What Biden's State of the Union address means for PEPFAR

When former U.S. President George W. Bush made his State of the Union address in 2003, it came with a bang — the creation of a global program to address the HIV and AIDS epidemic. Two decades later, on its 20th anniversary, advocates of the U.S. President's Emergency Plan for AIDS Relief, or PEPFAR, were hoping U.S. President Joe Biden would announce something big too, such as a commitment to reauthorize the program and increase its funding. That didn’t go exactly as they hoped — Biden’s PEPFAR tribute was down to five words, “it’s been a huge success” was all he said — but some analysts say it speaks volumes. “State of the Unions are precious real estate. And the fact that PEPFAR got some of that real estate is pretty notable, and I think sends a signal that this program is important to the administration … but also signaling that this is truly a bipartisan legacy that carries on,” Jennifer Kates, senior vice president and director of global health and HIV policy at the Kaiser Family Foundation, told Devex. But even if the U.S. Congress doesn’t reauthorize PEPFAR, Kates said it can continue to operate, and Congress can still appropriate funds for the program. Last month, Biden stated his intentions of working with Congress on PEPFAR’s reauthorization in 2023. Reauthorizing PEPFAR has its advantages, however, including sending the message that members of Congress support and recognize its achievements, and that the U.S. remains steadfast in supporting the global HIV response. In the current U.S. political climate, a funding increase will be difficult for Biden to achieve, given “the overall dynamic in the Congress, not specific to PEPFAR, but around the budget, around partisanship,” Kates said. But there are several reasons why increased funding matters, not just for the HIV response, but also in reducing deaths from other causes, as well as for pandemic preparedness efforts. With inflation, the program may do less over time if it continues to operate on a flat level of funding. And PEPFAR may no longer have unspent appropriated funds to do more, Kates said. That could have devastating effects on the HIV response, given its importance as a donor. Millions continue to be infected with HIV yearly, don’t know they are infected, and aren’t accessing antiretroviral therapy. UNAIDS estimates 1.5 million people were newly infected with HIV in 2021, and 5.9 million didn’t know their status. A quarter of the people who knew, meanwhile, aren’t accessing antiretroviral treatment. Asia Russell, an AIDS activist and executive director of the Health Global Access Project, also wrote in a press release prior to Biden’s SOTU address that the pace of HIV treatment scale-up in PEPFAR countries has slowed down under his watch. In addition, there’s been an increase in attacks targeting populations at greater risk of getting HIV, such as sex workers, LGBTQ people, and people who use drugs in PEPFAR-supported countries. She called on Biden to commit to a funding increase of $750 million for PEPFAR, alongside calls to “defend the rights and freedoms of marginalized groups,” and “break the stranglehold of drug company monopolies” obstructing the rapid rollout of “game-changing” HIV therapies. But financing PEPFAR has gains beyond HIV. According to a KFF analysis, the program has contributed to a reduction in mortality from all causes in countries where it operates, including in maternal and child mortality. It also found PEPFAR funding contributed to child immunization rates in countries, and GDP growth. “It suggests that if there's additional funding, there could be even further effects in the future, not just for HIV,” Kates said. PEPFAR is also operating at a time of increased attention to global health security, both in the U.S. and globally. Many health experts and observers are looking at how the program, with its flat funding and new vision, will continue to address the HIV epidemic, while also helping countries prepare for and respond to other health threats. “I hope to hear more about how [the Biden administration] plans to leverage existing PEPFAR investments to serve as a platform for pandemic preparedness and response while re-doubling efforts to close gaps in access to HIV prevention, diagnosis and treatment services,” Katherine Bliss, senior fellow and director for immunizations and health systems resilience at the Center for Strategic and International Studies’ Global Health Policy Center, wrote to Devex.