Opinion: The US legacy in HIV is unraveling

Right now, the U.S. global AIDS response could best be described as rearranging deck chairs while the ship drifts entirely off course. We are not witnessing bold reform, but an intentional unraveling of America’s legacy in global health. And it’s happening without the congressional engagement that has, historically, yielded such remarkable success. Reimagining and realigning global health programs is not inherently bad. In fact, it was a spirit of reimagination that led to the creation of the President’s Emergency Fund for AIDS Relief, or PEPFAR, the most successful global health program in our country’s history. But we were off track on global targets related to HIV before Jan. 20. To right the ship requires a thoughtful, intentional strategy. That is not what is happening. Before Donald Trump’s second presidential inauguration, we were lagging behind in progress toward established HIV targets due to COVID-19, among other factors. But now, we are in a parallel universe entirely. Once upon a time, when Rubio supported PEPFAR In the original PEPFAR legislation, Congress intentionally included a direct line of accountability from the global AIDS coordinator, who oversees the program, to the U.S. secretary of state. That structure mattered — both for U.S. credibility abroad and for effective, data-driven results at home. In his hearings on Capitol Hill last week, Secretary Marco Rubio shared details around the administration’s proposed plan to restructure the State Department. These changes would marginalize the program, moving it to report to the under secretary for economic growth, energy and environment oversees. This creates an additional, wasteful, and ineffective layer of bureaucracy. It also consolidates authority under a State Department with diminishing health expertise, due to the dismantling of the U.S. Agency for International Development, which means the intellectual capital of hundreds, if not thousands, of global health experts has been lost. Again, realignment is not a bad thing. But there are core principles that must guide any change to PEPFAR’s structure — sustainability, local ownership, transparency, and comprehensive prevention. Once we have aligned around these principles, only then can we have conversations about the right level and structure of the program. Conversations around both principles and structure must include Congress. PEPFAR’s incontrovertible success has been possible only through bipartisan and bicameral support. The program has been upheld for more than two decades through rigorous congressional oversight. Members of Congress — Republican and Democrat — have long demanded accountability, performance, and results. And they got them. Ongoing assessment is built into the very fabric of the program. Throughout its 20 years and across multiple presidential administrations, PEPFAR’s strategy, operations, and impact have continually been evaluated to ensure it remains successful. Each global AIDS coordinator has talked about going to Capitol Hill to defend PEPFAR’s budget. And, every year, that defense was successful, including during Secretary Rubio’s tenure on the Senate Foreign Relations Committee. In fact, no one knows better than Secretary Rubio — who served on the U.S. Senate Foreign Relations Committee from 2011 until his confirmation as secretary of state — what it means to be a member of the committee overseeing PEPFAR’s impressive data. Then Sen. Rubio has said of PEPFAR: “The dividends it pays from a human element are extraordinary, and you need to look no further than Africa, where millions of people are alive because the United States pays for their antiviral medication.” HIV treatment, prevention, and integration into global health agenda A sustainable HIV response means saving lives, consistently, predictably, and comprehensively. PEPFAR realignment should be driven by how best to sustain impact. And sustainability should not be interpreted as strictly financial. With 1.3 million people newly infected each year, we can’t just treat our way out of an epidemic, we must also prevent. Right now, there are nearly 40 million people living with HIV globally; more than 30 million are on lifesaving HIV treatment. Under the Trump administration, PEPFAR’s focus is solely on treatment, with no prevention treatment for anyone except pregnant and breastfeeding women. Sustaining impact requires that national governments don’t just own their own responses; they must also fund them. To ensure that people don’t fall out of treatment, that needs to happen in a comprehensive way. In addition to treatment and prevention, an effective strategy needs to integrate the HIV response into the broader global health agenda. PEPFAR doesn’t need a departmental reorganization. What it requires is congressional recommitment to protecting the program’s mandate and ensuring it stays focused on what it does best: saving lives through data-driven, evidence-based health programs. PEPFAR represents a 21-year congressional legacy of bipartisan, bicameral support that has fundamentally changed the trajectory of the epidemic. Through deep congressional engagement, we have changed the way the response to HIV is designed, funded, and monitored. And we’ve had a game-changing impact on global health security and diplomacy. If the administration is intent on unraveling America’s legacy in global health, Congress must veto that agenda. It must preserve PEPFAR’s integrity and the U.S.’s commitment to the goal of ending HIV as a public health threat. We don’t need to rearrange deck chairs. We need political courage. Lives depend on it.