The next phase of the global HIV/AIDs fight

The President's Emergency Plan for AIDS Relief  — the biggest effort by one nation to address a particular disease — is hitting a milestone anniversary. But advocates worry the U.S. may take its foot off the gas.

Why it matters: 20 years after then-President George W. Bush launched PEPFAR in his 2003 State of the Union address, the $7 billion-a-year program is up for reauthorization in Congress.

• Despite past bipartisan support, PEPFAR has been flat-funded for years and could fall victim to partisan fights and shifting public health priorities.
• This five-year renewal partly hinges on whether there are any basic changes to the program, or whether lawmakers opt for a "clean" reauthorization.

"Too many times, I think we start patting ourselves on the back before we're done," said Deborah Birx, former White House coronavirus response coordinator, drawing a parallel to the U.S. COVID-19 response. "We still have a long way to go."

The details: PEPFAR, which was architected in part by former NIAID director Anthony Fauci, was started at a time when communities in Africa were being devastated by HIV/AIDS, said Birx, who led PEPFAR from 2014 through January 2021.

• When Bush announced PEPFAR — and then later when Congress allocated up to $15 million in spending over five years for it — Birx and her colleagues were stunned. "I couldn't believe it," Birx said. "This was not business as usual. This was about doing things differently and consistently, and being data- and science-driven," Birx said.
• Congress has since allocated more than $100 billion globally for access to tools like antiretroviral medications, preventative pre-exposure prophylaxis drugs, HIV counseling and testing, voluntary male circumcision, as well as health care worker training.
• An estimated 25 million lives have been saved and more than 5.5 million babies have been born HIV-free as a result of the efforts. And of the 25 countries where almost two-thirds of all people live with HIV, more than half are now either at or near epidemic control over that time, per the Kaiser Family Foundation (KFF).

What they're saying: "By pretty much any measure, it's been a success. It's saved millions of lives in what was a death sentence," Jen Kates, senior vice president and director of global health and HIV policy at KFF told Axios.

• "Not only has PEPFAR had this impact on HIV outcomes, but it's had a spillover impact on other areas, and even an economic impact," she said.

What to watch: Partnerships and programs created by PEPFAR were able to be used almost immediately to respond to COVID globally, said Mitchell Warren, executive director of AVAC, a non-profit focused on HIV prevention.

• They've also been used in responses to H1N1 and Ebola.
• "That is something we can't backtrack on," Warren said. "This is not just about HIV. It's about how global health gets delivered."

Yes, but: While remarkable progress has been made, a majority of countries missed 2020 global targets for identifying HIV patients and getting them on effective treatment. They're now reaching for even more ambitious targets by 2025.

• A GAO report released in December highlighted some of the challenges that have plagued PEPFAR, such as coordination between the State Department and overseas federal agency officials and persistent program staffing vacancies.

What to watch: The State Department, which oversees PEPFAR, has said it is reimagining its strategic direction to enable "partner countries to build responsive and sustainable systems capable of meeting the broader health care needs of their populations to sustain HIV impact."

• The administration has proposed creating a single bureau for global health threats within the State Department to oversee PEPFAR, as well as other global pandemic threats. The idea would be to "integrate" those resources, Kates said.
• But those discussions have raised concerns on Capitol Hill. "There are questions about the future of the office, however, and making sure its core mission is protected," David Kramer, executive director of the Bush Institute told Axios. "PEPFAR still has a mission to accomplish."

Be smart: PEPFAR doesn't actually need to be reauthorized in order to get funding, Kates points out. Funding is allocated every year through the congressional budget process.

• But, reauthorization is critical because it makes a global statement about the U.S. government's plans and priorities, Kates said. "What we've found in past times is that a lot of those individuals don't understand that if something doesn't get reauthorized, it can still continue. It's a perception issue."
• There are also some lawmakers who don't like to fund programs that aren't reauthorized, Kates said. "I think in this Congress, with the fiscal constraints and some of the other issues, that could come up," she said.

The bottom line: There are important lessons should be gleaned from the differences in the U.S. responses to HIV and COVID.Great efforts were made to decouple PEPFAR from either political party, Birx said.

• "The way President Bush and all the presidents since then have handled PEPFAR, they've ensured that it was never linked solely to one president. I think that's what success looks like: People in charge being willing to give credit to others," Birx said. "Isn't that a hard thing today? But I think that lesson is still out there."

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