PEPFAR highlights gains and accountability, while treatment advocates highlight “Deadly Impact” of policy, funding gaps

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Boasting “first-ever, site-level program results” and a “new transparency milestone,” the United States President’s Emergency Plan for AIDS Relief today released its 14th Annual Report to Congress, highlighting advances against HIV globally that could not have been imagined when President George W. Bush announced the launch of a U.S.-led intervention in response to the worldwide toll of AIDS. But it also leaves open questions about the eventual success of a program facing persisting challenges of unmet needs, a population explosion among those at greatest risks, flat budget allocations, an unprecedentedly restrictive “Mexico City” policy, and the continued threat of radical funding cuts.

Noting the opportunity to control a pandemic without a vaccine or a cure “for the first time in modern history,” the report lays out steps taken toward that goal since 2003, when only 50,000 of 25 million people living with HIV in sub-Saharan Africa had access to the antiretroviral treatment that could save their lives and prevent transmission. Since then, PEPFAR has made treatment accessible for 13.3 million people living with the virus, made it possible for 2.2 million babies born to mothers living with HIV to be born free of the virus, provided access to medical circumcision that lowers the risks of infection to 15.2 million men and boys, and, in 2014, initiated the public-private “DREAMS” partnership to tackle risks faced by young women and teenage girls across 10 countries that have seen HIV incidence among the target population drop nearly everywhere the partnership operates, according to the report. The report also spells out the signs of success, claiming that five African countries are poised to achieve “epidemic control,” when the numbers of new infections are exceeded by the numbers of deaths from all causes among people with HIV. It also notes progress toward goals that UNAIDS has projected would end HIV as a global public health threat — with some countries edging toward 90 percent of people living with HIV being aware of their infection, 90 percent of those accessing treatment, and treatment suppressing the virus in 90 percent of those receiving it.

But along with those advances, the report marks persisting as well as looming challenges — in surveys indicating that testing and treatment for HIV remains out of reach for disproportionate numbers of children, adolescents and young adults, and in projections that the numbers of young people in sub-Saharan Africa will double by 2020. More work must be done, the report says, to reach those, as well as gay men and other men who have sex with men, transgender women, people who earn income through sex work, as well as girls facing risks of sexual violence. How that work will be supported, however, the report, which extols the program’s efficient use of every dollar spent, leaves an open question. Instead, it veers into a startling non sequitur, mentioning in its executive summary the reinstatement and expansion of the Mexico City Policy (also known as the Global Gag Rule)  now called the Protecting Life in Global Health Assistance policy. PEPFAR staff, the report says, work with partners to implement and monitor the policy, which bars overseas programs receiving U.S. money from providing information or services to terminate a pregnancy. The report does not mention the policy in the body of the report, and does not address its impact on other funding, or on health services for young women, girls and children.

It is left to another report to discuss where the resources to meet unmet needs, and fill other gaps could be found. That report, Deadly Impact: How Flat Funding Is Undermining U.S. Global AIDS Programs, from Health GAP, presents other challenges as well — in unmet needs across three countries — South Africa, Mozambique, and Cameroon — not included in PEPFAR’s 2017 to 2020 strategy of concentrating resources and programming in 13 “focus countries,” and of young women and teenage girls outside of PEPFAR’s 10 “DREAMS” partnership countries. To those challenges, the authors of the report write, Congress must take the initiative to raise, rather than simply preserve funding in the face of White House proposals for deep spending cuts. The White House, in turn, must recognize and meet the challenges ahead in its spending proposals and PEPFAR must shift its strategy to encompass challenging as well as promising countries and to increase outreach to marginalized populations. The Global Gag Rule, referred to in the PEPFAR report as the Protecting Life in Global Health Assistance policy, the authors write, should be recognized as a barrier to health services, and eliminated.

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