Why PEPFAR has bigger problems than reauthorization

Congressional authorization for the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, is all but certain to expire tomorrow. But that is far from the main threat to PEPFAR’s survival. Because the program is written into federal law, “actual permission for the program to exist doesn’t expire,” even if PEPFAR’s authorization does, Katie Coester, the associate director of public policy and advocacy at the Elizabeth Glaser Pediatric AIDS Foundation, told Devex. In addition, the U.S. Congress allocated money to PEPFAR in the budget it adopted earlier this month to keep it funded through the end of the fiscal year. “As long as there is funding appropriated for the program, it can technically and legally continue,” Jennifer Kates, the director of the global health and HIV policy program at KFF, told Devex. That does not ensure that it will continue, though. The program, which is credited with saving 26 million lives since it was launched in 2003, is in disorder. PEPFAR was stalled by the stop-work order on all U.S. aid two months ago as the Trump administration conducts a review of American spending on global assistance. Waivers granted by the U.S. Department of State theoretically allowed some services to resume. However, the administration has dismantled much of the U.S. Agency for International Development, which implemented the majority of PEPFAR programs. Payment programs have also been stalled or shut down completely, slowing the distribution of crucial funding. As a result, even the lifesaving HIV services permitted under the waiver are in jeopardy. Kates called it “the most disruptive and biggest threat to the future of the program.” In Uganda, where PEPFAR serves as the backbone of the country’s HIV response, it is impossible to comprehensively establish what services are actually working. But faults are emerging. Enid Kyomuhendo, a Kampala-based sex worker, was due for a refill of the antiretroviral drugs that suppress her HIV infection just days after the stop-work order went into effect. The clinic where she normally picks up the treatment was closed. That immediately sent her into a panic. “I got so worried,” she told Devex. “I started taking alcohol. I was thinking that anytime I am going to die. It became this life of hopelessness.” It took two months before Kyomuhendo was able to get her refill. At that time, her skin broke out in a dark, itchy rash. She worries she is now resistant to the ARVs, a possible consequence of interrupting treatment, which would worsen her condition. The test she would need to determine if she is resistant is unavailable. “The health workers just tell me to take the medicine because they don’t know what is going to happen next,” she said. Even basic services are breaking down. An HIV counselor working at a PEPFAR-funded clinic in eastern Uganda told Devex she ran out of testing kits last week. The shortfall highlights the gaps in the Trump administration’s waivers. While treatment can resume, health workers have been told that the agencies responsible for transporting medicines and supplies, such as HIV tests, had their USAID contracts canceled. Supplies are now dwindling, where they haven’t run out entirely. Speaking on the condition of anonymity for fear she would lose her job, the counselor said she was forced to use a store of self-tests last week instead of the standard HIV testing kits. But only 100 of the self-tests were available and she often conducts more than 170 HIV tests each week. “When I don’t have, I will stop testing,” she said. “Because we tried to look around from other facilities. They were also like, we don’t have stock, we don’t have stock, we don’t have stock.” Following local media reports of shortages in HIV treatment last week, Uganda’s Ministry of Health released a statement last week pledging “that HIV prevention and treatment services remain accessible and free nationwide.” Civil society groups in Uganda have also flagged the fact that PEPFAR’s country operational planning, or COP, process does not appear to have started. These annual discussions, which usually begin around this time, take place in most PEPFAR partner countries to set the strategic plan for the coming year. On a global level, “we have no insight into the COP process,” said Coester, who also serves as co-chair of the Global AIDS Policy Partnership, an advocacy coalition focused on U.S. global HIV policy. Right now, she said, “The most important thing is to have a greater understanding of what work is actually functioning right now than it is about reauthorization.” At the same time, she said there are practical and political implications if PEPFAR’s authorization is allowed to expire. On the practical front, the current PEPFAR legislation has eight time-bound requirements that will lapse tomorrow. Among these are guidance on how PEPFAR funds are spent and how much the United States will contribute to the Global Fund to Fight AIDS, Tuberculosis and Malaria. “Those requirements will not be requirements if it’s not reauthorized,” Kates said, although Washington can still follow the provisions if it chooses. Politically, “PEPFAR reauthorization is about Congress having a say and a role in the future of the program,” Coester said. “By not reauthorizing, they’re sort of giving up that opportunity.” Congressional engagement with the reauthorization process also sends a signal about the health of the program. Since it was created, PEPFAR traditionally received five-year reauthorizations with bipartisan support. However, the process was nearly derailed last year over allegations that the program provided funding for abortion. Instead of its usual five, PEPFAR received only a one-year extension. A routine compliance check later uncovered that $4,100 in program funds went to the salaries of four nurses who performed 21 abortions over a two-year period in Mozambique. That money was returned to PEPFAR, and no similar revelations have emerged, but it is no longer clear if PEPFAR retains the same degree of bipartisan support it has had in the past. PEPFAR’s supporters are now debating how to advocate for the program going forward. Coester said much of the community has rallied behind a request that Congress keep PEPFAR’s funding levels the same when it draws up the budget for the next fiscal year. It is not at all certain, though, that PEPFAR as it existed before the stop-work order fits within the Trump administration’s emerging vision for international assistance. A memo reportedly written by Trump aides emphasized that ongoing U.S. international assistance needs to prioritize making “America safer, stronger, and more prosperous.” Within that context, a group of experts at Duke University’s Global Health Institute has released a PEPFAR reform proposal that would accelerate already existing sustainability efforts, including formalizing plans to transition more financial responsibility for HIV services to PEPFAR partner governments. They’re also looking to save money by accelerating access to emerging prevention innovations, such as long-acting injectables, and reducing administrative and operational costs. That assumes PEPFAR will survive the ongoing disruptions. One of the program’s architects, Ugandan physician Peter Mugyenyi, told Devex that is not something that should be taken for granted. Mugyenyi, who advised former President George W. Bush’s administration as it developed PEPFAR, sees the failure to reauthorize the program as yet another signal of just how much it is now in jeopardy. “It is a successful program, and we should not snatch failure out of it,” he said. “We are at the last stages of seeing what has been a devastating epidemic being ended and then we sort of allow it back. It is inconceivable.”