Remember the days when the antiretroviral medicine that saved the lives of people living with HIV — and that would later be proven to prevent transmission of the virus — was provided to the people who needed it only in countries that could afford it?
That past, when lines between life and death followed the lines of a map, would be prologue for countries around the world under the terms of a Trump administration plan for the U.S. President’s Emergency Plan for AIDS Relief to “continue to work towards epidemic control” in just 12 countries.
The plan is included in the White House “Major Savings and Reforms” document, describing how spending reductions in the Trump budget proposal for the coming fiscal year would impact programs and services across the federal government, aiming to, it says, “curtail programs that fall short on results or provide little return to the American people.”
That, according to the document, includes PEPFAR, a program not only lauded for its impacts on global health, development, economies, national security, international diplomacy and goodwill, across party lines and previous presidencies, but singled out for praise by Secretary of State Rex Tillerson during his nomination hearing when, noting the program’s measurable impacts, he called the flagship U.S. global health program “remarkable,” “extraordinary,” “a model” and “a marvelous way to send the message of the compassion of the American people.”
That was then. Tillerson’s appreciation of the program and its aims was less clear during his defense of the Trump budget’s impact on the State Department before the Senate Appropriations State and Foreign Operations Subcommittee when he explained that after a billion-dollar cut to U.S.-led global HIV responses, remaining PEPFAR money would be used “to sustain the HIV AIDS treatments in 11 countries to continue to take those to conclusion. As patients roll off those rolls, new treatments can be available.” As treatment for HIV is a lifelong necessity, “to conclusion” as well as when “patients roll off the rolls,” refer, apparently, to the deaths of patients receiving treatment being a prerequisite for more patients to be added to “the rolls.”
The number of included countries differs by one, but the impacts detailed in the “Major Savings and Reforms” plan are similarly at odds with PEPFAR accomplishments and goals toward ending HIV as a global public health threat and making the interventions leading to that achievement sustainable.
“Within the proposed budget for PEPFAR, the State Department would prioritize 12 countries in which the United States will continue to work towards epidemic control, while maintaining all current PEPFAR-supported patient levels on treatment across the program,” the section on Reduction to Global Health Programs says. The paragraph concludes, optimistically, “This proposal would allow PEPFAR to continue to achieve impact within a lower budget by reprioritizing resources and leveraging funding from other donors and host country governments.”
It does not explain how, with the cessation of all efforts but limited levels of medicine provision in all but 12 countries, returning the program’s outreach below its earliest levels, PEPFAR would continue to “achieve impact,” as opposed to seeing exponential increases in new infections, loss of patients to follow-up, climbing rates of treatment resistant disease, a reversal of steep drops in mother to child transmission, and, once again, bearing witness to rising incidence of preventable illnesses and deaths. In 2014 a Health GAP report documented how precipitous efforts to “transition” PEPFAR-led HIV programs in South Africa to “country ownership” threatened gains that had been made in a country with the largest burden of disease where capacities to deliver essential HIV services were still developing. The results, including failures to follow up on patients’ outcomes, the authors of the report noted, represented “both an ethical lapse and an enormous missed public health opportunity” — in a country where capacities, systems and resources, even then were stronger than those of other PEPFAR countries.
Neither Tillerson nor the document expanded on which countries would be on their own in 2018, or how they would be chosen. A coalition of organizations advocating for global HIV responses has written Sec. Tillerson, and copied members of Congressional appropriating and foreign relations committees expressing concerns that include the impacts of a plan that would “drop focus on countries:
- with some of the largest burdens and highest rates of HIV in the world like South Africa, Mozambique, and Angola.
- most urgently in need like South Sudan where just 4% of children with HIV have treatment but where PEPFAR is making a huge difference.
- with challenged governments like Nigeria and Angola, punishing more than half of people living with HIV who do not yet have treatment for their governments’ failures.
- among the 25 poorest in the world from Ethiopia to Mozambique to South Sudan.
- among our neighbors in the Caribbean and Central America, where stigma is a huge problem and PEPFAR funds are needed to assist in the important inclusion of key communities.
- recovering from conflict like the Democratic Republic of Congo, where just 34 percent of people living with HIV have access to treatment. “
Science Speaks will continue to follow responses and developments, and welcomes information and insights from readers.