The Issue
The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), now in its 20th year, supports initiatives that train health workers, strengthen laboratory capabilities, and deliver critical treatment and prevention services to people living with and at risk of human immunodeficiency virus (HIV). Credited with having saved more than 25 million lives and enabled more than 5.5 million children to be born HIV-free, PEPFAR programs currently sustain at least 20 million people on antiretroviral therapy. They have also built local capacities that have allowed PEPFAR-supported countries to respond effectively to other health threats, such as the 2019 cholera outbreak in Mozambique, the Covid-19 pandemic, mpox, and the Ebola outbreak in Uganda in 2022. Recognizing the contributions made by PEPFAR to addressing recent health crises, the Biden administration has begun to more explicitly align HIV/AIDS and health security approaches, both in the December 2022 PEPFAR strategy as well as through the July 2023 launch of the Bureau of Global Health Security and Diplomacy at the U.S. Department of State. In this report, the CSIS Working Group on Reinvigorating U.S. Leadership on HIV/AIDS offers concrete recommendations for advancing progress on reaching the goal of eliminating HIV as a global public health threat by 2030 while maximizing the contributions of a disease-specific health initiative to pandemic preparedness and response.
PEPFAR’s Response to the Global HIV/AIDS Pandemic: A Brief History
At the beginning of the twenty-first century, the HIV/AIDS pandemic killed more than 2 million people worldwide each year, with at least 5 million new infections in 2000 alone.[1] Considering the number of countries where the burden of disease was significant but access to costly new antiretroviral treatments was out of reach, many worried that the high rates of illness and death associated with HIV/AIDS threatened to provoke instability and conflict in settings ill-prepared to confront a health crisis.[2] To support countries’ response to HIV/AIDS, the United States announced the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, committing vast public resources to bilateral and multilateral programs promoting access to HIV prevention, diagnostics, and antiretroviral treatment in a set of select low-income countries.
The United States has spent more than $110 billion in foreign assistance funds through PEPFAR since 2003 to support programs to prevent, diagnose, and treat HIV in severely impacted countries, primarily in sub-Saharan Africa. Bipartisan support in the U.S. House and Senate has led to PEPFAR’s reauthorization multiple times and underpinned consistent appropriations for bilateral programs, as well as the Global Fund to Fight AIDS, Tuberculosis and Malaria, a multilateral organization that provides eligible countries with financing to support the response to HIV. In January 2023, President Biden noted that U.S.-supported HIV programs have saved at least 25 million lives since PEPFAR’s launch 20 years ago.[3]
But PEPFAR’s impacts on outbreak response go well beyond helping countries respond to the HIV pandemic. During recent health emergencies, including outbreaks of cholera, Zika, mpox, and Ebola, as well as Covid-19, it has become clear that in many of the countries with which PEPFAR has engaged intensively over two decades, partner governments, civil society organizations, and community-based healthcare providers have drawn on skills honed by delivering HIV prevention and treatment services to respond effectively to new crises.[4] At the same time, civil society groups advocating for people living with HIV have ensured that their movements’ core values, such as a focus on equity, gender equality, community engagement, solidarity, and respect for human rights, are incorporated into the response to newer health threats as well.[5]
Recognizing the assets, values, and knowledge PEPFAR programs have contributed to the broader response to public health crises, the Biden administration has sought to more formally integrate U.S. policy approaches related to HIV, global health security, and pandemic readiness. The December 2022 PEPFAR strategy prioritizes “measurable and sustainable gains in partner country public health systems and health security to strengthen public health prevention, data, and response capabilities for HIV and other health threats.”[6] And the U.S. Department of State’s new Bureau of Global Health Security and Diplomacy, which incorporates the Office of the Global AIDS Coordinator that oversees PEPFAR programs, has a stated mission to “fortify the global health security architecture to effectively prevent, detect, control, and respond to infectious diseases, including HIV/AIDS.”[7] PEPFAR is also working with implementing countries to develop “sustainability roadmaps,” which ask countries to prepare long-term plans for mobilizing financial and programmatic resources in the response to HIV and place a clear focus on tracking “progress in enhancing health security.”[8] There are additional steps the Biden administration can take, including by more purposefully aligning HIV and global health security approaches within U.S.-supported overseas programs and by using targeted diplomatic engagement to motivate increased global commitments to place HIV initiatives at the center of health security and pandemic preparedness and response agendas.
