Building on PEPFAR's Success: Is a win for U.S. foreign policy

PEPFAR and the Global Fund have put many countries on the road to achieving the sustainable development goal to end HIV by 2030 and have created the health infrastructure that has been essential to responding to the COVID-19 pandemic. But the work isn’t done yet. Gaps in access to HIV prevention, care, and treatment still exist in many parts of the world. Emerging pandemics and noncommunicable diseases threaten progress against HIV and need solutions.

But thanks to the largest commitment by a nation to combat a single disease, the generosity of the American people, and bipartisan support across four successive presidential administrations and 11Congresses, most of the original recipients of treatment in PEPFAR’s early years are still alive and thriving today. The number of new HIV infections, especially among young people, continues to decline because of the great prevention work funded by PEPFAR and the Global Fund. Along the way, PEPFAR has taught us some critical lessons that we can use to solidify the program’s future as well as to improve U.S. engagement in global health and development.

Americans should be proud of how many lives they have saved and changed around the world through their generous contributions via PEPFAR. They have helped stabilize countries that otherwise would have been devastated by HIV/AIDS and become targets for extremist forces; this has engendered goodwill toward the United States. PEPFAR’s implementation also provides lessons that can apply to all U.S. investments in global health and development.

PEPFAR’s success derives largely from its focus on accountability. The program’s collection and use of real-time data to drive constant improvement and efficiencies have enabled the expansion of lifesaving services despite a flat budget over the last eight years. Real-time data ensure that the program can address the realities of the pandemic on the ground in communities; push critical policy changes; and allow PEPFAR’s approach to continue to evolve based on successes and failures. Budgetary authorities that cross usual appropriations lines and a direct reporting relationship to the Secretary of State have given the U.S. Global AIDS Coordinator the independence and leverage to make tough decisions in the interests of patients, not bureaucracy.

U.S. leadership will remain critical to achieving the global goal of ending AIDS by 2030. Stubborn gaps in access to services remain in the countries where PEPFAR works, despite tremendous successes. The underserved include children; adolescent girls and young women; and other key populations, including men who have sex with men, sex workers, people who inject drugs, and transgender people.

Colliding pandemics, such as COVID-19, and recurrent outbreaks of Ebola and other deadly diseases have threatened progress against HIV, Tuberculosis, and malaria. Especially over the past three years, PEPFAR has demonstrated its centrality to pandemic response and global health security as the platforms it funds and workforce it trains quickly transitioned to respond to other infectious threats. The global rise in noncommunicable diseases, such as heart disease and cancer, are additional challenges increasingly facing people living with HIV.

The Bush Institute released a series of papers that examine critical lessons learned from PEPFAR and make recommendations for the program’s future as well as continued U.S. engagement in global health and development. These recommendations summarize those offered in more detail in the papers and should guide the U.S. Government and Congress as they work together with other stakeholders in promoting global health and well-being.

Congress should reauthorize and fully fund PEPFAR and the Global Fund

What was once thought impossible – controlling the HIV pandemic without a vaccine or cure – is within grasp after 20 years of dedication. Scaling back would put the investments of U.S. taxpayers, and the lives of those PEPFAR serves, at risk. PEPFAR effectively matches its budget to demonstrate need through the constant employment of site-specific data.

Congress should appropriate the amount PEPFAR requires to end HIV and leverage its platform carefully for global health security. PEPFAR must have access to sufficient resources to close identified gaps, plan for the long-term sustainability of the program, support rapid interventions to stop outbreaks of other infectious diseases, and care for the people the program helps across their lifetimes. With PEPFAR’s authorization set to expire in 2023, Congress should also reauthorize the program without major changes for five more years.

The administration and Congress should preserve PEPFAR’s focus and location within the U.S. Department of State, reporting directly to the Secretary of State, while taking advantage of the lessons PEPFAR has to offer to improve the U.S. Government’s preparedness for, and response to, pandemics

President Bush strategically positioned PEPFAR in the Department of State – and made the U.S. Global AIDS Coordinator an ambassadorial appointment – to coordinate a whole-of-government response to HIV. The decision also harnessed the heft of the U.S. diplomatic corps to advance critical conversations and make progress on policy.

It’s imperative that the U.S. Global AIDS Coordinator and the Office of the Global AIDS Coordinator (S/GAC) maintain their positioning in the State Department with a direct reporting line to the Secretary of State. This will help ensure PEPFAR effectively fulfills its promise and has the stature bureaucratically to end HIV in the countries where it works and amplify U.S. support for democracy and human rights.

PEPFAR has been, and will remain, central to global health security. Through the COVID-19 pandemic, recurrent Ebola outbreaks, and the monkeypox (mpox) threat, PEPFAR used the laboratories, health care workforce, data systems, and supply chains it funded to help national health authorities respond more quickly to other diseases. This has benefited people living with HIV and served by PEPFAR programs along with the larger health care infrastructure and global health security, including for Americans. PEPFAR has proven that responding to the pandemics at hand positions national governments and their partners to be better prepared to respond to other emerging diseases and provide for the health and well-being of all their citizens.

The U.S. response to global health challenges will be more effective when it leverages existing global public health infrastructure under the convening leadership of the State Department, whose mission is to “protect and promote U.S. security,” including from biomedical threats. As the State Department, with Congressional approval, considers expanding the mandate of PEPFAR to coordinate the U.S. Government’s activities in global health preparedness and response, it is imperative that any added responsibilities come with appropriate allocations of new funding and personnel. This is critical for effective execution and to preserve the attention to PEPFAR’s original mandate to end HIV/AIDS and protect the resources necessary to fulfill it.

