Combating AIDS through PEPFAR Should Remain a U.S. Priority

Peter Mugyenyi created a clinic in rural Uganda that became a model for health care delivery for PEPFAR. (Marco Longari/AFP/Getty Images)

In a scene from the sixth season of the HBO series “Veep,” the fictional former president Selena Myer, played by Julia Louis-Dreyfus, and her advisors discuss potential policy themes for her charitable foundation. When one staffer suggests AIDS, Myer dismisses the subject as passé. “It had a good run,” she says.

Unfortunately, what played as satire a few years ago now reflects a disturbing reality. The notion that it is time to move past HIV as a focus of American foreign aid has taken hold in some quarters of the professional foreign-policy class in Washington.

Why curb a program that works?

The latest to espouse this cynical idea is former U.S. Ambassador to Botswana Michelle Gavin. In a recent blog post for the Council on Foreign Relations, she claims that PEPFAR “has come to constrain and distort” U.S. diplomacy on the African continent. She also advocates shifting the program’s resources into other areas that she views as more important.

As the President’s Emergency Plan for AIDS Relief (PEPFAR) marks its 20th anniversary, we should celebrate the program’s enormous successes that have provided us with the hope that the end of AIDS is in sight. For example, statistics published by UNAIDS show that new yearly HIV infections in sub-Saharan Africa are down by more than 50 percent since the launch of PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, to which the United States is the largest contributor.

Deployed smartly, PEPFAR’s investments can and do attack corruption, promote transparency and citizen-responsive governance, sustain civil society and a culture of democratic community participation, and boost economic growth led by the private sector.

Thanks to treatment provided largely through the generosity of the American people, AIDS-related deaths on the African continent declined by two-thirds over the same period. According to the Office of the U.S. Global AIDS Coordinator, PEPFAR has saved over 25 million lives.

But Ambassador Gavin’s call to unwind PEPFAR is premature. The World Health Organization estimates almost 26 million people are living with HIV in sub-Saharan Africa today, and UNAIDS projects more than one million more will acquire the disease this year. The problem is particularly acute among adolescent girls and young women, who represent 63 percent of new HIV infections in East and Southern Africa.

We can address other African priorities, too

Ambassador Gavin is correct about one thing, however: The United States can and should spend more in Africa on priorities other than health, including to promote economic freedom and two-way trade, bolster democratic governance, and help fragile societies defend themselves from violent extremism.

When former U.S. Agency for International Development Administrator Mark Green asked his in-country leadership to develop dream budgets for their new five-year country strategies in 2019, all of the mission directors in Africa proposed making additional investments in areas beyond health. But few suggested reducing PEPFAR to do so. They recognized the program is not the reason we are failing to devote funds to other fields in Africa.

President Bush gives remarks at The AIDS Support Organization Center in Entebbe, Uganda on July 11, 2003.

Congress bears responsibility here. In the aggregate, there should be plenty of money in the almost $50 billion in bilateral foreign assistance provided by the Consolidated Appropriations Act for Fiscal Year 2023 to reorient towards non-health priorities in Africa. However, an impossible-to-solve jigsaw puzzle of interlocking country-level, regional, and sectoral directives in the annual appropriations legislation removes almost all discretion from the Executive Branch to respond to emerging policy priorities in Africa (or anywhere else).

By my count, last year’s appropriations act contained more than 60 mandatory allocations for individual countries, regions, and international organizations, along with billions of dollars in requirements to spend on the pet causes of senators and representatives of both parties. The “Statement of Managers” that accompanies the law has dozens more spending instructions that are technically advisory but politically obligatory.

Once introduced, these directives never disappear; there are now so many of them that they add up to more than the actual amount of foreign assistance the Congress appropriates. This is what crowds out funding from other priorities in sub-Saharan Africa, not PEPFAR.

PEPFAR’s residual effects

The other important fact that Ambassador Gavin and others who share her view (such as Jon Temin) ignore is that PEPFAR’s approach of partnership instead of paternalism has proven a remarkably effective tool for advancing progress in the areas she cites in her essay.

First, while President George W. Bush did not intend or design PEPFAR to focus on economic growth or education, research published by the Kaiser Family Foundation (KFF) at the end of last year found PEPFAR has generated positive, quantifiable effects in both. The KFF analysis estimates that Gross Domestic Product per capita grew at a rate 45.7% higher in PEPFAR countries than in others.

The picture is even better (61.5%) for those in which PEPFAR puts together formal Country Operational Plans. In education, the report demonstrates a decline in the percentage of girls who are not in school in PEPFAR countries by over 40 percent.

