Farley R. Cleghorn l Palladium - Sep 08 2023
After 20 Years, We Still Need PEPFAR

Twenty years ago, in much of the world, a HIV diagnosis was a death sentence. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) was born to address the quickly growing epidemic at a global scale, putting U.S. resources and support to work. PEPFAR is the largest congressionally mandated investment in global health in history. Since then, the U.S. has invested over US$100 billion in the global HIV/AIDS response, saving over 25 million lives, preventing millions of HIV infections, and helping several countries to control the HIV epidemic, all while strengthening global economic security and boosting health systems.

Today, the 4th reauthorization of PEPFAR is being debated on Capitol Hill. It’s currently stuck in political limbo and I’m very concerned, because losing PEPFAR would be an unmitigated disaster for the world and an enormous blow to the U.S.’s reputation.

It’s easy to look at the program’s success in terms of the numbers, which alone make the case for its reauthorization, but the story is so much more than what the numbers can tell us. PEPFAR has been a collaborative enterprise for two decades, predicated on a treatment best practice model that can be adapted for places with lower resources and higher prevalence of HIV. And while its focus has been on HIV treatment and prevention, the knock-on effect has been to bolster health systems by improving laboratory capacity and testing, enhancing surveillance and data collection at national and local levels, and building a better equipped health workforce.

The outcome has been better, more efficient primary healthcare and more data-informed health services in countries across the globe. Even the next generation has been saved by the enormously successful strategies to prevent mother to child HIV transmission.

What’s more, PEPFAR was a game-changer during the COVID-19 pandemic, pivoting to channel funds for the response efforts around the world and saving even more lives. The ways in which PEPFAR has worked for decades and its response to COVID-19 have helped to lay the foundation for what our emerging global health security approach will look like, particularly around planning for future pandemics, detection, mitigation, and working hand-in-hand with local communities.

But we know firsthand that the work isn’t done.

While some may argue the U.S. should reduce its investment over time, it’s simply too soon. HIV is now a chronic disease for those in treatment, allowing people to maintain a healthy lifestyle and return to productive work, for decades. We can thank science for that, but the treatment doesn’t come free, and we have a growing population who need life-long treatment. Rather than reducing investment, we need to find cost efficiencies in other places (such as reducing the cost of drugs). PEPFAR is not a program that can simply disappear without massive geopolitical implications.

Efforts to shift the financial burden of prevention and treatment to countries also took a big hit from the pandemic, as countries shifted into rapid response mode. More needs to be done to equip countries to accurately cost their HIV service delivery. Palladium, a leader in policy, advocacy, financing, and analytic solutions for HIV/AIDS, is deeply involved in that costing, which is complex and must be done repeatedly over time as the response evolves. But despite the complexities, it’s the only way policymakers and AIDS program leaders can develop a rationale for these costs and funding allocations based on that reality. As funding tightens, efficiencies gained in the delivery of HIV/AIDS and related services will be paramount to ensure testing, drugs, adequate patient follow-up, and maintenance activities will continue.

A critical part of PEPFAR’s work is ensuring that focus countries are best prepared for the treatment and mitigation of HIV/AIDS. We must tread cautiously in countries, including Uganda, where the legal rights of LGBTQ+ people have been diminished; where reduced access to services threaten a return to the past. With a growing emphasis on localization, we need collaborative, global leadership in the fight against a disease that’s still prevalent among marginalized community members.

Historically, PEPFAR will be viewed as the U.S.’s most valuable investment in lifesaving solutions in the worst epidemic of the 20th and 21st centuries in terms of morbidity, mortality, and years of productive life lost. Its leadership has elevated global guidance and stewarded national strategies. No other program has protected and provided life-saving solutions to those at risk of HIV around the world more than PEPFAR.

Diminishing PEPFAR with the assumption that local and national health agencies are ready to fill the gap risks a tremendous loss of the many protections gained for the most at risk.

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