A look at PEPFAR's strategy: Controversies and motivations

WASHINGTON — Last September, the United States President’s Emergency Plan for AIDS Relief announced a new strategy, one that left some AIDS experts with questions — and concerns — about what it would mean for the future of the flagship U.S. global health program and the fight against an epidemic that faces growing demographic challenges.

The strategy for 2017-2020 focuses on “13 priority high-burdened countries” with an aim to achieve control of HIV/AIDS in those countries by 2020, using the Joint United Nations Programme on HIV/AIDS 90-90-90 framework: Getting 90 percent of people living with HIV to know their status, 90 percent who know their status accessing treatment, and 90 percent of people on treatment with suppressed viral loads.

What concerned several AIDS leaders and advocates is what would happen in the rest of the 50-plus countries where PEPFAR works, including notably South Africa and Nigeria, which have some of the largest numbers of people with the virus.

Some told Devex the short document left questions unanswered, including what was meant by PEPFAR ensuring it will “maintain life-saving antiretroviral treatment for all the people we support.” They asked, did that mean that PEPFAR would no longer provide ART to those newly diagnosed outside the focus countries? Would some of the countries with the toughest challenges be left behind?

Ambassador Deborah Birx, the U.S. Global AIDS coordinator and head of PEPFAR, recently sat down with Devex to discuss the new strategy, addressing some of those concerns. She said that so far, the new strategy has not dramatically changed funding for PEPFAR countries. Congress rejected President Trump administration’s proposed cuts, holding funding steady so that PEPFAR has fully funded all the programs where it works, she added.

“The great thing is, we funded them at their full amounts but organized the strategy and program in line with the other 13, so everybody is on the road to controlling the pandemic,” she said.

But the HIV/AIDS epidemic is entering an uncertain phase in many places, where those who haven’t yet been reached are the hardest to access, and a growing number of young people are approaching the age where they are most at risk.

A controversial selection

There are some skeptics of the new strategy, many of whom question what is sacrificed by focusing on 13 countries, particularly in a resource-constrained environment where the administration has twice proposed cuts to the program.

Some of those concerns are geographic. Several AIDS experts have told Devex that the epidemic cannot be controlled globally if it is not controlled in Nigeria and South Africa.

“Epidemic control focused on 13 countries necessarily also leads to the question of what’s being left out if you focus the strategy this way in these countries,” said Charles, or Chip, Lyons, the president and chief executive officer of the Elizabeth Glaser Pediatric AIDS Foundation. “So there’s a danger in a political context of focusing so much that you leave out either key cohorts or key geographies. I worry more about that in the current political context than I do [about], ‘are investments being made here or there.’”

Lyons said that despite these concerns, he thinks it could be an appropriate approach “because I know that we’re capable of doing more than one thing at a time.” PEPFAR can thus support countries in the strategy — particularly those who are, through their own efforts, making good progress — while not turning its back on countries that lack the same momentum or political will, he said, giving Nigeria as an example of one country crucial to epidemic control where lack of government buy-in is an issue.

PEPFAR picked the 13 focus countries to see what it would take to get them to epidemic control, with the hopes that they would provide a roadmap for other countries as well as help PEPFAR determine what its role would be once countries reach that benchmark, Birx said.

In general those countries were chosen by epidemiology — that they had a chance of reaching epidemic control by 2020, with the exceptions of Côte d’Ivoire and Haiti, which were added because PEPFAR felt it needed a West African country and a country in the Western hemisphere to “really understand what does progress look like,” she said.

Part of the decision was also to get countries that were excluded thinking about why they weren’t in the strategy, in what Birx called a “wake-up call.”

Some of the countries were left out for very specific reasons, she said. In Nigeria, for example, PEPFAR felt it didn’t truly understand the breadth and depth of the epidemic and has launched a roughly $125 million survey to define the epidemiology in the country and determine how to best tackle the epidemic and direct its funds.

Mozambique was left out, in part because it lagged behind many other countries in the region, due to previous conflicts and floods that made reaching rural areas harder. This past year was Mozambique’s best ever in serving both prevention and treatment needs, partly motivated by those working on HIV/AIDS in the country asking questions about why it was left out of the strategy, Birx said.

In South Africa, where the government funds about 80 percent of the response, the key question was around what resources it will take to address the largest pandemic on the continent. Despite not being in the strategy, South Africa got a surge in funding this fiscal year from PEPFAR to help it meet the government’s goal of getting 2 million more people on treatment. While South Africa has made strides in prevention, the focus on treatment is important too, as suppressing viral loads is key to reducing transmission, she said.

In the past, a focused strategy has had a positive impact on countries outside the program area as well, Birx said, pointing to the Accelerating Children’s HIV/AIDS Treatment program, which resulted in countries both included in the program and not included increasing the number of children on treatment.

While the strategy is a reflection of the progress made in many of those 13 focus countries, when Matthew Kavanagh, director of the Global Health Policy and Governance Initiative at the Georgetown University O'Neill Institute, saw Nigeria and South Africa left out of the focus countries, he said he thought that what was “very obvious is that PEPFAR has insufficient funds to be able to do its work.”

