PEPFAR looks to the future

Abstract

On May 5, 2022, John Nkengasong was confirmed as US Ambassador-at-Large, Coordinator of the United States Government Activities to Combat HIV/AIDS Globally. The role, which oversees the President's Emergency Plan for AIDS Relief (PEPFAR), as well as partnerships with the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and UNAIDS plays a crucial role in the global HIV response. Since the former Coordinator, Deborah Birx, retired in January, 2021, Angeli Achrekar has been providing cover. However, the COVID-19 pandemic had already drawn leadership away from PEPFAR with Birx's secondment, beginning in early 2020, to the role of White House Coronavirus Response Coordinator, and involvement in the US COVID-19 response. Nkengasong's confirmation, 8 months after the initial nomination, is welcome news for PEPFAR amid criticisms levelled at the US Government for their lack of urgency in installing a new leader. PEPFAR, launched in 2003, has played an important role in the HIV response in the countries it supports, with funding to date of over US$100 billion. The PEPFAR 2022 Annual Report to Congress highlighted that, as of Sept 30, 2021, 20 PEPFAR-supported countries have reached epidemic control of HIV or surpassed the UNAIDS 95-95-95 targets. Between 2004 and 2020, new HIV infections in PEPFAR-supported countries dropped by half. Benefits of PEPFAR are also likely to extend beyond HIV, with a recent piece by the Kaiser Family Foundation suggesting that PEPFAR-supported countries saw larger improvements in maternal and child health measurements, such as child immunisations, than similar non-PEPFAR funded countries. PEPFAR has also supported the COVID-19 response with $3·8 billion in emergency funding from the 2021 budget of $10·3 billion (which also included $1·6 billion for the Global Fund and UNAIDS). However, for all its successes, PEPFAR has not been free from controversy with political ideology determining some of the policies. The initial authorising legislation (United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003) for PEPFAR required that 33% of prevention funds were allocated to abstinence before marriage programmes, widely shown to be ineffective. Although subsequent legislation relaxed some of the requirements around prevention programmes, PEPFAR is still required to “report to Congress with a justification of the decision if this strategy provides less than half of prevention funds for abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction in each such host country”. Over the years, funding has also been restricted for promoting or advocating for legalisation of sex work and for needle exchanges. More recently, an audit of PEPFAR from 2020 raised concerns about communications, especially around targets and lack of local input, between the Office of the Global AIDS Coordinator and the PEPFAR country teams. Nkengasong is a good choice for the role of Coordinator, with a wealth of experience as the inaugural director of the Africa Centres for Disease Control and Prevention (CDC) and previous roles at the US CDC and WHO. Given the previous communication issues at PEPFAR, Nkengasong's written Senate testimony with a promise on the “need to capitalize on the capacity and experience of those in the countries where we work, coming to the table with a deep respect for their perspectives and needs” will be welcome. Alongside strengthening communications, Nkengasong will also need to regalvanise the US Government and wider community at a time when the ongoing COVID-19 pandemic has overshadowed HIV. Ongoing struggles, such as the invasion of Ukraine, which is a country supported by PEPFAR, also need urgent attention. PEPFAR has initially responded with $13 million to procure antiretroviral therapy for Ukraine but more funds will undoubtedly need to be allocated in coming months. With new leadership, and the approaching end of the current PEPFAR legislation (PEPFAR Extension Act of 2018) in 2023, PEPFAR is entering a new stage. As an increasing number of countries reach epidemic control, priorities must shift beyond immediate HIV care to providing holistic care for a population living and ageing with HIV. PEPFAR can play an important role in supporting health-care systems to adapt. Nkengasong has recognised this as a priority, with his written testimony highlighting the need to ensure “services and systems are sustainable and resilient to prevent and respond to HIV/AIDS in the future, as well as other diseases”. Despite the criticisms, PEPFAR has achieved much to be proud of—may this continue under the new leadership.