As HIV and COVID-19 collide, questions loom over PEPFAR's future

On Tuesday, the acting U.S. global AIDS coordinator, Angeli Achrekar, sent an email informing partners of the U.S. President’s Emergency Plan for AIDS Relief that the next country and regional operation plan process — known as the COP process — has been paused. “We have heard from many of you directly as well as from multiple missions all over the globe, and recognize the toll COVID-19 has had on everyone during this unprecedented time,” Achrekar wrote in the email, which Devex obtained. She instructed PEPFAR’s partners to focus on implementing the current 2020 operational plans — which set annual country investments and expected results — and added that the pause, which will extend at least until the first week of April, is intended to provide “some relief.” The decision reinforces a widely held fear among HIV experts and advocates that the COVID-19 pandemic is derailing efforts to stamp out other diseases such as HIV/AIDS. It also alludes to a key question about the future of U.S. global health engagement: What happens to a flagship HIV/AIDS initiative in the age of COVID-19? Few figures in American politics have been as engaged in the U.S. government’s fight against the HIV epidemic as U.S. President Joe Biden. As a senator and as chair of the powerful Foreign Relations Committee, Biden played a key role in negotiating the legislation that created PEPFAR in 2003, and in crafting the legislation that reauthorized and expanded the initiative in 2008. “As the world's leading economic power, we have a responsibility to lead the world in fighting this plague,” Biden told lawmakers in 2003, while pushing for more aggressive legislation. On World AIDS Day in December 2020, during the presidential transition, Biden released a statement reiterating his commitment to maintaining a focus on the HIV epidemic even in the midst of COVID-19. Biden has also pledged to make pandemic response, preparedness, and health security a central focus of America’s global cooperation. The details of what those efforts might look like — and who will lead them — are still taking shape. In bringing these pieces together into a comprehensive global health strategy, the president’s team faces hard choices. A particularly important one is how to balance PEPFAR, a “vertical” fund that targets a specific disease and accounts for roughly half of the U.S. global health budget, with a growing recognition that countries need strong health systems that can withstand shocks and provide a wide range of services. “The worst that could happen is some kind of competition among diseases or pandemics.” --— Christine Stegling, executive director, Frontline AIDS As the global health and development community strives for greater integration, PEPFAR — as one U.S. global health expert who spoke on the condition of anonymity put it — “is the elephant in the room.” Reading tea leaves Some of Biden’s picks for key global development and health roles, both during the transition and the early days of his administration, have led to speculation that the White House favors a more integrated role for PEPFAR, and could consider folding the initiative into USAID. Linda Etim, the senior director for development, global health, and humanitarian response on Biden’s National Security Council and co-lead for international development during the transition, co-authored a discussion paper last June, which Devex obtained, which called for shifting from vertical funds to a health systems strengthening approach. The paper, which Devex understands was not an official campaign document, envisions PEPFAR playing “a larger role in creating resilient health systems able to manage multiple diseases,” and argues the initiative “should be reimagined and could serve as the backbone of a later Health Systems Strengthening initiative run by USAID.” “The Office of the Global AIDS Coordinator at the Department of State should be refocused on broader global health diplomacy with global institutions and partner countries rather than managing day-to-day PEPFAR programming, which should revert to the USAID Office of Global Health,” it adds. Last year, the Trump administration appeared to take the opposite approach with a proposal many understood to involve shifting USAID’s global health programs to the State Department under PEPFAR. One critic of that idea was Jeremy Konyndyk, who also served on Biden’s transition team, and has now been appointed to coordinate USAID’s role in the COVID-19 response. “While PEPFAR’s robust budget and long-term political commitment are both characteristics we want to emulate here, other aspects of that initiative are poorly suited to pandemic preparedness,” Konyndyk told lawmakers when he testified in July about how to structure the U.S. international pandemic response. PEPFAR has also endured its own operational challenges. Last year, just as the initiative’s former head, Deborah Birx, was transitioning to her role as coordinator of the White House coronavirus task force, the State Department’s Office of the Inspector General issued a highly critical report on PEPFAR’s management, which some of the initiative’s partners described as “dictatorial” and “autocratic.” While Biden has yet to nominate a U.S. global AIDS coordinator — a source of anxiety among some HIV advocates — his nomination of Samantha Power as USAID’s administrator and a full member of the NSC has been seen as a clear indication that the agency will have significant political influence. “My understanding of where people in the Biden administration are in this conversation is that [they believe] another five years of funding is a realistic expectation, and that would mean that several years into that, the discussion about what next really will be front and center,” Chris Beyrer, professor at Johns Hopkins University and former president of the International AIDS Society, told Devex. Beyrer is considered a candidate to lead PEPFAR under