Opportunities for U.S. Leadership at Its Moment of Reckoning on Global HIV
September 1, 2017
Over the course of 15 years, the United States has generated exceptional experience, tools, and knowledge as the leader in the global fight against HIV. However, this tremendous example of U.S. leadership is in jeopardy. In its FY 2018 budget proposal to Congress, the Trump administration’s proposed $2 billion-plus in cuts to global health funding includes a $1.1 billion reduction in international HIV/AIDS programs. This 18 percent reduction to the President’s Emergency Plan for AIDS Relief (PEPFAR) and its companion financing partner, the Global Fund to Fight AIDS, Tuberculosis and Malaria, would put millions of lives at risk and raise the possibility that the pandemic will reignite, threatening both U.S. and global health security. A reduction in U.S. leadership would come at an unfortunate time. Global donor funding for HIV has declined in the last two years, just as experts advise that the world is within reach of bringing the HIV epidemic under control—even without a vaccine or cure. To succeed, countries affected by HIV will need to accelerate treatment initiation, increase support to keep those already on treatment virally suppressed, and a recommit to expanding access to proven HIV prevention interventions. With 17 million people living with HIV worldwide still in need of treatment and 1.7 million more newly infected each year, now is not the time for U.S. leadership on global HIV to wane.
Three key considerations should guide the Trump administration, Congress, and others in this period of significant change and heightened uncertainty:
- U.S. leadership on HIV continues to advance U.S. national interests. HIV/AIDS remains a worldwide health security threat that requires sustained U.S. engagement. When President Bush supported the creation of the Global Fund in 2002 and launched PEPFAR in 2003, the United States made a profound historic commitment to control global HIV/AIDS driven by American compassion and a moral obligation to care for those who were dying and share the treatment that had become available in the United States. The decision was also driven by U.S. national interests and international security. Protecting Americans at home by answering dangerous health security threats abroad remains relevant today—U.S. commitment to combating HIV successfully confronts head-on the genuine threat that a runaway HIV epidemic in eastern and southern Africa will gut these societies and economies and spread instability. By investing to stabilize and control the epidemics in this region, the United States advanced its own interests by creating markets for U.S. products and good will toward the United States. While recent UNAIDS data shows that eastern and southern Africa has made exceptional progress in recent years largely due to focused effort from PEPFAR, the Global Fund, and others, the scenario is not as rosy in other places. New infections and deaths are rising in eastern Europe and central Asia—the only region where this is occurring worldwide. The failure to seize the opportunity to control the epidemics in any of these countries could see them spiral out of control.
- U.S. leadership centers on a proven formula for success. The U.S. HIV/AIDS effort has been driven by sustained leadership by Presidents Bush and Obama; bipartisan congressional support; relatively stable multiyear funding; the requirement that U.S. investments in the Global Fund be matched two-to-one from other donors; synergies in planning and implementation between PEPFAR and the Global Fund; a centralized decisionmaking structure; clear, concrete, measurable goals; and empowered and engaged ambassadors and country teams that harness the technical expertise of multiple U.S. government agencies and nongovernmental partners. Since the beginning, the United States has insisted on evidence-based programmatic and scientific rigor, programmatic accountability, and strong partnerships with host governments, combined with the steady achievement of efficiencies and lower commodity prices that have come from increasing scale. U.S. HIV programs draw systematically from American innovation, public health expertise, and scientific achievements largely attributed to public, private, and philanthropic investments in research and development (R&D). The exceptional bipartisan base of support in Congress for global HIV programs is backed by a diverse coalition of the faith community, businesses, security experts, foundations, universities, NGO implementers, civil society groups, and advocates. Deft diplomacy brings forward financial investments from partner governments, other donors, and private corporations. This formula for success remains as valid today as it was in 2003.
- We know what needs to happen next and we know what is at risk. A strong consensus exists in the United States on the priorities of HIV/AIDS programs for the next four years: deploying new testing approaches to identify those who are not yet diagnosed and get them on treatment to suppress their viral load, while working to prevent new infections. New tools, such as self-testing and pre-exposure prophylaxis (PrEP), are already showing an impact, while vaginal rings and injectable HIV drugs offer promise. Implementing these measures and developing additional new tools will require financial and political investment, but they are feasible and affordable and will deliver concrete results.
In February 2017, the CSIS Global Health Policy Center convened an expert working group on HIV to discuss critical issues affecting continued U.S. leadership and progress toward control of the pandemic. The group’s recommendations to the Trump administration and Congress are provided in several papers, including the policy brief “A Moment of Reckoning for U.S. Leadership on Global HIV”2 issued in June 2017 and companion papers focused on the Global Fund, adolescent girls and young women, and sustainability and country ownership, the content of which is briefly cited in this paper.3 This paper, “Opportunities for U.S. Leadership at Its Moment of Reckoning on Global HIV,” is written for a nontechnical policy audience to demonstrate how HIV remains a relevant policy priority for the U.S. government.
 Sara M. Allinder is deputy director and senior fellow of the CSIS Global Health Policy Center; Lillian Dattilo is program coordinator and research assistant with the CSIS Global Health Policy Center. This paper grew out of a CSIS Global Health Policy Center working group on HIV and the work of one of its sub-groups on the evolution and sustainability of the U.S. response. The members of the sub-group included the following (organizations listed for identification purposes only): Chris Beyrer, Johns Hopkins University; Catherine Connor, Elizabeth Glaser Pediatric AIDS Foundation; Reuben Granich, International Association of Providers of AIDS Care; Charles Holmes, Johns Hopkins University; Ronald MacInnis, Palladium Group; Carolyn Reynolds, PATH; Tyler Smith, CooperSmith; Jeffrey L. Sturchio, Rabin Martin; Taylor Wilkerson, LMI; Jason Wright, Management Sciences for Health. See CSIS, “HIV Working Group,” https://www.csis.org/programs/global-health-policy-center/hivaids/hiv-working-group, for a full list of working group and sub-group members.
 Sara M. Allinder and J. Stephen Morrison, “A Moment of Reckoning for U.S. Leadership on Global HIV,” CSIS, June 21, 2017, https://www.csis.org/analysis/moment-reckoning-us-leadership-global-hiv.
 CSIS HIV Working Group webpage with all papers: https://www.csis.org/programs/global-health-policy-center/hivaids/hiv-working-group.