Playing Tennis Without a Net

March 4, 2015

The American poet Robert Frost once said that writing “free verse” — poetry without a formal structure, like a rhyme scheme — was like “playing tennis without a net.”

Targets, goalposts and milestones are what give meaning and inspiration to the incredible work that the AIDS community is engaged in each day. They allow us to challenge ourselves and, equally important, comprehend how far the AIDS community has come. To work without targets is to play tennis without a net—and it seldom yields works of beauty, unlike free verse.

In 2011, US President Obama announced an evidence-driven agenda for US global AIDS programs focused on high-impact interventions including antiretroviral treatment (ART), prevention of mother-to-child transmission and voluntary medical male circumcision. He set specific targets for PEPFAR to reach by the end of 2013, including support for two million more people on ART by 2013 and 4.7 million more VMMC procedures.

By the end of 2013, both goals had been exceeded via the combined effort of PEPFAR, national governments, other funders and community stakeholders.

But since then, there have been no new targets — and PEPFAR has been playing tennis without a net.

Even more concerning, there may not be funding to develop ambitious targets. On February 2, the Obama Administration unveiled its proposed budget for Fiscal Year 2016 (FY2016, which begins in October 2015) that included flat funding for PEPFAR and reduced funding for the Global Fund reflecting the cap on US contributions set by Congress.

Also concerning is a recent Lancet article that suggests the absence of targets may have slowed treatment enrollment, which declined in 2014 by 35 percent. More recently, at last week’s Conference on Retroviruses and Opportunistic Infections (CROI), in a presentation on VMMC scale-up, PEPFAR staff showed a worrying slow-down in those programs in the absence of a target.

Targets in 2015 and restored PEPFAR funding for FY2016 are needed in order for the program to get back on the trajectory it needs to end the epidemic.

It is out of character for PEPFAR not to have targets. PEPFAR has often in its 12-year history identified critical goals and met them. From supporting 7.7 million people on ART treatment, to reducing the cost of treatment, and meeting ambitious male circumcision goals, PEPFAR and partners have shown they can rise to the challenge.

Where are new PEPFAR intervention targets? We had hopes that new treatment and prevention targets would be announced on World AIDS Day 2014, but that day came and went. With the UNAIDS making the call for “90-90-90” as a new target for 2020, primary prevention targets are especially critical now to stem the tide of new infections and to ensure a truly comprehensive response to the epidemic. As we said in our Report, Prevention on the Line, global targets, particularly for prevention, still lack precision and plans to turn them into reality.

Targets are risky. PEPFAR may not achieve them, or Congress may not fund them. But our greatest achievements have not always been fully achieved, and they were never sure bets. For targets to have impact they need some key attributes to turn a target into impact. Targets need to be resourced, audacious, achievable, measurable, accountable, politically supported and a collective priority. Targets without these attributes can be a focal point for frustration, criticism and cynicism — see Prevention on the Line for our “Anatomy of A Target” and an analysis of targets that have worked in the past.

Under PEPFAR 3.0, the Office of the Global AIDS Coordinator has aggressive plans to support targeted efforts to combat HIV/AIDS. The new $300 million PEPFAR Impact Fund will be allocated to countries with the greatest need and ability to realign resources based on evidence to reach epidemic control, increase their own share of HIV budgets, and take greater ownership of data collection and expenditure analysis. PEPFAR’s focus on impact is welcome and needed. Yet without treatment and prevention targets to assess that impact, PEPFAR may still be playing tennis without a net.

We hope and expect that within the next months, the Administration will work to set, and Congress will work to fund, bold new treatment and prevention targets for PEPFAR in the future.