Kavanagh’s concern is that some of the countries that need the most assistance to control the epidemic but have been left out could see funding shortfalls in the future — or, even if they do get a boost, as South Africa is getting in 2018, it won’t be sustained enough to enable them to get ahead of the epidemic.

Demographic concerns

Beyond the country selection and geographic concerns, experts and advocates have raised a number of other questions about the strategy.

There are questions about what happens to key populations, and to children and teenage girls who have among the highest new infection rates.

Children, and ending AIDS in children, can’t be left behind, and while there is progress being made, continued investment is necessary, Lyons said.

“I just think the issue of ending AIDS in children is a winner — politically, morally, and in terms of a step toward epidemic control and achieving a visible priority so that everybody knows where the U.S. government stands on that issue,” he said.

PEPFAR has identified adolescent girls as a particularly at-risk population, and developed the DREAMS program, which has shown some early success in reducing infection rates. The problem is budget: During the most recent country operation plan reviews, current strategy countries were struggling to figure out how to expand the DREAMS program to even one or two additional districts, Kavanagh said.

“If the strategy was really about maximum impact, it would expand DREAMS,” he said.

The conversations at this year’s planning process were “nuanced and thoughtful,” as countries have reached high levels of coverage and are challenged with identifying how to reach the last 15-20 percent of the population in need, Kavanagh said. The challenge there is that the “low hanging fruit” has been reached and those that are left are those who aren’t engaged in the health system, particularly men and young people who are not yet sick, he said.

“How to get to them and figure that out in flat funding is challenging,” Kavanagh said.

An early question for the ONE campaign that causes continued concern is whether the strategy as written — that PEPFAR would maintain all patients on treatment — means that PEPFAR wouldn’t scale up treatment outside the 13 focus countries.

The ONE campaign has determined that if PEPFAR were to stop adding new people to treatment entirely, the epidemic would rebound, said Jenny Ottenhoff, the global health policy director of the ONE Campaign.

“The bottom line is treatment is one of — if not the most — powerful tools to stop or slow the AIDS epidemic globally. You have to keep pace, have to add people to treatment,” Ottenhoff said.

Birx said that this year funding won’t be cut in any of the PEPFAR countries and it would continue to add new people on treatment.

But Sara Allinder, the deputy director and senior fellow at the Center for Strategic and International Studies’ Global Health Policy Center, is concerned about the years ahead — particularly if Congress does support cuts to PEPFAR funding.

“[There is] no big donor waiting in the wings if the U.S. government is going to pull back in the immediate or near term,” she said.

If the U.S. takes a step back in funding, there is a question of whether it will even be able to maintain people on treatment, Allinder said.

Development assistance for HIV/AIDS has dropped $3 billion between 2012-2017 with low- and lower-middle income countries especially vulnerable to the cuts, according to a recent study by the Institute for Health Metrics and Evaluation.

“There are a lot of questions about what some of the motivations were for the decisions and what it means for countries that maybe are having major issues getting on course with epidemic control and how will those be addressed,” Allinder said.

Kavanagh echoed these sentiments, adding that the strategy seems to have been guided by the administration and its proposed budget cuts. With Congress rejecting those cuts, “this is a different program than what was described in the strategy, it’s more robust,” he said. “I think what we see is a program being implemented and guided far more by Congress in terms of its capacities and where it’s going than by the White House… I think that’s probably good for AIDS.”

What’s next

Many of these challenges — from reaching children to young women and men, as well as the difficulty in using existing health systems to reach them and determine PEPFAR’s role once countries reach epidemic control — are top of mind at PEPFAR, Birx said.

“I know I keep coming back to the demographics, but that’s our biggest threat to control of the pandemic,” she said.

It’s not only about the growing group of children who will soon be in the most vulnerable window for transmission the prevention efforts need to reach — increasingly, young people are moving to cities and informal settlements, so programs have to examine the delivery and prevention they have in those areas to keep up with the growing demands, Birx said.

There are also questions about key populations and ensuring that progress is made for those groups, who also typically bear the greatest burden of the disease, she added.

One of the main challenges today is reaching people who are well and do not interact with the health care system, in part because that system was built with pregnant women and children under the age of 5 in mind, Birx said.

“Finding people soon after infection and giving them the ability to maintain the health of their immune system. That's what will give them a full, thriving, and productive life. But that requires healthy people interacting with a health care delivery system, and that's a very new challenge and the teams are meeting that,” she said.

Countries are working to figure out how to find men and young women under 25 who need testing and treatment. In Lesotho, the country created “men’s corners” to address the challenge of reaching men. They have male nurses and doctors, and serve other men, factors that men asked for, and it seems to be working, with more and more coming by word of mouth, Birx said.

PEPFAR is already planning the next generation of surveys, which will be more focused on people under 35 and urban areas, she said.

There are also remaining questions internally about what the future will look like for countries that reach epidemic control, but PEPFAR seeks to answer them through the new strategy, Birx said. The 13 countries will help PEPFAR to figure out what kind of surveillance is needed, what kind of rapid recency tests should be used and what sort of structures and support is necessary to keep countries that reach epidemic control on the right track, she said.

“We don't know what that looks like, but we believe that the structures and the infrastructures that we're creating today will put us in a good place to really have the platform that can monitor not only the HIV/AIDS pandemic but any future pandemic,” Birx said.