The Road to Sustainable HIV Programming in PEPFAR Countries

The President's Emergency Plan for AIDS Relief (PEPFAR), the U.S. government’s multibillion dollar, 20-year global HIV effort that has been credited with saving millions of lives around the world, is associated with improvements in mortality, maternal and child health, educational, and economic outcomes. In countries that received support from the program, it has helped to galvanize the global HIV response. PEPFAR began as an emergency initiative to quickly deliver HIV services to countries with few resources to address their exploding epidemics—up to 40 percent of adults in some African countries were HIV positive in 2003, and life expectancy had plummeted across the continent. To respond urgently, PEPFAR built systems and programs outside of local health infrastructures and government functions.

As PEPFAR enters its third decade, discussions about the program’s long game are intensifying. Sustainability is a core element of PEPFAR’s new five-year strategy, which outlines a “reorientation” of its approach to cultivating sustainable HIV programming in supported countries. Further, the issue was raised during a recent congressional hearing held in advance of the program’s upcoming reauthorization. Policymaker expectations on this front will likely continue to grow as the global HIV epidemic evolves, budget debates intensify, and the U.S. government advances broader global health security efforts in response to the Covid-19 pandemic. These efforts include the August 1 launch of the new Bureau of Global Health Security and Diplomacy at the U.S. Department of State, which includes the Office of the Global AIDS Coordinator overseeing PEPFAR, aimed at consolidating and bolstering the department’s global health security and diplomacy capabilities.

PEPFAR’s current five-year authorization ends in September. Many PEPFAR stakeholders were anticipating a relatively straightforward process, with few, if any, changes made to the legislation. Members of Congress on both sides of the aisle have voiced their support for reauthorization. However, inaccurate information about PEPFAR funding being used for abortions has clouded discussions, slowing the trajectory of reauthorization. While Congress can continue to appropriate funding without reauthorizing PEPFAR, this development could impact the program in the near and long term, including its efforts to support sustainable programming.

As PEPFAR considers its sustainability agenda, there are key questions to be explored and steps the U.S. government can take to support a more sustainable HIV response.

Q1: How is PEPFAR reorienting its approach to sustainability?

A1: In 2003, the year PEPFAR was enacted, nearly 1.9 million people were newly infected with HIV and 1.5 million people died of AIDS-related causes in sub-Saharan Africa alone. The urgency to act resulted in an emergency effort that “directly built multiple health systems—in some cases resulting in systems operating in parallel to the national HIV response.” The idea of a “sustainable” response was reflected in PEPFAR’s original legislation and strategy, however. Since that time, PEPFAR’s approach to sustainability has evolved and the program has made efforts to address this through various models, including by establishing “Partnership Frameworks” with countries. PEPFAR also developed a tool to track countries on various indicators related to sustainability.

The focus on sustainability—helping countries increase their leadership and management of their HIV responses over time—has sharpened in PEPFAR’s new five-year strategy. “Sustaining the response” is one of five pillars of the strategy, which states that achieving sustainability will require “a substantial reorientation of the way PEPFAR, and the entire HIV/AIDS ecosystem, implements.” This would include engaging a wide range of stakeholders; greater financial investment by national governments over time; strong local institutions to deliver HIV services; the integration of HIV efforts into country health systems; and equitable approaches that promote human rights. PEPFAR’s latest operational guidance calls for country teams to work with governments and relevant stakeholders over the next two years to develop “Measurable Sustainability Roadmaps” that will address these elements and guide investments. PEPFAR acknowledges that the path will be long, gradual, and may require different investments, and assures partners that funding will not be suddenly cut.

Q2: What challenges does PEPFAR face in promoting sustainable HIV programming?

A2: As the world approaches the 2030 goal of “ending AIDS” as a public health threat, the HIV epidemic is far from over. There are stubbornly high numbers of new infections and millions of people with HIV are not getting needed treatment. Additionally, there are other challenges facing the global response. Stigma and discrimination against LGBTQ+ and other populations in need of HIV services is escalating—one of the more extreme examples being the anti-homosexuality law enacted in Uganda. Additionally, the latest failure of a HIV vaccine candidate underscores the biological complexity of the disease and reality that a vaccine will not be included in the HIV prevention toolkit in the near future.

PEPFAR-supported countries face numerous health concerns in addition to HIV. Fragile health systems struggle to provide adequate primary health care and must contend with shortages of health care workers, the growing burden of chronic disease, lingering effects of the Covid-19 pandemic, increasing health impacts of climate change, and other emerging health threats. Countries also have many other challenges and competing policy priorities.

