support from U.S. bilateral programs—100% funded by the President's Emergency Plan and those receiving support from the Global Fund to Fight AIDS, Tuberculosis and Malaria—approximately 30% funded by the President's Emergency Plan."

This figure appears to show that PEPFAR is counting the Global Fund's treatment numbers in the focus countries towards its 822,000 total even in the 400,000+ instances in which the United States is not providing any upstream or downstream support other than being a contributor to the Global Fund. It is not clear how this fits into the breakdown of upstream and downstream. Since the Global Fund's treatment numbers in focus countries exceed the 293,700 people for whom the United States claims to be providing upstream support, they certainly can't be all counted in the "upstream" support number.

All-in-all, although the United States is claiming to provide support for treatment for 822,000 people, well more than 35% of those people are receiving nothing from the our country other than "upstream systems-strengthening support" or the U.S.'s contribution to the Global Fund (and, I should add, the United States was a contributor to the Global Fund before the advent of PEPFAR). And, if the United States is counting all of the Global Fund's people on treatment as receiving downstream support from the United States (which it may not be, but it didn't provide the information one way or the other in the annual report) simply because this country is a 30% contributor to the Global Fund, then more than 85% of the 822,000 people are receiving nothing from the United States other than "upstream systems-strengthening support" (or the U.S.'s contribution to the Global Fund). Whether 35% or 85% or somewhere in between, clearly the United States is not "supporting" treatment for 822,000 in the way that people thought they were, especially when even "downstream" support requires only that the United States provide at least part of the components of treatment.

Tune in tomorrow for "PEPFAR MythBusters: Episode Two."