PEPFAR has increased equity across the countries in which it works. Throughout sub-Saharan Africa, U.S. ambassadors have used PEPFAR to push for legal and regulatory changes that have strengthened human rights, increased access to health and education, fought corruption, and improved the governance and performance of public-sector organizations.

Second, PEPFAR’s investments and business model have promoted freer, more open societies. Through advocacy for, and direct funding of, grassroots, community- and faith-based groups across sub-Saharan Africa, PEPFAR has supported the growth of civil society in many countries. The local nongovernmental organizations (NGOs) that now receive more than 60 percent of PEPFAR’s bilateral funding are critical vehicles for citizens to express their views and defend their rights, and not just on health care.

Through these NGOs and collaborations with governments and other donors PEPFAR has increased accountability across the board in the countries in which it works. PEPFAR’s open, accessible, and real-time data heighten transparency, promote better decision-making, and improve the outcomes and impact of public and private health care.

The community-led monitoring PEPFAR sponsors (which former U.S. Global AIDS Coordinator Deborah Birx and I discuss in a new report from the Bush Institute) involves clients and their neighbors directly in the process of ensuring clinics, hospitals, and other sites are providing high-quality care and adhering to standards. Grass-roots watchdogs check whether reforms are reaching the local level; call out legal, policy, and structural barriers that remain; and reduce stigma and discrimination. In addition, through quarterly and annual planning conferences and programmatic reviews in each country, PEPFAR gathers community representatives, advocacy organizations, and government officials to design their country’s response to HIV together.

PEPFAR has given ordinary people a role in how their nations manage public services — often for the first time. The result is that communities in PEPFAR countries are holding governments and NGOs accountable for their promises. In fact, the Bipartisan Policy Center has found a strong connection between a higher level of PEPFAR funding in a country and improved government effectiveness, regulatory quality, and rule of law, as measured by the World Bank’s indicators of governance.

Third, in many countries PEPFAR is training the next generation of democratic leaders, especially women. PEPFAR’s DREAMS (Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe) partnership assists adolescents and young women to supersede the structural barriers and societal factors that make their rate of HIV infection three times higher than that among boys and men the same age. DREAMS helps keep girls in school (especially high school), lowers rates of child marriage, opens doors to jobs in the private sector, and builds leadership. DREAMS is democracy in action: Many of the young women involved are now activists on the national, provincial, and local level who have become clear voices for accountability and change.

Fourth, PEPFAR has increased equity across the countries in which it works. Throughout sub-Saharan Africa, U.S. ambassadors have used PEPFAR to push for legal and regulatory changes that have strengthened human rights, increased access to health and education, fought corruption, and improved the governance and performance of public-sector organizations.

In fact, the Bipartisan Policy Center has found a strong connection between a higher level of PEPFAR funding in a country and improved government effectiveness, regulatory quality, and rule of law, as measured by the World Bank’s indicators of governance.

In West Africa, PEPFAR is responsible for eliminating informal and formal health fees in public hospitals and clinics, a transformation that will have positive economic and health ramifications for the poorest for years to come. Through realigning its funding and programming based on granular, disaggregated data collected at the site and community level, all of which are publicly available, PEPFAR has prioritized care for those who need it most and made it harder for politicians to distribute national health budgets only to their supporters.

It is true that PEPFAR has not brought multiparty pluralism and free and fair elections to Zimbabwe, Rwanda, or Ethiopia. But even in those countries the program has spurred reform.

The bottom line is that collateral economic, educational, and democratic impact of PEPFAR has been more profound than most realize. The program is not responsible for the limited foreign-assistance budgets that U.S. ambassadors and USAID mission directors in sub-Saharan Africa bemoan; The most nimble of our diplomats and aid professionals on the African continent realize this, and they use PEPFAR’s resources and leverage in the service of broader goals. Deployed smartly, PEPFAR’s investments can and do attack corruption, promote transparency and citizen-responsive governance, sustain civil society and a culture of democratic community participation, and boost economic growth led by the private sector.

It is true that PEPFAR has not brought multiparty pluralism and free and fair elections to Zimbabwe, Rwanda, or Ethiopia. But even in those countries the program has spurred reform.

The perception that we have made “enough” progress against HIV to transfer PEPFAR’s resources to other issues is not only wrong, but it is a real threat to the program’s future. Along with proposals being floated to dilute the authority of the U.S. Global AIDS Coordinator while burdening the post with an unclear, unfunded mandate to coordinate our international pandemic-preparedness efforts, a move to deprioritize HIV in our African assistance portfolio would be a tragic mistake.