Conceived as an urgent response to a global health crisis with national security ramifications, the design of the U.S. President’s Emergency Plan for AIDS Relief as a historically ambitious attack on a single disease was unique from the start. In recognition of economic and political factors that had hampered responses to the pandemic at home and worldwide, as well as of the role participants across U.S. government agencies, and across in-country partnership would play, the bi-partisan legislation that created PEPFAR directed that the coordinator of the program would report to the Secretary of State, and be supported by diplomatic structures. An analysis released this week by the O’Neill Institute for National and Global Health Law at Georgetown University argues that decision has been pivotal to the success of the program, and that removing PEPFAR from diplomatic authority could endanger the gains it has made.
The analysis, Reorganization and the Future of PEPFAR: Implications of State and USAID Reform, follows a White House directive to reorganize the executive branch of the government with plans to redesign the State Department, potentially removing PEPFAR from its authority. Prepared by the O’Neill Institute with representatives from organizations that include the Center for Strategic and International Studies, the Kaiser Family Foundation, the Elizabeth Glaser Pediatric AIDS Foundation, and the Infectious Diseases Society of America (which produces this blog), the analysis notes both factors that led to the program’s placement under the Department of State and benefits that have since accrued.
Unlike previous aid and development responses, efforts against HIV relied on a whole of government approach — from both donor and partners, the authors write. Drawing on expertise across the Department of Defense, the Department of Labor and the Department of Commerce as well as USAID, the Peace Corps, and the Department of Health and Human Services, PEPFAR programs also relied on buy-in from in-country agencies — to reach marginalized populations and to change policies that include treatment guidelines. The analysis highlights the results of the $72 billion invested in PEPFAR responses since, that include 14.5 million of the nearly 20 million people receiving antiretroviral treatment for HIV, an estimated 2.2 million neonatal infections prevented, 15.2 million men accessing medical circumcision to lower their risk of becoming infected, and 85.5 million people tested for HIV in the last year. Those gains have led to goals that, if reached, could end the global public health threat of HIV in the next decade and a half, the authors note. But, they note, continued momentum depends not only on continuing to expand access to HIV treatment and services, but accelerating the pace of expansion.