Raise your hand if know what PEPFAR stands for. Raise both hands if you now how much it costs. Launched in 2003 by George W. Bush, PEPFAR stands for President’s Emergency Plan for AIDS Relief, and it has now grown to the point where it is virtually a promise to help pay for AIDS treatment for every infected poor person in the world. During its first five years, from 2003 to 2008, PEPFAR cost American taxpayers $25 billion. Almost all of that went to Sub-Saharan Africa. In 2009 worldwide, there were an estimated 35 percent more new HIV infections than AIDS-related deaths, so there is no end in sight for the president’s “emergency” program.
You can be infected with HIV, human immunodeficiency virus, without actually being sick. HIV steadily attacks the body’s immune system, however, and most HIV-positive people eventually get AIDS, and without treatment they die. Antiretroviral treatment (ART) does not kill HIV, but it interferes with its ability to replicate, thus reducing “viral load” on the body. People with AIDS have to keep taking the drugs their entire lives to keep the disease under control.
So, just what did George W. Bush get us into? The World Health Organization estimates that in 2008 there were 33.4 million HIV-infected people in the world, with another 2.7 million or so new infections every year. Sub-Saharan Africa has 12.5 percent of the world’s population but an estimated 67 percent of the world’s HIV carriers, which means black Africans are about 15 times more likely than other people to get the disease. (In the United States, black men are six times more likely than white men to carry the virus, and black women are 18 times more likely than white women.)
Antiretroviral treatment is expensive but the big drug companies that invent the drugs are subject to “compulsory licenses,” which means generics go on the market long before drug patents expire. This has brought the annual cost for treating one person in black Africa down as little as $200 or $300 for the “first-line” drugs that people start with. This is still a huge sum in the poorer countries, which have an annual per capita GDP of under $1,000, and annual per capita public health spending of less than $10. A year’s worth of “second-line” drugs, necessary when the virus develops immunity to the cheaper drugs, costs anywhere from $600 to $1,500. Treatment at these prices is beyond the reach of any but a tiny elite of black Africans, so the continent expects us to pick up the tab. With proper treatment, a patient can expect to live 30 or 40 years, so a commitment to treat every HIV-infected African for the rest of his life is a very long, very expensive, very crazy undertaking.
Despite the billions we are spending, not all the black Africans who are thought to need ART are getting it, so the United States and other rich countries that pay for drugs are routinely accused of murder by neglect. The Obama administration has promised to boost the number of doses, but the budget squeeze means there has been virtually no increase planned for the next fiscal year. HIV-infected foreigners will have to make do with just under $7 billion in 2011.
Curiously, keeping millions of Africans alive does not give the U.S. government any leverage over their governments. As Princeton Lyman and Stephen Wittels explained in the July/August 2010 issue of Foreign Affairs, the U.S. government does not dare cut AIDS funding no matter how nastily dictators behave. The half-billion a year we give to the thug government in Zimbabwe, for example, buys us no influence because Robert Mugabe knows we will not turn off the tap and open ourselves to charges that we are killing off black people. The psychopaths who run Uganda, Ethiopia, and most of the rest of the continent thumb their noses at us for the same reason.
Aside from whatever influence we thought we were buying in Africa -- and who cares about influence in Africa, anyway? -- why are we on the hook for decades of handouts? Why are our children on the hook? Except for the small number of people who got AIDS from infected blood transfusions or for babies who got it directly from their mothers (newborns catch it from infected mothers about 25 percent of the time), AIDS is a disease you can avoid with almost 100 percent certainty. Virtually everyone with AIDS got it because of deliberate, reckless promiscuity.
Come to think of it, why are we on the hook to treat all HIV-infected Americans for free? You knew we do that, didn’t you? Fewer than 20 percent of people with HIV have private insurance -- the kind of people who get the disease are not the sort that get insurance -- so you and I pay to treat the rest. The fiscal 2010 federal AIDS budget was $19.4 billion and the request for 2011 is $20.5 billion.That makes a total of nearly $30 billion a year we spend on AIDS drugs for Americans and foreigners.
The British philosopher Herbert Spencer once pointed out that “the ultimate result of shielding men from the effects of folly is to fill the world with fools.” He could have been describing antiretroviral treatment. Before the first AIDS drug, AZT, was introduced in 1987, AIDS was a death sentence. Even the most promiscuous homosexuals curbed their lust, and the gay bathhouses in San Francisco became ghost towns. AZT had awful side effects and was not very effective, but it was a start. After protease inhibitors were introduced in 1996, it became possible to lead a more or less normal life despite AIDS.
As Spencer would have predicted, the gay clubs filled up again, and homosexuals are back to the most dangerous, AIDS-inducing kind of sex: unprotected anal intercourse. And why not? Taxpayers will ladle out billions to keep them alive.
Americans are generous. They rush to help victims of misfortune. But how many taxpayers would reach into their pockets to pay for a disease that most people get through deliberate self-indulgence of a kind many Americans find repellent? How many would do so, knowing that treatment encourages yet more self-indulgence, in a vicious cycle that could keep their grandchildren on the hook?
If Americans don’t like the idea of paying for a lifetime of treatment for fellow citizens, what would they think if they knew we are supposed to be paying for endless millions of promiscuous foreigners? They would be hopping mad, especially if they knew most of the money was being swallowed up by Africans who can’t control their sex lives. They might not admit it in public, but if they had the chance in the privacy of the voting booth, Americans would cut PEPFAR off without a dime.
Of course, if you quote Herbert Spencer to explain why the gay clubs are full again, you’re a “homophobe.” If you don’t want to fill Africa with fools either, you’re a “racist.” It looks as though American and European taxpayers will go on paying for their leaders’ foolish altruism.