BERLIN — As it wraps up its latest funding round, the President's Emergency Plan for AIDS Relief is prepared to introduce unprecedented cuts to country programs in sub-Saharan Africa, designed to spur domestic policy changes and programmatic improvements.
But observers warn that if enacted, the cuts could undermine advances those countries have made against the HIV epidemic, particularly among marginalized communities that struggle to access health services.
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More than 16 years after its authorization, PEPFAR is in the midst of a program-wide pivot. In 2017, officials identified 13 countries with both a high HIV burden and an opportunity to achieve epidemic control by 2020. With global funding for HIV flagging, PEPFAR's leadership has underscored the importance of achieving epidemic control — which means limiting the number of new infections each year to less than the number of deaths among people living with HIV — to ensure the sustainability of the response.
PEPFAR flooded those 13 priority countries with programs designed to dramatically reduce HIV transmission. As a result, some nonpriority countries have seen funds shrink.
But dramatic cuts to two priority countries during the current funding round, Tanzania and Kenya, took civil society organizations by surprise.
In individual letters sent this year to U.S. ambassadors, who are responsible for implementing PEPFAR programs in their respective countries, PEPFAR chief Deborah Birx laid out the planned allocations for fiscal year 2020.
Planned spending in Kenya fell from $505 million in last year's Country Operational Plan to $350 million in next year's plan. Tanzania fell from $512 million to $395 million. A Center for Global Development analysis found a 44% cut from Kenya's actual funding in fiscal year 2017 — the year PEPFAR announced its pivot — and its projected funding in 2020. Tanzania saw a 30% drop.
"Everyone in Kenya is alarmed with the cut," said Nelson Otwoma, executive director of NEPHAK, a network providing support to Kenyans with HIV. “Especially for key populations," such as sex workers and men who have sex with men, "if PEPFAR left them, the government will not take them up."
PEPFAR officials have told local activists that Kenya’s programs for key populations will be slashed from $16 million to $5 million, according to Maureen Milanga, associate director of the global HIV advocacy group Health GAP. PEPFAR did not respond to repeated requests for comment from Devex.
Milanga, who is based in Kenya, said the cuts could force marginalized groups to seek services in general health facilities, where they are likely to face discrimination.
“We are outraged by PEPFAR’s move to slash the key population program,” she said. “This won’t deliver epidemic control. It will increase the vulnerability of HIV-positive and HIV-negative Kenyans.”
Some nonpriority countries also took unexpected hits. While their PEPFAR budgets are often smaller than their priority counterparts, they share similar concerns about the impact rollbacks could have.
Under Birx, PEPFAR has focused on judicious spending to achieve definitive results. With these cuts, PEPFAR is intensifying its message that if a country is not making progress toward specific targets, either for programmatic or policy reasons, then the money will go elsewhere. "This last COP round has been more of a heavy hand," Jen Kates, director of global health and HIV policy at the Henry J. Kaiser Family Foundation, told Devex.
In Kenya, Milanga said PEPFAR officials have highlighted gaps between domestic policy and international recommendations, and a shortage of health workers to administer programs. But cuts are not the answer to those problems, she said, instead urging officials to redirect money to improve program quality. PEPFAR has also been critical of the delayed release of the Kenya Population-Based HIV Impact Assessment survey, which is needed to understand the state of Kenya's epidemic.
In Tanzania, Birx expressed concern about the country program's underperformance in some areas of its response. But the main problem appears to be the government's growing intolerance of marginalized groups, which has led to restrictions on HIV services for men who have sex with men. In her letter to the Tanzania team, Birx warned, "Formal and informal policy developments in Tanzania undermine efforts to diagnose and treat persons most vulnerable to HIV infection."
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There could be opportunities to regain the lost investments. Birx laid out five steps Tanzania needed to take to receive additional funding, including ensuring access to HIV services for vulnerable communities. In Kenya, Otwoma hopes releasing the KENPHIA results could jump-start discussions.
PEPFAR has pledged that HIV patients already receiving life-saving anti-retroviral therapy will be able to continue their regimens in all countries. But advocates say the cuts will have implications, particularly for vulnerable populations that domestic governments do not want to support, ultimately moving them further away from epidemic control.
Though it is mostly too late to reverse decisions on this year’s COPs, some are looking to the example set by South Africa, where activists successfully lobbied PEPFAR to restore proposed cuts, as an example for when the next year’s discussions open.
South Africa is not a priority country but has the largest HIV epidemic in the world and receives significant PEPFAR funding. Government officials said they received $670 million during the last fiscal year, which included some money rolled over from the previous year. PEPFAR threatened to slash spending to $400 million this year, because "progress has been grossly sub-optimal and insufficient to reach epidemic control," according to Birx's country letter.
Activists argued that the problems PEPFAR identified were likely linked to government shortcomings, including the failure to hire 8,000 community health workers with PEPFAR funds.
They argued that patients should not suffer as a result of government dysfunction. And with the commitment of government officials to improve, they were able to convince PEPFAR to increase its commitment to $730 million, according to Nkululeko Conco, an attorney with Section 27, a public interest law center that was involved in the lobbying effort.
While the uncertainty is alarming, he said the threat may have achieved its objective of refocusing government attention on the target of epidemic control. "I believe the [health department] has started taking the program seriously, which it did not before the threat of the funding cuts," he said.
In other countries, though, advocates worry about what will happen if governments don’t take the threat so seriously.