PEPFAR’s Existential Moment
August 20, 2021
The President’s Emergency Plan for AIDS Relief (PEPFAR) has entered its most consequential, indeed its most existential moment. Several reasons stand behind this claim.
Across southern and eastern Africa, Covid-19 has slammed HIV programs, disrupting prevention services, enrollment in treatment and supply chains, and diverting staff and laboratory capacity. PEPFAR has taken some important measures to protect its programs, processes, and resources against disruptions so that it continues to reach its core constituency of people living with HIV. However, PEPFAR remains very much in the line of fire and has paid a high price. The damage done is serious, and matters are getting worse.
As the current Delta variant surge tears through Africa, the threat to the integrity and sustainability of PEPFAR’s achievements—bringing life-sustaining treatment to over 25 million people, with a cumulative investment exceeding $85 billion—is escalating. The same is true for PEPFAR’s DREAMS program, which has invested almost $1 billion in reducing the acute risks of HIV infection that adolescent girls and young women confront through improvements in education, legal rights, economic empowerment, sexual and reproductive health, and access to prevention technologies. We now need to anticipate that the damage wreaked by Covid-19 will only expand further as we move into 2022 and beyond. Regression, a return to rising HIV infection rates, looks more and more likely. Data collected by the Global Fund to Fight AIDS, Tuberculosis, and Malaria at health facilities in 32 African and Asian countries indicate a 41 percent decline in HIV testing and a 37 percent decline in referrals for diagnosis and treatment during the first Covid-19 lockdowns in 2020, as compared to 2019. The question is whether there will be an accelerating reversal of gains in the fight against HIV and other related infectious diseases, or whether the threat of regression will be reversed.
The Geopolitical Context Has Changed Radically
PEPFAR and its companion institution, the Global Fund, now find themselves operating in a globalized, urgent health security crisis—dominated by Covid-19—that stretches across Latin America, Africa, and Asia. This crisis is compounded by unprecedented uncertainty about the future as the long-term investment requirements for HIV are jeopardized.
When PEPFAR and the Global Fund were launched nearly 20 years ago in the immediate aftermath of 9/11, HIV was seen as a pressing global security threat. That ceased to be the case a few years later, and when PEPFAR’s budget flattened for more than a decade after 2008, few questioned the security consequences. Today, Covid-19 rules as the predominant urgent global health security threat, driving a surge of deaths across countries rich, poor, and in between. At the same time, HIV is wrongfully viewed as a managed problem, concentrated in eastern and southern Africa. Far too few observers recognize the risk of regression and how much unfinished business remains in responding to this persistent, entrenched epidemic, in which over 15 million people still lack access to antiretroviral therapy.
PEPFAR now lives amid two pandemic long wars. There is the familiar world of the slow and quiet HIV pandemic, which has just crossed its 40-year mark. And there is the new world of the loud and fast Covid-19 pandemic, which is nearing the end of its second year with few prospects of being contained soon and presents continued risks of a cascade of humanitarian emergencies, economic insolvency, and famine and instability. Each week, it seems, the virus races ahead across the world, and we witness another state in meltdown (e.g., Haiti, Cuba, Tunisia, Ethiopia, Lebanon). Among the latest and most dangerous is South Africa, still the epicenter of the global HIV pandemic and still the single most important PEPFAR country partner, with over $5.6 billion of U.S. government investment.
Roots of Success, Roots of Weakness
PEPFAR has been widely admired for its achievements since it was first announced by President George W. Bush in his state of the union address on January 28, 2003. Its success has rested on a combination of factors.
A hierarchical design backed by ample, multi-year funding placed exceptional decision authority in the hands of the coordinator, based in the State Department. While highly autonomous in many respects, the coordinator, equipped with a high rank and ambassadorial title, has access to the secretary of state and has oversight of the contributions made by the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), and other agencies. As PEPFAR’s title indicates, the organization is understood to carry the imprimatur of the Office of the President of the United States, a critical source of prestige and influence.
Fairly rapidly, PEPFAR built country partnerships and data and management systems that delivered concrete results in quantifiable terms.
