This World AIDS Day Congress Remains Essential to Stopping Global HIV

Each year, on December 1, the world commemorates World AIDS Day. We pause to remember the millions of people who have lost their lives due to the disease and express support to the nearly 40 million people around the world currently living with it . In the aftermath of the U.S. elections, this World AIDS Day we should also consider the legacy of U.S. leadership, particularly the overwhelming bipartisan support, and why bipartisan engagement is more essential than ever to meet the challenges ahead to end the epidemic.

When I first traveled to Uganda in 2001, coffin makers lined the road between the airport in Entebbe and the capital Kampala. Only 50,000 people across sub-Saharan Africa were on antiretroviral treatment (ART) then, and people were dying at a rapid pace that was destroying the social, political, and economic fabric of families, communities, and countries. Virtually everyone had family members or friends who were sick or dead. Economies were crumbling as people in the primes of their lives were dying. Grandparents, many sick themselves, struggled to care for orphaned grandchildren. Fifteen years later, U.S. investment in life-saving treatment and care totaling over $72 billion has saved millions of lives and turned countries around. That road from Entebbe to Kampala is now a robust marketplace that bustles with people almost around the clock. Important scientific discoveries have identified tools that may enable us to break the pandemic once and for all.

Bipartisan U.S. Leadership

Presidential and congressional leadership has been critical to this dramatic turnaround. President George W. Bush’s 2003 State of the Union proposal to fight AIDS in Africa through the President’s Emergency Plan for AIDS Relief (PEPFAR) was a game changer. President Barack Obama has continued to champion PEPFAR, and a coalition of bipartisan support in Congress has repeatedly authorized PEPFAR and sustained financing.

Whether driven by compassion, altruism, economic or security interests, members of Congress have come together across the aisle to support HIV funding in politically unlikely collaborations, even during times of political stalemates and economic recession. These collaborations—Bill Frist and John Kerry, Russ Feingold and John Sununu, Tom Lantos and Henry Hyde, the Congressional Black Caucus, and the 67-member bicameral Congressional HIV/AIDS Caucus—have been crucial to this fight. From its initial funding for AIDS research in 1985 to passage of the “Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990” to overwhelming support for the Global Fund to Fight AIDS, Tuberculosis (TB), and Malaria since 2002 and PEPFAR since 2003, congressional leadership has been instrumental in making the United States the global leader on HIV.

PEPFAR’s Impact

As a result, U.S. support through PEPFAR and the Global Fund contributes to ART formore than 11.5 million people living with HIV worldwide. Almost 2 million babies have been born free of HIV due to PEPFAR support of prevention of mother-to-child transmission programs. HIV counseling and testing, voluntary medical male circumcision, and viral load monitoring are among the many critical interventions that have made PEPFAR a success and contributed to a 43 percent reduction in AIDS-related deaths since 2000.

PEPFAR’s impact is visible in the communities and countries that have been hardest hit, as evidenced by the Kampala-Entebbe Road. ART has enabled teachers, entrepreneurs, government officials, and others to live, work, and contribute to their economies. The United States itself has also benefited from its PEPFAR investment in countries through the resulting economic stabilization and growth and the broader reductions in insecurity, some of which can be attributed to the Department of Defense’s targeted military-to-military assistance under PEPFAR. A study published in Health Affairs on PEPFAR’s economic impact in 10 sub-Saharan African countries found that increasing PEPFAR per capita funding by $100 was associated with an increase in male employment of 9.1 percentage points, which generatedeconomic benefits equaling one half of the money spent on PEPFAR. U.S. exports to sub-Saharan Africa have increased 250 percent, which has created markets for U.S. goods and opportunities for U.S. private-sector investment. In addition, countries with PEPFAR programs have experienced a 40 percent reduction in political instability and violent activity compared to a 3 percent reduction in those without a PEPFAR program in the same region.