Biden. Some veterans of bureaucratic reshuffling — and the turf wars that inevitably ensue — caution against reading too much into what individual members of the administration have said in the past, and point to Biden’s long standing commitment to PEPFAR and fighting HIV. “I have zero — zero — concern about [the Biden administration’s] prioritization of, or interest in PEPFAR and HIV/AIDS in general,” Mark Dybul, who helped create the initiative and served as its first coordinator, told Devex. “It’s a good problem to have, to have all of these health experts there around the table,” said another U.S. global health expert who spoke on the condition of anonymity. “You hope that this administration can figure out a way to make that structure work better than it has, especially of late.” Falling behind Over the course of nearly two decades, PEPFAR — launched by Republican former President George W. Bush and expanded by Democratic former President Barack Obama — has built a critical base of bipartisan political support. Many advocates are wary of doing anything that would dilute its identity as an HIV-focused initiative out of fear that would alienate some of PEPFAR’s stalwart champions — particularly in the U.S. Congress. For many communities where PEPFAR operates, the health and economic devastation wrought by COVID-19 are more pressing concerns than HIV at the moment. “I look at some of the communities we work with, where people are literally looking at you and thinking, ‘you know, this is not my problem right now. My bigger problem is to stay alive in the truest sense of the word and to feed myself and my family,’” said Christine Stegling, executive director of Frontline AIDS. At the same time, Stegling added, Frontline AIDS made the conscious decision when it rebranded in 2019 to retain its specific focus on HIV as a reminder that “the epidemic is not over.” In fact, COVID-19 has put HIV targets further out of reach. Even before the pandemic erupted last year, forcing lockdowns and disrupting health care services, the world was not on track to meet the Joint United Nations Programme on HIV and AIDS — or UNAIDS — global HIV goals. Of particular concern was the rate of new infections, Beyrer said. Beyrer noted that the rate of new HIV infections among women who participated in a major recent vaccine trial in South Africa was 4% per year, which is higher than it was when he was working in the country in 2001. HIV prevention and treatment programs now face the politically thorny challenge of reaching populations whose own governments often make them difficult to reach, such as sex workers and men who have sex with men. They must do so against the backdrop of an economic crisis and government budgets that have already been stretched to their limits. With the COVID-19 pandemic now layered on top of the fight against HIV, progress is even more uncertain. While PEPFAR and its partners worked hard to prevent interruption of HIV treatment — and should be “commended,” Beyrer said — prevention and testing are seen as more “elective,” and suffered from the impacts of the pandemic. “We expect that unfortunately there may be an increase in undetected HIV infections, incident HIV infections, and of course these are stressed health systems that are facing the COVID challenges,” Beyrer said. Paul Wekesa, CEO at the Centre for Health Solutions in Kenya, told Devex there was a significant dip in the number of people who came to health facilities for HIV testing, particularly during the second quarter of 2020. “The numbers of newly diagnosed individuals went down, and also the provision of prevention of maternal to child transmission services went down, just because of limited access to health facilities,” Wekesa said, adding that the numbers rebounded somewhat after the government relaxed COVID-related restrictions. “That says to me that whether or not this stays as a vertical program five or 10 years out, we still are going to be engaged in HIV prevention, treatment, and control globally and domestically,” Beyrer said. ‘Holding our breath’ The next several months present a crucial stretch for strategic and policy decisions about the future of the international fight against HIV, highlighted by the launch of a new global AIDS strategy by UNAIDS. The United Nations will also host a high-level meeting on HIV/AIDS in June to assess progress toward ending the epidemic by 2030. HIV advocates had hoped Biden might nominate a U.S. global AIDS coordinator quickly to succeed Birx and represent PEPFAR and the U.S. government in those discussions. So far, the White House has appeared to focus on its highest-level nominees, while filling in other positions that do not require Senate confirmation, which can be a lengthy process. “We are all holding our breath to see what has actually happened to infection and to treatment rates and mortality during these last months where things were interrupted, but we've come a very long way and it feels like this is this juncture where if we take away emphasis on HIV, we will definitely create a much bigger problem somewhere down the line,” Stegling said. “The worst that could happen is some kind of competition among diseases or pandemics,” she said. PEPFAR’s partners and advocates are quick to point out that while the initiative might be focused on HIV, its decades of investment have helped countries build health infrastructure that extends far beyond the treatment of a single disease. “There has to be some synergy, and that synergy can be better enhanced if we build upon what exists, if we stand on the shoulders of what investments have been made through PEPFAR,” Wekesa said. “It's important that all stakeholders feel part of the process ... with all of us moving together, because we've done so much and moved so far. We need to keep moving in that direction so that we close in on epidemic control,” he said. Update, February 16, 2021: This story has been updated to correct the year of PEPFAR's reauthorization.