The quality and longevity of PEPFAR’s leadership—most notably the tenures of Mark Dybul, Eric Goosby, and Deborah Birx—have been a vitally important element in creating a record of stability and performance stretching over many years. Success has also rested on both the active leadership of U.S. ambassadors in key partner countries and the strength of ties with the exceptionally strong HIV advocacy and implementor communities. PEPFAR’s rigor and accountability have gone a long way toward building strong, persistent bipartisan support within Congress.
PEPFAR has not been, however, without its deep internal tensions and its critics, who often looked at the alleged elements of success and saw sources of weakness. USAID and the CDC never arrived at a stable consensus over the division of responsibilities, and relations between them have remained chronically strained. Some critics questioned whether PEPFAR was excessively siloed, a fortress really, and argued that it should be housed at USAID, where it might be better integrated into long-term development streams. At various times, close observers questioned whether PEPFAR’s exceptionally empowered leadership had taken an authoritarian turn (as attested by the Department of State Office of Inspector General’s 2019 report).
Other critics, alternatively, questioned whether PEPFAR favored a leadership style that at times was too tolerant of far-flung initiatives and too undisciplined. Many asked if any of the coordinators were truly accountable to anyone on a day-to-day basis.
Inevitably, as the Bush administration transitioned to the Obama administration, which subsequently transitioned to the Trump administration and now the Biden administration, there was the inevitable impulse for those coming into power to ask: Does PEPFAR, a program of such impressive scale and cost, housed at the State Department and with no defined end game, embody the values and priorities of this new president? And how is the new president to leave his mark, and where does PEPFAR fit?
An Unprecedented PEPFAR Leadership Gap
In the midst of a global pandemic, PEPFAR has over the past year and a half endured the longest and most dangerous interruption to its leadership. Then PEPFAR coordinator Deborah Birx moved to the White House on March 1, 2020, to become the response coordinator for Covid-19. Since that moment, for over 18 months, management of PEPFAR has been in the hands of an acting coordinator, a very able and committed civil servant, but one who by definition lacks the authority of a confirmed coordinator. The role has, not surprisingly, been confined to holding things together. Overall, the PEPFAR enterprise finds itself in a reflexively defensive, impassive, protective posture.
Opportunities have gone missing. Essential U.S. diplomacy, the responsibility of the coordinator acting in partnership with U.S. ambassadors in focal states, has stalled out. In 2020, the first year of the pandemic and the final year of the Trump administration, there was no appetite whatsoever to gird PEPFAR with emergency funds to bolster its program to defend against the pandemic crisis and use its full strengths to support the Covid-19 response. This stood in stark contrast to what Peter Sands and his team did at the Global Fund to pivot rapidly to respond to the pandemic, mobilizing over $1 billion in resources and expanding the fund’s mandate. In 2021, the first year of the Biden administration, Congress allocated $3.5 billion to the Global Fund for non-vaccine pandemic response, a powerful signal of bipartisan enthusiasm for the fund’s rapid innovations. By contrast, PEPFAR received an additional $250 million in funds. Other U.S. agencies, most notably USAID and the U.S. Department of the Treasury, have dominated the pandemic response.
As of August 2021, the Biden administration has not yet nominated a PEPFAR coordinator.
Drift, paralysis, and absence of empowered leadership persist, at considerable cost. In terms of morale, this has led to foregone programmatic and diplomatic initiatives and investment opportunities and a weak and ineffectual voice in making PEPFAR’s case internally within the administration, on the Hill and elsewhere, on what is needed in this extraordinary period to adapt and sustain PEPFAR.
Presumably, PEPFAR’s leadership gap will be corrected once the Biden administration nominates a coordinator to take up duties, which it is expected to do in late 2021 or early 2022. That individual will be entering a difficult situation unlike those faced by any of her or his predecessors. She or he will need to align with other senior global health security agencies and their leaders in ways that reach well beyond the experience of prior coordinators. It remains to be seen whether a fundamentally different style of leadership emerges, fitted to new geopolitical realities.
As the Biden team weighs its options for change of PEPFAR, it is useful to look back at a few select moments of high stress that PEPFAR has experienced and ask what lessons from those episodes are relevant to today’s call for a fundamental reassessment of PEPFAR’s value and fit in the era of Covid-19.
