If Congress walks away from PEPFAR, it will undo decades of global HIV progress

In 2001, eight months after President George W. Bush was inaugurated, I was on a plane to volunteer with the Peace Corps at Mali’s only HIV/AIDS clinic.

Back home, people living with HIV had access to lifesaving antiretroviral medicines, and a once terrifying killer had transformed into a chronic but highly manageable disease. Outside the U.S. and Europe, the HIV pandemic still raged, and even as generic HIV medicines became more available, people in most countries did not have access to them.

While working in the clinic, I met people who had traveled for days to be tested, some of whom were gravely ill from advanced HIV disease. For most, the best we could do was send them home with antibiotics for AIDS-related opportunistic infections and try to keep them comfortable before they died.

This disease was treatable, but every day, approximately 8,000 people globally were dying of AIDS simply because of where they lived.

That began to change near the end of my assignment, amid a chorus of HIV activists’ voices. The President’s Emergency Plan for AIDS Relief, or PEPFAR, was announced — a bipartisan global health program that has played a transformative role in HIV treatment and prevention worldwide.

PEPFAR has saved an estimated 25 million lives and made the fight against HIV a truly global one. In the early 2000s, in impoverished settings like Mali, very few people with HIV were on treatment, due to its price and lack of availability in developing countries. Today, with the help of PEPFAR, 75 percent of people with HIV globally are on the medicines they need to live long and healthy lives.

In a relatively short period of time, the world has gone from questioning whether HIV treatment was feasible in resource-limited settings to understanding that if enough people are on treatment the virus can be brought under control. We went from doctors not being able to provide targeted medical treatments in many low-resource settings, to, in 2013, the U.S. announcing a goal of an “AIDS-free generation” — something the U.S. had never reached for because it once seemed implausible. This progress is due, in no small part, to PEPFAR.

Despite the historic success and two decades of bipartisan support, Congress failed to reauthorize the program earlier in the fall and instead let it expire. We must ensure that Congress reauthorizes this critical global health program for the full five years without any restrictions, as it has already done four times, before the end of the year.

For the last 12 years, I have worked at Doctors Without Borders. As an international medical humanitarian organization working in many places where people don’t have access to health care, Doctors Without Borders was on the ground before PEPFAR, trying to get people access to treatment in any way we could, because there were no systems in place to do so. In the time since, we have witnessed how PEPFAR helped to change the trajectory of the disease in resource-limited settings. In fact, we have been able to hand over some of our HIV programs in Kenya, Uganda, and Malawi, since PEPFAR has paved the way for governments and other health actors to carry out these lifesaving activities.

Today, due to a global effort heavily supported by PEPFAR, communities in historically high-HIV-burden countries such as South Africa and Eswatini (formerly Swaziland) have reached the ambitious treatment targets set by the United Nations in 2015 to help end the AIDS pandemic. This means that at least 90 percent of people know their status, 90 percent of people who are HIV-positive are on antiretroviral medicines, and 90 percent have a suppressed viral load that makes it harder to transmit the virus to others. But the potential disappearance of PEPFAR has put all these accomplishments at risk.

We’ve already seen glimpses of what can happen when PEPFAR programs disappear from communities. Following the 2017 escalation of conflict in northern Mozambique, when 40 HIV treatment sites supported by PEPFAR had to close due to local conflict, access to lifesaving HIV antiretroviral treatment for most people was cut off. In addition to hurting those who rely on lifesaving medicines, it also left the community vulnerable to a resurgence of the virus. When Doctors Without Borders tried to reopen some of the sites, not everyone who had previously been on treatment came back.

We saw a similar situation unfold in South Sudan in 2021, as PEPFAR stopped funding HIV products such as antiretrovirals, lab equipment, and prevention methods in that country. As a result, other donors have had to divert funding to cover this gap. For example, the majority of the Global Fund to Fight AIDS, Tuberculosis and Malaria funding allocated to South Sudan is nw going toward HIV products,, leaving little to no funding for other HIV work such as prevention efforts.

The costs of failing to reauthorize PEPFAR will be catastrophic. Stable funding is critical for stable care. Without a five-year reauthorization, people with HIV and the local programs they rely on will be at the mercy of annual congressional negotiations, making it difficult to plan care and services confidently and to reach longer-term HIV goals.

For two decades, the U.S. government has invested in the global fight against HIV. To turn back now, so close to what medical experts say is the “finish line” in terms of HIV treatment and prevention, would not only be morally wrong, but financially reckless. After all, responding to a global resurgence of AIDS would cost far more than continuing PEPFAR.

Doctors Without Borders does not accept U.S. government funding and will not be directly affected by any cuts to PEPFAR. We are an emergency humanitarian medical organization. We will be ready to step up and fill some of the local gaps that result if U.S.-funded programs close or if there are new needs due to HIV reemergence in some places. But there would be no excuse for letting this completely treatable disease become a global health emergency again.

American leadership and bipartisan cooperation has made PEPFAR one of the most successful global health programs in history. We cannot allow this progress to languish with the finish line in sight. U.S. lawmakers must immediately put this program’s reauthorization back on the agenda, to ensure stable support for HIV-positive people and programs for the next five years.

Dr. Carrie Teicher is director of programs at Doctors Without Borders.