Half truth:  There are efficiencies to be realized in HIV/AIDS programming and until those efficiencies are realized it doesn’t make sense to invest more money on HIV and AIDS treatment, but

• Many of the inefficiencies are the result of unwise US policy decisions and many of those decisions are already being reversed; there is only so much in terms of efficiency gains that can be squeezed out of the system.

Truer:  Because of its eagerness to get its Global AIDS Initiative off the ground and because of certain counterproductive prevention and treatment policies, the US PEPFAR initiative 2003-2008 had many inefficiencies.  These included abstinence-only prevention policy, the global gag rule, the anti-prostitution pledge, disallowance of needle-exchange, earlier purchases of higher-priced brand-name medicines, high internal overhead and central administration charges, reliance on high-price ex-pat consultants and technical assistance, excess training costs, and high overhead to international NGOs that were the prime implementers during PEPFAR I.  Treatment in particular was more expensive in PEPFAR programming, often costing more than $1000 per patient per year.  However, many of these inefficiencies are being addressed, including excess overhead costs, and the cost of treatment in PEPFAR programs has fallen to approximately $400 per patient per year because of reliance on cheaper generic ARVs, task-shifting, and greater efficiencies in treatment protocols as economies-of-scale are reached.  It is clear that economies have been realized throughout treatment programs as 1.2 million new patients began receiving antiretroviral therapy in 2009 despite the fact that overall donor assistance for AIDS programming actually decreased from $7.7 billion in 2008 to $7.6 billion in 2009.  Although some additional efficiencies are possible, there are also increased costs in future programming including higher costs for improved- and second-line treatment regimens, earlier initiation of treatment, and expanding the HIV-trained health workforce and strengthening health systems.