In addition, PEPFAR’s investments in health systems—establishing clinics and hospitals, improving diagnostic and laboratory capabilities, training new health care workers—have served the greater public health good. It assisted the Ebola response in Nigeria and served as a platform for the U.S. role in the Global Health Security Agenda, through which it is assisting 17 of the 55 partnership nations to ensure they have the minimum infrastructure necessary to prevent, detect, and respond to disease outbreaks.

The Challenges Ahead

Though the impact of PEPFAR has been profound in focal partner countries, too often slogans about an “end” of AIDS on the horizon have been overly optimistic and misleading. HIV remains a critical public health threat with far-reaching political, social, and economic impact, especially in highly affected countries. Even with the movement toward a “Test and Treat” model (treatment immediately after diagnosis) in the last few years, an estimated 4 of 10 people living with HIV do not even know they have the virus, and less than half of all those living with the virus worldwide are on ART. 20 million people still need treatment. The number of HIV infections per year decreased from 3.1 million in 2005 but since 2010 has plateaued at a rate of nearly 2 million each year. Providing ART to the 20 million who currently need it is an enormous task, but what if that number doubles to 40 million in 10 years’ time because we have not lowered the incidence rate? The challenge will become monumental and beyond our reach.

Evidence discussed at the International AIDS Conference in Durban, South Africa, in July indicates that the initial incidence reduction had more to do with the 70 percent decrease in new infections in children since 2001 and less to do with changes in adult infections. Thus, we may have only reached the “low-hanging fruit” (e.g., babies and mothers through prevention of mother-to-child transmission programs).

The imperative now is to address the growing rates of new infections in population groups, such as minorities in the United States and adolescent girls and young women in eastern and southern Africa, and in geographies, such as Eastern Europe and Central Asia. We must increase testing rates, especially in adult men, and decrease stigma to allow those who need services to access them in a safe, nondiscriminatory manner. And we must start addressing some big challenges due to ART drug resistance and coinfection with other deadly diseases such as TB and Hepatitis C.

The Need for U.S. Leadership

Sustained bipartisan support is a testament to PEPFAR’s success, and it is largely taken for granted that the program will receive funding every year. PEPFAR has received total funding of more than $72 billion; the United States remains the largest funder of HIV treatment globally, accounting for 66 percent of HIV funding in 2015. In a time of budget constraints, the fact that funding levels have been flatlined for the last six fiscal years can be seen as a win.

Yet the end of AIDS can only be accomplished if there is sufficient funding and targeted efforts to stem new infections, accelerate ART uptake, address the economic and social issues that drive new infections, and continue investment into research and development of new tools, including a vaccine and a cure. Addressing these challenges takes resources and political will.

The U.S. government’s continued bipartisan leadership and diplomacy is needed now more than ever, as other donors have reduced or eliminated their bilateral HIV resources in recent years. The notable absence of heads of state and even ministers of health at the Durban AIDS conference was disheartening, but even more so was the news that global HIV funding decreased by $1 billion in 2015 ; 13 of 14 donors reduced their disbursements. The Global Fund was successful in raising $13 billion at its September 2016 replenishment conference, which demonstrated the collective determination of many, including the U.S. government and the Bill & Melinda Gates Foundation, to maintain commitments. The pledges were $1 billion more than at the previous replenishment conference in 2013, but that largely represents a flatline given the 2015 reduction. Donors must now come through on their pledges. There are opportunities to work even more closely with countries, such as South Africa, which are demonstrating their own political will and investing resources to work in partnership with the United States.

The financing news is sobering, but with 37 million people living with HIV and micro-epidemics threatening to expand that number, the U.S. government’s $72 billion global HIV investment should be sustained. We cannot afford to be complacent. The incoming Congress and administration should build on the legacy of bipartisan political will to maintain and expand the U.S. investment to break the HIV/AIDS pandemic. The gains in the fight against HIV are too critical to lose now.

Sara M. Allinder is a senior fellow and deputy director of the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).

© 2016 by the Center for Strategic and International Studies. All rights reserved.

Photo credit: ASIT KUMAR/AFP/Getty Images
Sara M. Allinder
Senior Associate (Non-resident), Global Health Policy Center