PEPFAR chief warns waning political will could hurt AIDS fight

John Nkengasong, the U.S. global AIDS coordinator, is worried that if the world fails to eliminate HIV as a public health threat by 2030, political leaders will lose interest in fighting the disease and pave the way for its resurgence. “We cannot relent,” Nkengasong told Devex in advance of the 25th International AIDS Conference in Munich, Germany, which began Monday. But HIV advocates hope Nkengasong’s own government shares that sense of urgency. In the face of reported budget reductions for partner countries of the U.S. President’s Emergency Plan for AIDS Relief’s, or PEPFAR, next year, as well as concerns about transparency and a lingering domestic U.S. political fight over abortion, Nkengasong insists that U.S. President Joe Biden’s White House has not lost focus. “The Biden administration is very committed to PEPFAR and to the fight against HIV/AIDS,” he said, pointing to mentions of PEPFAR in both Biden’s 2023 State of the Union address and his speech to the United Nations General Assembly the same year. The global AIDS gathering in Munich, which brings together an estimated 15,000 people involved in the HIV response, comes at a critical time. With only six years remaining to achieve the U.N. Sustainable Development Goal on ending AIDS, as of 2023, the annual number of new HIV infections had stagnated at roughly 1.3 million, while 630,000 people died due to AIDS last year, according to the Joint United Nations Programme on HIV/AIDS, or UNAIDS, which released the latest figures on Monday. If the world fails to increase HIV testing and treatment services to achieve UNAIDS’ targets, the international body projects the result would be 17.7 million AIDS-related deaths between 2021 and 2050. The conference also arrives at a moment of heightened anxiety about PEPFAR, the 21-year old flagship U.S. global AIDS initiative that works in 55 countries and is credited with saving 25 million lives. Alongside concerns about the program’s budget allocations, some PEPFAR advocates have alleged that post-pandemic changes to the initiative’s famously detailed planning process have made it less transparent and less responsive to civil society groups. PEPFAR’s prognosis Perhaps more alarming, for the first time in its two-decade history, PEPFAR failed to secure bipartisan support for a full, five-year legislative reauthorization this year, after conservative groups launched a public campaign against the Biden administration accusing it — without evidence — of using PEPFAR to fund abortion, which is legally prohibited. PEPFAR supporters were forced to settle for a temporary one-year reauthorization that leaves the program’s policy direction open to renegotiation by U.S. lawmakers next March — raising the stakes of November’s U.S. elections for a global health sector that is increasingly drawn into American culture war battles over abortion, LGBTQ+ rights, and federal spending. HIV advocates predict that PEPFAR’s own health will be an unofficial topic of discussion in the AIDS conference hallways. Nkengasong told Devex that at the conference, PEPFAR will announce new efforts to protect funding for so-called key populations, groups disproportionately affected by HIV that include men who have sex with men, transgender individuals, sex workers, people who inject drugs, and people in prisons — which has been a central concern raised by advocacy groups. In Munich, Nkengasong plans to focus on the importance of zeroing in on what he calls the “Five Ps” — programs, policies, politics, partnerships, and a better understanding of the pathogen. Getting those things right, he told Devex, will allow HIV responders to sustain and accelerate the gains they have made, while also charting a course to supporting people living with HIV after 2030. “2030 should be that mountain top moment when we get there and we say, ‘Yes, we did it.’ Without that, I think my concern and worry is that the political strength behind the fight against HIV will wane,” he said. Don’t call it a cut Earlier this month, Politico reported that PEPFAR’s 2025 program budget includes a 6% reduction spread unevenly across its partner countries. HIV advocates in some of those countries — such as Botswana — have warned that lower allocations from PEPFAR could fall especially hard on community-based programs that are particularly dependent on external support. Speaking to Devex, Nkengasong sought to clarify the reason for those reductions. The Biden administration is not requesting any less funding from Congress for PEPFAR, he emphasized. However, the amount of money the program has available to spend has gradually declined as PEPFAR has drawn down funds that were carried over from previous years. That has happened even as PEPFAR has increased the number of people on treatment for HIV, which Nkengasong