The CSIS Working Group on Reinvigorating U.S. Leadership on HIV/AIDS
During the first half of 2023, the CSIS Bipartisan Alliance for Health Security’s Working Group on Reinvigorating U.S. Leadership on HIV/AIDS met to review the impacts of PEPFAR investments in countries’ responses to health crises, including Covid-19; consider the Biden administration’s efforts to more explicitly define PEPFAR’s contribution to health emergency preparedness; and discuss how these approaches will influence the program’s evolution and contribute to its sustainability over the next several years. The group of experts concluded that in the current moment of heightened global focus on pandemic preparedness, the United States should put the full strength of its diplomatic and programmatic energies toward making the case that sustaining the response to HIV/AIDS is pandemic response and that HIV/AIDS programs should inform the response to new and emerging pandemics as well.
But the path toward better integrating HIV and health security is not without obstacles, including the current failure of Congress to act before September 30 to reauthorize PEPFAR for another five years; a challenging legal landscape in several PEPFAR countries, where laws criminalizing homosexuality and sex work make it difficult to ensure equitable access to HIV services for some of the most vulnerable populations; slow progress in many countries in preventing new infections, particularly among adolescent girls and young women, and in initiating children and adolescents on treatment for HIV; and a shortage of funds available to maintain existing progress on ending HIV as a public health threat by 2030.[9]
Keeping in mind the overarching importance of accelerating momentum in helping countries reach global goals related to HIV testing, treatment initiation, and viral suppression by 2030 and ensuring countries are on a clear trajectory for sustaining the response to HIV in the years ahead, the CSIS working group offers the following recommendations for maximizing the contributions of a disease-specific health initiative to pandemic preparedness and response:
- A five-year reauthorization and full funding of PEPFAR across agencies and programs is essential to reaching the global goal of ending HIV as a public health threat by 2030 and preventing the re-emergence of HIV/AIDS as a global pandemic; the Biden administration should mobilize all tools at its disposal to call on Congress to reauthorize PEPFAR.
- With the launch of the new Bureau of Global Health Security and Diplomacy at the U.S. Department of State, the United States should elevate its diplomatic engagement, both bilaterally as well as multilaterally, to raise awareness, promote political leadership, and build consensus regarding the contribution of HIV/AIDS programs to pandemic preparedness and response.
- At the policy and programmatic levels, there is an urgent need for the United States to enhance coordination and strategic alignment between PEPFAR’s contributions to pandemic preparedness and response and those of other U.S. global health security initiatives, which are carried out by multiple U.S. agencies, to ensure a unified and complementary approach.
- To build a bipartisan cohort of PEPFAR and global health security champions in the House and Senate, the Biden administration should communicate clearly regarding how PEPFAR both stands at the center of a unified and aligned U.S. approach to global health security and pandemic preparedness and reinforces U.S. national security through supporting countries’ responses to the HIV pandemic as well as new and emerging pandemics.
The Evolution of PEPFAR’s Contributions to Global Health Security
When President George W. Bush proposed the initiative that became PEPFAR in 2003, the outlook for people in high-burden countries who were living with or at risk of HIV was not promising. That year an estimated 2 million people worldwide died from AIDS-related causes, with the majority living in low-income countries in sub-Saharan Africa, where they had reduced access to antiretroviral therapies compared to people living with HIV in high-income countries. By framing PEPFAR’s work as that of emergency response to a health crisis taking shape in countries with fragile health systems, the U.S. government created a vertical service delivery platform focused on addressing the challenge of a specific infectious disease.
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