What the Trump administration could mean for US HIV/AIDS spending

In Cambodia, the Centers for Disease Control and Prevention's Global AIDS Program works with the national government as well as PEPFAR and other partners in the prevention and treatment of HIV and AIDS in the country. Photo by: Un Yarat / U.S. Embassy Phnom Penh / CC BY-ND

HIV/AIDS advocates are warning against any cuts to U.S. spending on the fight against the disease as the new administration of President-elect Donald Trump determines how it will approach global assistance.

The U.S. government is the single largest donor to international HIV efforts worldwide and the U.S. President’s Emergency Plan for AIDS Relief, created by President George W. Bush 13 years ago, has dedicated approximately $60 billion to the fight against HIV/AIDS.

While Trump has not said anything specifically about the PEPFAR budget, comments such as  “Americanism, not globalism, will be our credo,” and his statement that the U.S. should “stop sending foreign aid to countries that hate us,” have raised concerns among some development professionals that Trump may cut the foreign aid budget and that this in turn could spell a reduction in funding for HIV/AIDS prevention and treatment.

Top development officials also told Devex in interviews they feared the administration will limit the kinds of organizations and work PEPFAR funds, namely family planning services, as previous Republican administrations have done.

On the other hand, PEPFAR has “long received strong bipartisan support,” PEPFAR chief Ambassador Deborah L. Birx, said in a release on Thursday morning, timed with World AIDS Day. Analysts expect that attempts to reduce funding would be met with strong opposition from both parties.

The U.S. has played a major role in the dramatic increase in treatment coverage across countries, mostly in Africa, which have the highest HIV infection rates. U.N. figures show the number of people receiving lifesaving treatment rose from 49 percent in 2014, to 56 percent by 2015. Furthermore, AIDS-related deaths have fallen by 45 percent to 1.1 million people in 2015, and the number of new HIV infections among children has declined by more than 70 percent since 2001.

On Thursday morning, PEPFAR released new data indicating that the epidemic is coming under control among older adults and babies in Malawi, Zambia and Zimbabwe, three countries where the program invests heavily. The program said it had exceeded implementation goals set in 2015, now reaching 11.5 million with ARV treatment and preventing transmission to 2 million babies.

However, the most recent HIV/AIDS statistics still paint a worrying picture. There were approximately 2.1 million new infections in 2015, the majority in sub-Saharan Africa, and of this number about a third are young people, aged between 15 to 24, a quarter of which are women. Young women and adolescent girls are 14 times more likely to contract HIV than their age peers among men in sub-Saharan Africa, according to PEPFAR.

On top of this is the decline in non-U.S. donor funding for HIV/AIDS, which fell by more than $1 billion in 2015, the first drop off in five years, according to Jen Kates, director of global health and HIV policy at the Kaiser Family Foundation.

Kates said the shortfall was mainly due to European governments experiencing “competing demands” due to the refugee crisis, and so there was less “attention on HIV.”

Any future reduction in U.S. commitments to global HIV/AIDS funding would be bad news, she said.

“If Trump doesn’t get the sequester lifted on spending, then that would mean everything that wasn’t entitlement or infrastructure spending would be enormously squeezed and we could expect the aid budget to be cut,” according to Amanda Glassman, vice president for programs at the Center for Global Development.

The global health community, Glassman said, needs to remind both policymakers and the public that protecting domestic public health often requires addressing issues overseas.

She said the recent downgrading of the Zika virus, so that it is no longer an international public health emergency, by the World Health Organization was “bad timing,” since it could downplay the importance of international health priorities.

Kates cautioned against the Trump administration re-instituting restrictions on what PEPFAR can fund if it reinstated the “Global Gag Rule”.

The rule, first instituted by Ronald Reagan in the 1980s but repealed by Barack Obama, prohibits U.S. agencies from providing funding to foreign organizations that offer information about abortions or provide the service.

In the past, aid organizations say the rule affected HIV prevention and treatment because many NGOs working with adolescent girls, which are an “extremely vulnerable” group when it comes to the epidemic, combine HIV services with family planning and other offerings, Kates said.

“There is a risk that if policy restrictions come into force, this could mean some girls and women do not get the full range of services they need,” Kates said.

This could undermine PEPFAR’S current direction under Birx of greater flexibility and an emphasis on directing funding to “marginalized groups,” where evidence and data show there is the greatest need, Kates said.

“In recent years PEPFAR has been able to evolve and change and move with the epidemic, and has bipartisan support to do that.  It’s unknown whether this new administration will make moves to change that,” she said.

However, other development professionals expressed cautious optimism that the PEPFAR budget would be protected. Program director for global HIV/AIDS at the World Bank, David Wilson pointed out that that the composition of HIV funding has changed in recent years to emphasize treatment as the “big item.”  

“I try and focus on broad consensus that treatment really matters and is likely to be preserved,” he said.

Another senior development professional, who did not want to be named for commercial reasons but who works on PEPFAR-funded HIV/AIDS projects, emphasised bipartisan support for PEPFAR in Congress and pointed to South Carolina Republican Sen. Lindsey Graham as “the single biggest proponent” of PEPFAR, making it unlikely the Senate would “roll over on something as important as PEPFAR,” he said.

He added that the incoming secretary of state would hear “loud and clear” from every ambassador in sub-Saharan Africa, and other countries affected by AIDS, that PEPFAR is “one of most important initiatives to come out of U.S. in terms of foreign assistance in last 15 years.”

However, the HIV/AIDS expert warned the Global Fund, of which the U.S. is the biggest donor, may not be as secure and said the incoming administration had made it clear it was not “predisposed to multilateral funding mechanisms” such as the fund. For example, at a Florida rally in early November, Trump pledged to “cancel billions in global warming payments to the United Nations” if he won the election.

The source cautioned against the view that the U.S. has single handedly fought the AIDS fight, citing UNAIDS figures showing that country contributions now represent more than 50 percent of funding to HIV/AIDS programs. He also warned that if the U.S. were to cut funding then that could be used as an excuse for other donors to also reduce their own commitments.

“Americans are not paying for everything. It’s a large chunk and it’s a leadership chunk, and the downside and damage of a stepping back would be substantial. The lives of millions of people on treatment will end and the epidemic will come back,” he said.

Stay tuned to Devex for more news and analysis of what the Trump administration will mean for global development. Read more coverage here and subscribe to The Development Newswire.

About the author

  • Sophie Edwards

    Sophie Edwards is a Reporter for Devex based in London covering global development news including global education, water and sanitation, innovative financing, the environment along with other topics. She has previously worked for NGOs, the World Bank and spent a number of years as a journalist for a regional newspaper in the U.K. She has an MA from the Institute of Development Studies and a BA from Cambridge University.