What should a responsible PEPFAR transition look like?

As the President’s Emergency Plan for AIDS Relief, or PEPFAR — the world’s largest bilateral HIV program — faces unprecedented budget threats and a shifting global health landscape, experts are calling for a responsible transition, one that ensures countries can take the reins without sacrificing the gains of the past two decades. Speaking at a recent Devex Pro Briefing, Dr. Mark Dybul, former U.S. Global AIDS Coordinator and one of PEPFAR’s original architects, emphasized that PEPFAR and The Global Fund to Fight AIDS, Tuberculosis and Malaria were never intended to be permanent. “If you go back and look at the legislation, partnership compacts are mentioned in the 2008 reauthorization, and we had started working on them before the end of the Bush administration,” he said, adding that the administration had agreed on a five-year transition plan with South Africa, which was later derailed by the 2008 financial crisis. By the end of 2023, around $19.8 billion was available to support the HIV response in low- and middle-income countries, with about 59% coming from domestic funding, though amounts varied by country. Looking ahead, Dybul said responsible transitions away from PEPFAR support should include a gradual pace reduction — with annual funding decreasing as countries assume more responsibility — developed in collaboration with recipient countries. He added that African leaders, including Ghanaian President John Mahama and Rwandan President Paul Kagame, are already taking an active role in shaping their countries’ transitions and working to bring other African leaders into these conversations. “I think there are probably about a dozen countries that could transition almost entirely within two to three years,” he said. “But then there are a lot that can’t and that will need five, seven [years], maybe even a little bit longer, and then there are some that we will need a humanitarian bucket for because there’s some countries that will never be able to do it.” Dr. Jennifer Kates, senior vice president at KFF, added that there are already existing models and frameworks for transitions. “Whether it’s putting in very specific graduation criteria that already are the kinds of things that the Global Fund uses, [or] putting in very specific co-financing requirements — again, something that’s used by many others, but just not typical in the U.S. context.” However, she cautioned that transitioning during a time of crisis could be dangerous. “Unfortunately, given what’s happened in the last couple of months, we are in a crisis situation, and that’s not good for transition for anything, because you can make rash decisions. You can make decisions that are hard to undo,” she said. For his part, Dr. Jirair Ratevosian of the Duke Global Health Institute emphasized that donor transitions are not just technical matters — they are also deeply geopolitical. “In places like in Africa and other regions, there’s already a shift happening in more local ownership and regional leadership from the emergence of the Africa CDC [and] PAHO in other regions, they’re actually moving to take more control over their policies and procurement policies,” he said. But Asia Russell, executive director of Health GAP, warned that “the politics go in multiple directions” and that many governments are still unwilling to fully acknowledge the scale of their HIV epidemics or embrace the necessary solutions. In 2023, 39.9 million people were living with HIV globally, with 1.3 million new infections. “If indeed we were just looking at science and just looking at the accountability of a prime minister or president to their own people. PEPFAR would have transitioned long ago,” she said. “But in reality, many countries are unwilling to accept the epidemics they have, unwilling to embrace science, unwilling to embrace human rights, and to step aside from colonial artifacts of criminalization of LGBTQ and other highly vulnerable populations.” Panelists agreed that the future of PEPFAR is closely tied to broader changes in U.S. foreign assistance, including the dismantling of USAID and the shift of its remaining programs to the State Department — which will likely lose thousands of staffers in a reorganization. Russell warned about the potential loss of institutional expertise, particularly from the U.S. Centers for Disease Control and Prevention and the U.S. Agency for International Development. “If on Day 1 of implementation of whatever the State Department’s new shape comes and that expertise is not there, then even with full funding, what [will] the awards look like?” she asked. “How are they managed? How is impact measured and tracked, and stood up? … It’s terrifying that these questions are not answered.”