What a PEPFAR funding cut could mean for the HIV response in Botswana

Concerns abound over the Biden administration’s planned funding cuts to the U.S. global AIDS initiative in fiscal year 2025. Politico revealed that the Biden administration plans to cut PEPFAR funding by more than 6% in fiscal 2025, which has been confirmed by the State Department. The cuts include reductions in programs for key populations. But news of the impending cuts doesn’t come as much of a surprise for one organization in Botswana, a country already anticipating a transition out of PEPFAR support in the coming years. “Because we are an upper-middle-income country … there is an expectation that at some point donors should transition out of the country. So in fact, the transition process had already started with PEPFAR and Global Fund [to fight AIDS, Tuberculosis and Malaria], helping the country put together a transition plan,” Cindy Kelemi, executive director at the Botswana Network on Ethics, Law and HIV/AIDS, or BONELA, told Devex. “So the cut was somewhat expected.” But that’s not to say the organization isn’t concerned about the planned cuts. Amid the rise of anti-gender movements and persistent challenges faced by key populations in accessing HIV and AIDS services, the reasonable response would be an increase in funding to support organizations addressing these challenges, according to Nana Gleeson, finance, operations, and resource mobilization manager for BONELA. “But instead, if the funding remains constant or goes down, it almost means … it's being ignored,” she said. PEPFAR has invested approximately $1 billion in health assistance to the government of Botswana, as well as additional financial support for service delivery and technical assistance to the government and local nongovernmental organizations. A cut in funding would be particularly consequential for community-based programs that support key populations. In Botswana, these programs are dependent on PEPFAR and Global Fund support, Kelemi said. “We find ourselves as a country having really made significant strides. But those strides are at risk because of the funding situation. … We may find ourselves regressing. --— Cindy Kelemi, executive director, Botswana Network on Ethics, Law and HIV/AIDS While the government, through the National AIDS & Health Promotion Agency, provides funding to organizations, it doesn’t have the full capacity yet to take over all programs funded by the donors, she added. Case in point: for the financial year 2023-2024, the agency cut its funding to organizations by around 30%, according to Kelemi. “That goes to show that sustaining, especially the community response, becomes a real challenge or at least it is at risk if we don't have funding from PEPFAR,” Kelemi said. It could also affect gains made by the country in addressing HIV and AIDS. Botswana has made significant progress in its HIV and AIDS response. It is one of five countries that has achieved the UNAIDS 95-95-95 targets, which translates to 95% of people with HIV knowing their status, 95% of people who know their status are on lifesaving antiretroviral treatment, and 95% of those receiving treatment achieve viral suppression. However, the country still has over 2,000 new infections annually among adults, according to Kelemi, indicating the need for continued investment in the response. The potential PEPFAR funding cuts could jeopardize the country's ability to sustain its achievements and further progress toward epidemic control. “We find ourselves as a country having really made significant strides. But those strides are at risk because of the funding situation. So it's highly likely that without the requisite support, we may find ourselves regressing, which will be the biggest challenge,” Kelemi said. While the organization does not receive substantial funds from PEPFAR — they received about $180,000 for community-led monitoring during the last financial year — she said a reduction in PEPFAR funding will affect their ability to provide services for key and vulnerable populations, including the provision of legal services to protect the rights of people affected by HIV. “In the absence of dedicated funding, it means the clients that we are currently supporting will be at risk of losing that service. However, for now, we can say because there is Global Fund, we still have the opportunity to continue some of our programs. But without both the Global Fund and PEPFAR, it will be really a dire situation for our clients,” Kelemi said. There are groups however that are 100% dependent on PEPFAR that will likely close down in the absence of PEPFAR funding, as well as government programs reliant on PEPFAR that may not be able to continue. “Botswana is an upper-middle-income country, and we don't have many donors that are at our disposal to say they can continue where PEPFAR has left off,” she said. If donors such as PEPFAR decide to reduce funding, they said it should be accompanied by substantial investments in building the country's capacity to take over the programs. “Until that is done, then it is irresponsible to do the transition, or to reduce funding because it means inevitably that lives will be lost,” Gleeson said.