The Cost of Inaction on PEPFAR, the AIDS Relief Program That's Saved Millions
Leaders of Partners In Health, the international public health nonprofit, write about the danger of not funding PEPFAR, a program that's saved 25 million lives and prevented millions of HIV infections.
Last month, Congress failed to meet the five-year reauthorization deadline for the President’s Emergency Plan for AIDS Relief (PEPFAR), jeopardizing millions of lives and stalling two decades of progress toward global health equity. Since bipartisan legislation signed by President George W. Bush launched PEPFAR 20 years ago, the program has saved 25 million lives and prevented millions of HIV infections by expanding access to HIV/AIDS prevention, treatment, and care. It has also been a diplomatic victory, resulting in significant goodwill toward the U.S. Despite this unprecedented success, the future of PEPFAR is endangered by Congress’ inaction.
At Partners In Health (PIH), we have seen firsthand the positive impact of the program across the five countries where we work that receive PEPFAR funds. We, and the patients we serve, advocated for the creation of PEPFAR and have lent our support and experience at each juncture of the creation and congressional reauthorization of this important diplomatic and global health effort. This is the first time that reauthorization has not received bipartisan support and comes at a perilous moment, as we begin to see the impact of slowed global progress against AIDS due to the COVID-19 pandemic. With PEPFAR’s far-reaching, life-saving interventions at risk, we urge Congress to reauthorize it, thereby sustaining access to these resources for the world’s most vulnerable populations.
In the early days of the AIDS crisis, the world witnessed the devastation of a progressive disease with no treatment. The arrival of antiretroviral therapy (ART) in 1996 in the U.S. and Europe changed everything for patients living with HIV—people emerged from the brink of death and regained the possibility of a full and long life. HIV became a treatable and manageable condition.
But this amazing, life-saving therapy was not available in poor countries. In 1996, there were about 26 million people in the world with HIV, and more than 95% lived in impoverished countries of the global South. The complete absence of ART in Africa until the authorization of PEPFAR in 2003, resulted in 8,000 deaths and thousands of orphaned children each day. This massive toll led to the collapse of communities in the hardest hit places—a reality that catalyzed strong bipartisan support for the U.S. to take a leading role in responding to this global catastrophe. From Senator Jesse Helms, the Republican from North Carolina to Senator Sherrod Brown, the Democrat from Ohio, there was broad support for the creation of new funding to combat the global pandemic.
We at PIH are proud to have been part of a global response to the AIDS pandemic. In Haiti, where PIH was founded, our organization began the HIV Equity Initiative in the mid-1980s, offering free testing, counseling, and care for patients with HIV and AIDS. And as treatment became available in the U.S. and Europe in the 1990s, we pioneered the use of antiretroviral drugs to prevent mother-to-child transmission and then ART as treatment for people living with HIV/AIDS in Haiti—the first program of its kind in an impoverished country. At a time when many said that treating HIV/AIDS in resource-poor settings was too complex and expensive, or simply impossible, PIH proved otherwise using a model of community-based care to leverage networks of community health workers and provide ART alongside social support. PIH’s documented successes in addressing HIV—and other diseases in impoverished settings—countered what our late co-founder Dr. Paul Farmer called “failures of imagination” and was part of the evidence base that led to the U.S. government’s creation of PEPFAR and the formation of The Global Fund to Fight AIDS, Tuberculosis and Malaria (a multilateral program to treat the world’s deadliest infectious diseases).
The importance of PEPFAR within global health extends well beyond the prevention and treatment of HIV/AIDS to transforming health care in some of the poorest places on earth. As a result, adults and children are living longer and health systems are more responsive to threats.
PIH in Haiti received early funding from PEPFAR that allowed us to rebuild local health infrastructure. We knew HIV/AIDS could not be treated unless there were robust systems in place to support that treatment—and that these same systems would improve overall community health, too.
By integrating HIV testing and treatment into PIH’s delivery of primary care, PEPFAR funding became critical in improving public infrastructure to allow for the delivery of a range of health services. Today, based on almost four decades of experience, PIH has honed a proven, replicable, and adaptable model for health system strengthening with five key elements: staff, stuff, space, systems, and social support. We know that this model works to deliver quality health care, but we need continued leadership and resources to support these efforts.
Failure to reauthorize PEPFAR would not only imperil the gains made in fighting HIV and AIDS but would undermine its transformative effect on strengthening health systems more broadly. The result could be millions of preventable deaths. We cannot only invest in communities and health care delivery during emergencies, leaving systems to collapse as funding and attention go elsewhere, we need sustained commitments to make lasting change.
Just as PIH’s trailblazing early work in Haiti proved that HIV could be treated in impoverished communities—inspiring global initiatives like PEPFAR—it’s time to reimagine a future fortified with the steadfast leadership and committed resources necessary to transform health systems and lives over the long term. This durable health system strengthening is even more important in a world still grappling with COVID-19, preparing for the next pandemic, and experiencing the wide-ranging effects of climate change. We need continued U.S. leadership and action, as demonstrated by another five-year reauthorization. We call on Congress to reauthorize PEPFAR and commit to global health equity now.
Dr. Sheila Davis is CEO and Dr. Joia Mukherjee is the chief medical officer of Partners in Health, an international nonprofit public health organization.
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