On May 27, 2003, the U.S. Congress appropriated $15 billion for a five-year plan to tackle the HIV/AIDS pandemic, heeding President George W. Bush’s call in his State of the Union address for a “work of mercy” for HIV/AIDS victims in Africa and the Caribbean. This legislation launched the President’s Emergency Plan for AIDS Relief, or PEPFAR, the largest commitment ever made by any country to fight a disease.
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Accolades for PEPFAR on its fifteenth anniversary celebrate what it has achieved, particularly its success in increasing the number of people on lifesaving antiretroviral (ARV) drugs. Without it, hopes for ending HIV/AIDS as a global threat within the next fifteen years would be inconceivable. The program’s impact places it in the pantheon of iconic U.S. policy efforts, such as the Marshall Plan and the Apollo space program.
PEPFAR’s success makes it hard to recall how unexpected and unprecedented the plan originally was. That the United States, led by a conservative president and Republican-controlled Congress, would—amid a war on terror, an invasion of Iraq, and an epidemic of severe acute respiratory syndrome (SARS)—launch a foreign assistance program of such ambition was stunning. Its creation was a black swan for global health and one of the most significant moments in the history of global health policy.
However, PEPFAR’s impact is fading, and the program is no longer the major catalyst for the fight against HIV/AIDS. With international assistance stagnating, HIV infections and untreated AIDS cases appear set to surge. PEPFAR has not supported robust contributions in other global health areas, including global health security. Ominously, President Donald J. Trump has sought to weaken it and other global health security programs. The bold, bipartisan leadership that produced and guided the program is breaking down, and rearguard actions are needed just to preserve the status quo. PEPFAR’s future in global health has never been more uncertain.
What Makes PEPFAR Great
PEPFAR is the most consequential initiative ever launched against HIV/AIDS. Through 2017, the United States had spent more than $70 billion on it. By comparison, the Geneva-based Global Fund to Fight AIDS, Tuberculosis, and Malaria has disbursed $17.5 billion for HIV/AIDS since 2002, a total that includes contributions from PEPFAR. The program has provided ARV treatment for more than 13.3 million people, the biggest contribution to the 20.9 million people on ARVs that the Joint United Nations Program on HIV and AIDS (UNAIDS) recorded in June 2017.
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Since its creation, PEPFAR has reported [PDF] enabling the delivery of more than 2.2 million HIV-negative babies with HIV-positive mothers, facilitating prevention through 15.2 million voluntary male circumcisions, reducing HIV infection rates in adolescent girls and young women in the highest HIV-burden communities in ten African countries by 25 to 40 percent, delivering care to 6.4 million orphans and other children, training 250,000 health workers, and contributing to health-system strengthening in recipient countries. In 2017 alone, it provided HIV testing services to 85.5 million people.
These efforts have not been without controversy. Its funding of abstinence programs and handling of intellectual property rights on ARV drugs generated disputes. Some experts also believed the program contributed to HIV/AIDS efforts consuming a disproportionate share of global health funding. However, these and other controversies have not prevented it from becoming the seminal effort to stem one of history’s worst pandemics.
PEPFAR’s importance also goes beyond HIV/AIDS. It contributed to a revolution in global health governance [PDF]. It involved a kind of U.S. leadership in global health never seen before. This commitment supported novel approaches, such as framing communicable diseases as security threats and understanding global health activities as the exercise of so-called smart power. As its example illustrates, the United States preferred initiatives that operated outside traditional health organizations, such as UNAIDS or the World Health Organization (WHO), and that involved nonstate actors, including nongovernmental organizations (NGOs), through public-private partnerships.
PEPFAR’s political and financial wake also affected many areas of global health. Development organizations leveraged the initiative to emphasize the importance of disease control in economic and social development. Human rights advocates connected the increase in access to ARVs with the right to health. The campaign against noncommunicable diseases took inspiration from the fight against HIV/AIDS. Despite worries that PEPFAR and other nontraditional efforts would weaken UNAIDS and the WHO, these organizations have become integral to implementing these initiatives, making them more important than they otherwise would have been.
What Threatens PEPFAR’s Legacy
While there is talk of an AIDS-free generation being within reach, the progress achieved through PEPFAR is fragile. Worrisome rates of new HIV infections, including by drug-resistant strains, and the still-growing number of people living with AIDS point to an expanding problem. National and international spending is not keeping pace. In 2017, UNAIDS observed that, “for several years now, resources for AIDS have remained stagnant, and we are not on track to reach the US$ 26 billion of [annual] investment we need by 2020.” Without more spending, UNAIDS believes that more people will become infected with HIV and die from AIDS. The prevention benefits achieved through treatment will shrink as the number of untreated people increases. Instead of ending AIDS as a global threat by 2030, the “next AIDS pandemic” may be looming.