All PEPFAR implementing agencies should continue to collect validated data consistently from all sites broken down by gender, age, and specific geographic location so that implementers, funders, host country governments, and communities can continuously use the data to improve programs and increase their impact

Data have been key to the success of PEPFAR since its inception, as have accountability and transparency. Granular data have allowed PEPFAR to determine what is working and what is not, to identify which groups implementers are serving and which groups they have left out of care, and to match programmatic results to the dollars spent. Over the years, PEPFAR added more granular information disaggregated by sex and age band. It also funded population-based surveys to measure progress across indicators and better understand HIV risk factors, such as experience with interpersonal violence, as well as considerations to improve programming, such as perceptions of HIV in the community.

S/GAC should set in place a strong monitoring framework as PEPFAR considers its next strategic phase. This includes careful planning for the long-term sustainability of the program through community leadership and the assumption of a greater share of funding by national programs.

To ensure equity in resource distribution, as well as high-quality care across its programs, PEPFAR must continue to collect and regularly analyze data matched to geospatial coordinates at the site level, and S/GAC should make funding decisions that reflect the reality on the ground. This enables the program to pivot funding to follow the epidemiological patterns of HIV and drive the greatest impact for the most affected communities. Managing through site-level data shows when a program is running effectively, when it is achieving its intended outcome, and when things need to change. It often reveals innovations adaptable across countries.

PEPFAR should also continue to prioritize qualitative data that can provide a fuller understanding of the nuances of the program’s results and maintain its emphasis on interdisciplinary site-level monitoring visits to identify and address issues of quality and access to care. PEPFAR’s system for collecting, analyzing, and applying data to improve programming is a model for all U.S. global health and development programs. The federal departments and agencies that manage international investments by U.S. taxpayers in health, education, agriculture, the environment, and other fields should learn from PEPFAR’s successes and adapt them to their contexts.

PEPFAR should continue to foster partnerships with global multilateral organizations and the private sector, coordinating efforts to ensure maximum impact and cost-effectiveness

S/GAC should continue to strengthen PEPFAR’s relationships with multilateral organizations and the private sector, especially as people living with HIV begin to face comorbidities across their lifespans, including noncommunicable diseases. One example of a successful public-private collaboration is the Go Further partnership between PEPFAR, the Bush Institute, UNAIDS, Merck, and Roche. Leveraging the strength of each partner, it has used the PEPFAR platform to scale up screenings for cervical cancer and the treatment of precancerous lesions across 12 countries in East and Southern Africa. Host-country governments have worked to ensure that national HIV and cancer-control plans address the relationship between HIV and cervical cancer and translate these commitments into policy and action. Go Further has brought global attention to the importance of cervical cancer among women living with HIV and has spurred advances to use and incorporate more effective prevention, testing, and treatment methods into HIV programs.

PEPFAR’s impact and effectiveness owes much to its complementary investments in multilateral organizations, such as UNAIDS, the Global Fund, and the World Health Organization (WHO). UNAIDS leads the development of the global strategy on HIV and tracks progress against HIV indicators (including those related to policy development) across countries. The Global Fund, the other major funder of HIV programs around the world, participates in PEPFAR’s annual process to develop Country Operational Plans to align resources and avoid duplication. The Global Fund also leverages financing from other donor nations and encourages national governments to share the cost of efforts to end AIDS. The WHO provides policy and technical recommendations, often based on data produced by PEPFAR-funded programs, that advance public health and clinical approaches to HIV and other health challenges.

Meanwhile, the private sector can take risks and make investments that the U.S. Government can’t, such as advancing science and technological applications across HIV or other global health programs. The private sector has also brought its understanding of market research and behavioral science to identify barriers to care and solutions to expand programs to those previously left out.

PEPFAR should increase its target for funding to local organizations, including peer-led organizations, to 90% by 2030 and continue to engage clients and local leaders in the design and implementation of programs

President Bush envisioned PEPFAR would form a series of partnerships between communities, national governments, implementers, multilateral institutions, and other stakeholders that would hold each other accountable and each contribute a fair and reasonable share to the collective responsibility to end HIV.

As PEPFAR works toward sustaining its investments into the future, communities must remain at the center of its efforts. Working with local leaders and implementers allows the program to have the deepest and longest lasting impact, while also being cost-effective.

PEPFAR has made tremendous progress in funding local organizations, which now receive almost 70% of the program’s investments with plans to increase that to 90% by 2030. People from the communities being served are most effective at reaching and providing care to those who need access to services, especially vulnerable populations often excluded from care at mainstream hospitals and clinics. Tapping into the ingenuity and deep knowledge of community partners will expand PEPFAR’s impact exponentially.

PEPFAR is one of the most successful international development programs since World War II, one made possible through the use of data to drive decisions and meaningful partnerships with diverse stakeholders. PEPFAR demonstrates that doing important, life-changing things requires working across the political divide in ways that transcend any one administration or Congress. It requires drawing the best from each individual federal department and agency by leading them to work in harmony to maximize outcomes and impact. It requires ensuring every U.S. taxpayer dollar is accounted for and directly linked to results. Finally, it requires every member of Congress, regardless of party, to recognize the importance of a program that represents the best of America and to understand and value their contributions to it.

The lessons of PEPFAR are crucial to improving the impact of other U.S. health and development investments. PEPFAR has saved millions of lives, and while its primary goal is the prevention of HIV and the care and treatment of people with the virus, its impact has gone well beyond these key indicators. PEPFAR has strengthened health institutions and networks, emboldened democracies, supported economic growth, boosted education levels, and pushed for progress on human rights. PEPFAR has been a win for both the countries it serves and for U.S. foreign policy. Congress and the American people should continue to support its critical work.