Exclusive: Some PEPFAR programs get waiver to restart operations

After days of confusion, anxiety, and speculation about whether critical HIV/AIDS programs might be included in the U.S. State Department’s “life-saving humanitarian assistance” waiver allowing for a limited amount of foreign aid work to continue amid the Trump administration’s ongoing review and stop-work order, the answer is in. The U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, has been granted “a limited waiver to implement urgent life-saving HIV treatment services” as part of the broader humanitarian assistance waiver, according to a memo sent to PEPFAR implementing agencies and country coordinators on Saturday by Jeff Graham, the senior bureau official in the State Department’s Bureau of Global Health Security and Diplomacy. During the 90-day pause on foreign aid, HIV care and treatment services — “inclusive of HIV testing and counseling, prevention and the treatment of opportunistic infections” including tuberculosis, lab services, procurement, and supply chain for commodities and medicines — can continue, according to the memo, which was obtained by Devex. The prevention of mother-to-child transmission services, including medication, is included in the waiver, as well as “reasonable implementing agency and implementing partner administrative costs strictly necessary to deliver and provide oversight of this assistance,” the memo said. This includes “related country-based data activities and portions of PEPFAR’s central data platform used for clinical monitoring and program management.” PEPFAR implementing agencies should continue to pause other activities not covered by the waiver until the Trump administration’s review of all foreign aid or further guidance, it said. “PEPFAR’s HIV treatment and care services are now confirmed to be included in the State Department’s humanitarian waiver — a crucial win for the millions who depend on daily antiretroviral therapy and for mothers and babies worldwide. However, serious questions remain about the program’s future,” said Jirair Ratevosian, a global health security expert at the Duke University Global Health Institute and former PEPFAR acting chief of party. PEPFAR, which has an annual budget of about $4.8 billion, supports about 20 million people globally who receive those medications, and interruptions in treatment can lead to a swift resurgence of disease. The waiver should cover about half of PEPFAR’s programs, Ratevosian said. “It is welcome news that this seems to be moving forward but the devil is in the details,” Jen Kates, the senior vice president and director of the global health and HIV policy program at KFF, told Devex. “Stopping existing work and making it hard to figure out what's being stopped and what exceptions are has created chaos. The chaos, whether it’s intentional or not, has effects on actual people’s lives and livelihoods and survival.” The Trump administration has said it is pausing aid as it conducts a review to ensure all U.S. foreign assistance aligns with its “America First” agenda. Decisions on whether programs will be continued, modified, or terminated altogether will follow the review. Implementers will still have some questions about the application of the waiver, and whether some specific expenses will be covered. But the language in the memo “seems that it could incorporate necessary components,” Kates said. The memo states that the waiver includes support for health workers delivering care and treatment services, HIV testing, drugs, as well as their procurement, transportation, and distribution. It also specifies that the waiver does not apply to activities that involve abortions; family planning; gender; or diversity, equity, and inclusion programs, and that “any other activities not specifically mentioned in this guidance may not be resumed without express approval.” PEPFAR agencies can now resume programs covered by the waiver, according to the memo, which says disbursements and obligations on existing awards and new obligations as part of preplanned transitions can be done as necessary. The global health bureau will review and certify that any resumption of work complies with the memo and directs implementers to also certify that the work aligns with agency policies every 30 days. As Devex reported earlier this week, many PEPFAR programs had already shut down in compliance with the State Department’s 90-day stop-work order and pause on new foreign aid. Now, those that fall under the waiver, once it is clear exactly what it includes, will need to restart work. “The healthcare system isn't one that works well when you sort of turn it on, turn it off,” Kates said. While PEPFAR does critical, lifesaving work, there are still other life-threatening diseases that need attention and waivers, including malaria and tuberculosis, she said. “I keep thinking about kids who need to sleep under bed nets and anti-malarial medications, and what might happen there. So it's not HIV. The situation with antiretrovirals is very acute, but there's many other ways that the U.S. government works to save lives, so we wait to hear what might happen with those services as well,” Kates said. This reprieve comes as PEPFAR’s one-year authorization is set to expire in March and the program is facing questions about its future — exacerbated by recent reports that PEPFAR funding paid $4,100 for the salaries of four nurses in Mozambique who provided abortions, which is against a U.S. law known as the Helms amendment prohibits any U.S. foreign funding from being spent on abortions. “The outcome of the 90-day review will be pivotal in determining how the program reforms to sustain its long-term impact and effectiveness,” Ratevosian said, adding that the newly confirmed Ebola case in Kampala, Uganda, underscores “the importance of having health security programs like PEPFAR back online.”