attributed to increased efficiency in the program’s service delivery. “The Biden administration has not asked for a budget cut for PEPFAR at all. I really want that to go on the record,” he said, adding that any suggestion that the White House is reducing PEPFAR funding is “absolutely not true.” What is true is that U.S. funding for PEPFAR has plateaued at roughly $4.8 billion, despite calls to accelerate HIV response efforts in the face of stubborn infection numbers and looming deadlines. “You go to war with what you have, not what you want,” Nkengasong said. A new earmark Against a backdrop of strained budgets, advocates have raised particular concerns that funds targeting key populations could fall by the wayside if external funding from donors such as PEPFAR recedes and national governments struggle — or choose not to — direct their own resources toward these groups. Nkengasong told Devex that PEPFAR is launching a new initiative aimed at protecting funds for key populations — “almost like an earmark in those resources so that it is sustained in the Country Operational Plan” that guides PEPFAR spending. That effort, not yet announced, will be supported by another initiative led from PEPFAR’s Washington, D.C., headquarters, Nkengasong said, emphasizing the importance of “leading with data.” “We are not doing this just because of key populations. We’re doing this because it is very important that we win the fight of new HIV/AIDS infections among key populations,” he said. That fight has been made harder by a rash of discriminatory laws and proposals in some of PEPFAR’s African partner countries that have sought to criminalize homosexuality. This wave of legislation presents a barrier to accessing key populations in the HIV fight by deterring people who fear persecution from seeking treatment and creating risks for those who seek to provide it. It also presents a conundrum at a moment when international donors, including PEPFAR, want national governments to take greater financial and programmatic ownership of their HIV services: What happens if those national leaders also support the persecution of LGBTQ+ people? “Countries must be in the driver’s seat,” Nkengasong said. “They have to lead the response with our support, and they also have to lead recognizing that you cannot discriminate, you cannot criminalize certain populations, otherwise you will not win the fight against HIV/AIDS.” Nkengasong, a Cameroonian virologist who won accolades as the first leader of the Africa Centres for Disease Control and Prevention, said he has leveraged his long-standing relationships with African heads of states and ministers to push back against discriminatory laws that endanger HIV treatment goals. “Everywhere I’ve gone I’ve met with the leadership on the continent. We’ve talked about it very openly,” he said. Nkengasong pointed to a joint statement written with Winnie Byanima and Peter Sands, the heads of UNAIDS and the Global Fund, respectively, warning Uganda President Yoweri Museveni over his endorsement of the 2023 Anti-Homosexuality Act — which prescribes life imprisonment for gay sex, among other draconian provisions. Despite international pressure and condemnation, the law remains in effect. Beyond 2030 Nkengasong said he has also pressed partner governments to keep the fight against HIV high on their own domestic political agendas — even as the images of hospital wards in Kenya, Uganda, Cameroon, and South Africa full of AIDS patients “waiting to die” recedes from memory, he said. “My message is clear: You need to up your own domestic contribution” to the HIV response, Nkengasong told Devex. He said that with Nigeria, Cameroon, Eswatini and others, that message — coupled with sustainability road map agreements that outline how countries will take greater ownership of their response — has led to more domestic spending on HIV. “It requires that we have these dialogues with the countries to say, ‘Look, yes, you’ve always had domestic financing, but let’s be a bit more intentional and make sure that you see this as an investment opportunity,’” he said. “Our donor funding is there to support and catalyze, but not to lead and replace domestic financing,” he said. Nkengasong sees a cautionary tale in the global effort to fight malaria during the last century. He pointed to a highly-successful global malaria program in the 1950s that was subsequently shut down in the late 1960s, only for countries that had brought down malaria rates to very low levels to witness a dramatic resurgence. Even if the world ends HIV as a public health threat by the end of this decade, the fight will not be over, he said. “When we get to 2030, we’ll have about 30 million people that will be living with HIV/AIDS, and they need quality care for the rest of their lives,” he said. “That is the sustainability that PEPFAR is advocating for.”