Recent research showed that most countries receiving PEPFAR support face circumstances that may complicate their ability to sustain HIV programming in the long term. While many PEPFAR countries included in the analysis have a high level of commitment to HIV and some have reached epidemic control (defined by PEPFAR as the point where new infections fall below the number of deaths among people with HIV), many countries fall short on indicators that assess their potential for sustaining HIV programming, including economic and health system measures. Overall, South Africa, Botswana, and the Dominican Republic appear to be better positioned to be able to sustain HIV programming, compared to other PEPFAR-supported countries such as Ethiopia. At a time when governments will be expected to take on more leadership and financial responsibility related to their HIV epidemics, fraught domestic budgets, challenged health systems, and competing priorities will undoubtedly have implications for sustainability efforts.

Q3: What are the resource considerations for supporting sustainable programming?

A3: Resources from donors—the U.S. government, multilateral organizations, and others—will continue to be critical to the HIV response but are increasingly stretched. PEPFAR has been operating with relatively flat funding in recent years and the FY 2024 appropriations bills currently being considered in the U.S. House and Senate maintain flat funding for bilateral HIV programs. Additionally, the availability of financing from country government varies considerably. PEPFAR accounts for the largest share (46 percent) of HIV budgets across the countries required to develop a Country Operating Plan. While domestic governments account for the second largest share of HIV budgets (29 percent), government contributions are as little as less than two percent in some countries.

Further, capacity-building at the local level is a critical element of a sustainable response, but investment remains limited. “Localization” has been a priority for PEPFAR and the program set a goal of having 70 percent of new funding going to local organizations. In FY 2022, about half (55 percent) of new funding across PEPFAR countries that have an operating plan overall was going to local partners and the 70 percent goal was met in only a few countries.

Q4: How will broader U.S. global health security efforts affect PEPFAR programming?

A4: The Covid-19 pandemic underscored the fragility of health systems in the face of emerging health threats. In the countries where PEPFAR operates, the program’s resources and capabilities were applied during the pandemic to minimize HIV service disruptions and address Covid-19 directly, bolstering discussions about an expanded role for PEPFAR in pandemic preparedness and response (PPR) activities. Lessons from PEPFAR’s two decades of addressing the HIV pandemic and its Covid-19 response can be applied to broader U.S. global health security efforts. Further, U.S. Global AIDS coordinator John Nkengasong will lead the new Bureau of Global Health Security and Diplomacy at the U.S. State Department, having been appointed ambassador-at-large and senior bureau official. This could be advantageous to furthering both HIV and global health security goals. Yet, there are concerns about an expanded mandate diluting HIV efforts and weakening the likelihood of sustainable programming, especially in the absence of additional funding for the new bureau.

Q5: What steps can the U.S. government take to support long-term HIV programming in partner countries?

A5: The U.S. government has a significant opportunity to help partner countries sustain robust HIV programming, as well as meet other health security goals. Steps the United States can take include the following:

  • Provide robust financing for HIV efforts and health infrastructures to support sustainable programming. PEPFAR’s funding remains flat despite more being asked of the program over the years, including its efforts during the Covid-19 pandemic. At the same time, ensuring sustainable programming will require additional resources. Therefore, investments will need to reflect HIV goals, the needs of local health systems so that they can sustain HIV programming, as well as any additional PPR activities expected of PEPFAR.
  • Solidify PEPFAR’s plans for sustainability. PEPFAR has an opportunity to further define the role it will play in countries in the future; how country teams will operationalize their approaches to sustainability; how additional activities will be financed and measured; how country governments will be able to meet PEPFAR’s expectations and goals while facing other competing needs and limited domestic resources; and how PEPFAR will coordinate with partners, including the Global Fund to Fight AIDS, Tuberculosis and Malaria.
  • Deepen engagement with governments to align PEPFAR goals and national priorities. Countries are at different stages of their HIV epidemics and responses, the development of their health systems, and in prioritizing health (including HIV and PPR) in their budgets. Additionally, the mix of other health and non-health challenges is unique to each country. Therefore, deepening efforts with country partners can help ensure that HIV-related governance, resources, and programming are moving in the right direction and roles and expectations of all stakeholders in nurturing sustainable programming are clear.
  • Align PEPFAR’s sustainability efforts with broader U.S. government health systems strengthening and PPR activities. Sustainable HIV programming, resilient health systems, and strong PPR capabilities are inextricably linked and can be aligned and advanced together. Additional clarity on the U.S. government’s expanding field of vision on global health security, including the newly launched Bureau of Global Health Security and Diplomacy, is needed to fully assess the implications for PEPFAR and sustainable HIV-focused programming in the long term, as well as how HIV, health systems, and PPR activities will dovetail and reinforce each other.

PEPFAR has made a deep impact on the HIV epidemic over the past 20 years, but HIV remains a global health threat. The U.S. government has a tremendous opportunity to take steps to preserve HIV gains, while traveling with partner countries on the road to sustainable HIV responses. These efforts have the potential to move the world closer to ending AIDS, bolster health systems, and strengthen global health security.

Alicia L. Carbaugh is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

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Alicia Carbaugh
Senior Associate (Non-Resident), Global Health Policy Center