PEPFAR seeks coordination with other aid donors, says US AIDS chief

WASHINGTON — Ambassador Deborah Birx, the U.S. global AIDS coordinator, says she is not worried about the Trump administration’s repeated proposals to slash her budget, but that is not stopping her from looking for other sources of funding wherever she can find them.

This year, for the first time, the President’s Emergency Plan for AIDS Relief is actively pursuing opportunities to enlist other countries’ official development assistance in its efforts to control the epidemic, Birx said in a discussion with Devex President and Editor-in-Chief Raj Kumar on Tuesday.

For example, PEPFAR’s DREAMS initiative, a partnership to reduce HIV infections among adolescent girls, has a vital interest in keeping young women in school. Birx said her team has been working to identify which donors are providing education funding in the countries where DREAMS operates and then working with those donors to align funding to reduce HIV transmission.

“Is it DFID? Is it Germany? Who do I need to go to to ensure the most vulnerable girls have access?” Birx said.

That proactive outreach is taking place alongside an administration criticized for repeatedly proposing budget reductions that experts say would, if enacted, cause millions of deaths and undermine progress in the global effort to end the HIV epidemic.

Birx has repeatedly downplayed the impact of these proposals on PEPFAR’s programs. On Tuesday, she said that an administration’s budget is not the sole indicator of its support for a given program. She pointed to President Donald Trump’s endorsement of efforts to defeat AIDS within the U.S. “and beyond” in his 2019 State of the Union address.

“President Trump added the ‘and beyond.’ It wasn’t in his speech, but he understood that we have a global epidemic as well as a local epidemic and we have to respond to both,” Birx said.

If the administration really did not like PEPFAR, Birx said, it would have fired her and cut the initiative’s budget entirely — instead of proposing a $1.35 billion cut, which it knew the U.S. Congress would likely overturn.

“I don’t see that the current administration is treating PEPFAR any differently than any prior administration,” Birx said.

The PEPFAR chief said that her team has been working to shield some of the initiative's high-performing partners from an interagency budget process that tends to fund the same things year after year. Her office has created a fund that allows “super high-performing partners” to come directly to PEPFAR for funding, Birx said.

“Agencies and partners can come forward, independent of that normal dialogue that occurs between the agencies, to ask for additional funding unilaterally,” she said, adding that the intention is to reward “extraordinary work.”

While Birx is one of very few senior officials appointed during the Obama administration and retained in her post by the Trump administration, she has also not shied away from pushing PEPFAR in directions that invite criticism.

In 2017, Birx announced a new PEPFAR strategy that focused on 13 priority countries and aimed to achieve epidemic control in those countries by 2020. That shift left some advocates wondering what would happen to the dozens of other countries where PEPFAR operates and raised questions about how Birx was prioritizing investments in a constrained budget environment.

In 2018, Birx unveiled a plan to direct 70% of PEPFAR’s funding to “indigenous” organizations — those based in the countries where PEPFAR operates. Given that former U.S. Agency for International Development Administrator Rajiv Shah struggled with a similar plan — but with only a 30% target — some have questioned whether Birx’s goal is realistic or aspirational.

“PEPFAR doesn’t make up fake targets,” she said Tuesday.

Birx credited work that was done under previous “localization” efforts with laying the groundwork for agencies to meet their allocation target this time around.

“There’s always a ramp-up, and before you get to the inflection point, it’s frustrating for everybody, but the groundwork that was laid is now making it possible,” Birx said.

All of the agencies that allocate PEPFAR funding have reached 40% local spending, and she said she expects most will get close to or exceed 70%.

“In no case are the indigenous partners performing at a lower quality or a lower performance than our international groups,” she added.

While Birx seeks to direct more funding to organizations in PEPFAR’s partner countries, she said that one of the biggest obstacles is often those countries’ governments, with some refusing to grapple with the reality of their epidemics or actively obstructing services to key populations for HIV prevention and treatment.

That has led PEPFAR to shift its approach to creating incentives, from providing more funding in the hope that governments will change their policies to withholding it from those that do not.

“We started out putting out more money, and more money, and more money, and the policies didn’t shift. Shockingly, taking away money has gotten people’s attention much more than giving more,” Birx said.

She added that while many equate “country ownership” of a PEPFAR program with government ownership, that is not how her team sees things.

“When we look at country ownership, we look at it as civil society and government voices equal at the table — and indeed, even the clients we’re serving should have the greater voice,” Birx said.

According to Birx, that focus on equity is what makes her willing to shift resources away from the places they have historically been directed and toward the places she thinks they are needed.

“When you have a program and you keep adding money, you add to what you have rather than what you need,” she said.