Interestingly, with the exception of Covid-19, the serious external geopolitical challenges that PEPFAR has already experienced have not been destabilizing: that was true for the shock of the sudden recession of 2008; the Ebola outbreak in West Africa in 2014–2015; the escalation of homophobic policies by several African partner governments in the early 2000s; and the denialist era of South African president Thabo Mbeki followed by the turn to gross misgovernance and corruption during the tenure of South African president Jacob Zuma. In retrospect, PEPFAR’s leadership was quite deft at navigating these threats with the support of Congress, U.S. embassies, allies in the senior ranks of the State Department, the White House, USAID and the CDC, and links to civil society in partner countries.
Paradoxically, the most serious existential shocks that PEPFAR has experienced since its launch in 2003 have been actions that emerged within the executive branch itself.
In the first Obama administration, a bid by the USAID administrator, with tacit support from the White House, to relocate PEPFAR from the State Department to USAID ignited a destructive battle that was chaotic, untransparent, and had no clear direction or high-level oversight. Over a three-year period, the takeover bid exhausted and preoccupied PEPFAR’s leadership. Ultimately, it ended in a stalemate, and the wounded status quo lumbered on. What saved the day was the unwillingness of key congressional appropriators and others to countenance such a change. The power of Congress prevailed, vested in the original authorizing legislation of 2003, followed by the reauthorizations in 2008, 2013, and 2018. In retrospect, the long fight over PEPFAR’s future did not resolve deep tensions among the State Department, USAID, and the CDC. Nor did it ensure that another similar costly battle does not recur in the future.
In the Trump administration, PEFFAR was subject to repeated annual assaults from the White House to gut PEPFAR’s budget. That too consumed the energies of the coordinator’s office and carried a heavy psychological cost, at the same time that the Trump administration’s attacks upon alliances and multilateralism eroded U.S. standing and strained PEPFAR’s relations with partner governments. Ultimately, the coordinator was able to quietly work closely with congressional appropriators to circumnavigate the Office of Management and Budget’s threats. Still, the aftermath of that experience remains unsettling: a future populist White House with similar intent may be far more skilled at executing its plans than the Trump administration.
In both the Obama and Trump administrations, powerful bipartisan congressional champions with exceptional longevity held the line and provided stability. They of course will not be there forever, as PEPFAR’s stalwart supporters retire, which begs the question of how to cultivate a whole new generation of PEPFAR proponents on the Hill.
One thing is very clear amid all this drama, past and present. Change in PEPFAR is inevitable, the status quo is not sufficient to meet current realities, and pressures are mounting for new forms of integration of PEPFAR into U.S. health security engagement.
Continued strong PEPFAR leadership will remain essential, but when that returns, by whom, and with what mandate are still to be defined.
The past teaches us that reform and restructuring of PEPFAR can be treacherous. If handled clumsily, without transparency and accountability, and without clear lines of responsibility and strong oversight, confusion and conflict will likely ensue. Success will rest to a large degree on whether there is strong and empowered leadership at PEPFAR soon. Any attempt at a major transition with weak, placeholder leadership at the helm of PEPFAR is asking for trouble.
Quiet conversations have begun over PEPFAR’s future, internally within the administration and elsewhere. Fundamental questions hang in the air over exactly what the changes will be in PEPFAR’s goal setting, leadership style, management, and revised overall approach, and how these changes will be executed. The challenges that the dual pandemics of HIV and Covid-19 pose—What is the concept that bridges these realities, and how does PEPFAR fit in a broader U.S. health security strategy? —now stand center stage, with few answers yet in terms of U.S. policy.
Ultimately, PEPFAR’s future will be far more secure when a clear U.S. global health security policy is firmly in place that integrates PEPFAR within a larger vision, takes account of the recurrent threat of multiple persistent pandemics, and anchors the vision in a commitment to building and maintaining resilient health systems. The United States needs a revised long-term investment strategy that resets and restabilizes the HIV/AIDS response in a way that takes full account of new geopolitical realities and epidemiological trends and lays the groundwork for a successful 2023 congressional reauthorization.
J. Stephen Morrison is senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C. Courtney Burks is a consultant specializing in global public health.
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