Nowhere on the horizon is anything to confront this threat like the catalyst PEPFAR provided fifteen years ago. Calls for more spending are ubiquitous, but no donor country appears willing to significantly increase its contributions. Despite claims that his administration is “deeply committed to the global HIV/AIDS response,” President Trump proposed slashing PEPFAR funding [PDF] in fiscal years 2018 and 2019. Congress rejected the 2018 budget request and funded PEPFAR at the 2017 level of $4.65 billion, continuing the pattern of stagnant donor assistance.
In addition, President Trump reinstated the so-called Mexico City policy, banning foreign NGOs from receiving U.S. family planning assistance if they provide abortion services and counseling. However, he applied the ban to all U.S. global health assistance, including PEPFAR. This expansion rejected the past approach, pursued by President Bush, of not applying the Mexico City policy to global HIV/AIDS programs. This change could hurt treatment and prevention efforts PEPFAR has advanced.
Tax cuts and spending increases passed in 2018 makes it unlikely that the United States will expand foreign assistance for the foreseeable future. Pressure to cut such assistance will mount as budget deficits and the national debt skyrocket. In this deteriorating fiscal environment, skepticism about PEPFAR’s contributions to U.S. security, foreign policy, and global influence will grow, especially as China and other rivals make strategic gains in Africa and elsewhere without providing large-scale HIV/AIDS assistance. The initiative’s resilience in U.S. politics over the last fifteen years may not survive the next few years.
Further, as CFR’s Thomas J. Bollyky notes in his forthcoming book, Plagues and the Paradox of Progress, PEPFAR’s spillover benefits for other areas of global health have been limited. For example, the HIV/AIDS catastrophe helped inform strategies to strengthen global health security by achieving more effective surveillance and containment of outbreaks. These strategies included revising the WHO’s International Health Regulations (IHR). However, global health security strategies imploded during the 2014 West African Ebola outbreak. This crisis revealed the ineffectiveness of the IHR, exposed a poorly led and inadequately funded WHO, and highlighted a failure to develop health systems in vulnerable, low-income countries—all factors that contributed to HIV/AIDS becoming a global calamity.
To make matters worse, the Trump administration’s budget requests for fiscal years 2018 and 2019 eliminated most funding for global health security activities, except for a one-time transfer of $72.5 million from unspent Ebola funds. Congress ignored the 2018 request and provided $172.6 million for global health security, $100 million of which came from unspent Ebola appropriations. Undeterred, the administration eliminated the global health security team within the National Security Council. The administration also asked Congress to rescind appropriations relevant to global health security, namely $252 million of unspent Ebola funds and $30 million from the Complex Crises Fund, which provides the secretary of state with resources to respond to emergencies, including disease outbreaks.
Make PEPFAR Great Again?
PEPFAR’s success means that accelerating progress against HIV/AIDS need not depend on another black swan event. Its 2017–2020 plan [PDF] aligns with UNAIDS’s Ending AIDS strategy. Neither the PEPFAR nor the UNAIDS blueprint calls for increased U.S. funding, and both seek to accomplish more with existing commitments. Once the indefatigable catalyst, PEPFAR has become the indispensable bedrock for global HIV/AIDS efforts. Given the Trump administration’s attempts to cut the program, Congress bears responsibility for ensuring that the United States does not flinch at this decisive point in the HIV/AIDS battle.
However, HIV/AIDS efforts need more investment to end the threat of the pandemic’s creeping resurgence. Other countries could answer this call, but adequate additional funding will not materialize if donor and recipient countries perceive the U.S. commitment to PEPFAR as wavering. Being too big to fail will not save it. The program is big enough that it is vulnerable to America First unilateralism metastasizing in a context of historic U.S. fiscal irresponsibility.
In this environment, the Trump administration should send unequivocal signals about PEPFAR’s importance to the United States. To start, it should end efforts to slash its funding. In addition, given the fiscal reckoning the U.S. government will face under present tax and spending policies, the administration should protect it within the foreign assistance budget. Finally, the administration should scrutinize the expanded Mexico City policy’s impact on PEPFAR, and the president should reverse course if the data indicates the policy reduces its effectiveness. The future of the global HIV/AIDS fight depends on preserving PEPFAR’s lifesaving impact.