President Joe Biden’s administration has made early progress on returning the United States to global health engagement. Biden reaffirmed the U.S. commitment to the World Health Organization on Jan. 21 — the first full day of his presidency. Now, the U.S. must consider the incredible equities that exist from decades of fighting HIV and AIDS.
COVID-19 is threatening some of the most hard-won gains against HIV/AIDS in affected countries. Programs supported by the President’s Emergency Plan for AIDS Relief have had to adapt to COVID-19 to continue providing essential HIV services.
The U.S. has been among the most generous donors in what has been a true golden age of global health, perhaps best exemplified by PEPFAR. PEPFAR, accounting for over $85 billion since its inception in 2003, has saved an estimated 18 million lives, prevented many millions of HIV infections, and helped more than 50 countries achieve gains against what remains among the deadliest pandemics of this century and the last.
PEPFAR is considered a classic vertical program, focusing resources, people, and policies with laserlike focus on a single disease: HIV/AIDS. Despite the program’s remarkable successes, and extraordinary advances in the science, we are not done with the HIV pandemic.
What is the way forward for the vital PEPFAR program in this complex landscape? And how can sustained investments by the U.S. and its partners be maintained, and leveraged, as COVID-19 ravages strained health care systems and threatens us all?
First, we cannot abandon our commitments to HIV/AIDS and the relationships and networks of trust built over decades. HIV has gone from an almost uniformly fatal infection to a chronic disease. While those living with HIV must have daily medication for life, those who have access and stay adherent can generally live nearly full lives.
The world can respond to a new pandemic without giving up on the main gains against the HIV pandemic. We really have no other choice.
—PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and affected country governments are supporting millions of people with daily oral therapy worldwide. That is a commitment we all have to keep until we have a cure or a vaccine against HIV/AIDS.
And new infections continue as well, reaching some 1.7 million globally in 2019. We expect more in the COVID-19 era, since so many testing and prevention programs have stalled or been put on hold.
Programs across the world responded with innovations such as scheduling medication pickups every six months instead of every month, greatly reducing foot traffic in crowded clinics. Clinical trial sites developed for HIV vaccines and other prevention trials quickly pivoted to COVID-19 vaccine trials.
The question of whether PEPFAR can stand alone as a vertical HIV program — or if it should broaden its scope to include COVID-19, other infectious diseases, and noncommunicable diseases — is one the Biden administration will have to grapple with, as did former President Barack Obama’s administration.
In 2018, my colleagues and I put forward a plan arguing that integration of HIV with other sectors and services could yield real gains for both HIV and broader global health. But we also made clear that these changes should be taken as we have advanced the HIV response itself: stepwise, with learning as we proceed and tailoring to contexts and community needs and goals.
Still, it is vital to keep the focus on the HIV pandemic as it continues to evolve. The same is true for most at-risk communities, whom those in the field call “key populations”: sex workers of all genders; gay, bisexual, and other men who have sex with men; transgender people; people who inject drugs; and prisoners and detainees. These groups now account for the majority of new HIV infections worldwide, including in North Africa, West Africa, and parts of Central Africa.
Outside of Africa, key populations account for the majority of people living with HIV in every country and region, including the U.S. These communities have too often been last in line for prevention and treatment services and too long denied basic human rights and freedoms. Going forward, if PEPFAR is to follow the science — and it must — improving outcomes for these stigmatized and often criminalized communities will be essential.
More reading:
► As HIV and COVID-19 collide, questions loom over PEPFAR's future
► Deborah Birx: PEPFAR's local partner transition 'critical' to coronavirus response
Finally, it is now clear that the COVID-19 vaccines are critical for global control of the pandemic. PEPFAR has helped develop the capacity of and support the workforce for the HIV/AIDS response in sub-Saharan Africa, Southeast Asia, and the Caribbean. This infrastructure can be harnessed for the COVID-19 vaccine rollout and supported to continue vital work on HIV.
In 2023, Biden will oversee PEPFAR’s 20th year. The anniversary is an opportunity to take stock of PEPFAR and to consider its future in a global health landscape marked by COVID-19.
PEPFAR can and should be the programmatic basis for stronger and more resilient health systems in partner countries. It will likely be more of a technical partner in many places, as economies recover and local health investments expand. But we will need to continue to support strong HIV/AIDS efforts in fragile states and in those where in-country resources for health remain challenged. The world can respond to a new pandemic without giving up on the main gains against the HIV pandemic. We really have no other choice.
