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PEPFAR Threatened: What does this mean for HIV treatment and prevention programmes?

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American leaders are currently discussing the future of the President's Emergency Plan for AIDS Relief, PEPFAR. Global health activists and experts have warned that these discussions could lead to reduced funding for, and threaten the autonomy of, PEPFAR in a period of declining donor interest in HIV/AIDS.

In order for South Africa and many other countries to reach universal access, a commitment endorsed by the United States, PEPFAR will need to continue to expand funding for HIV.

In its first five years, PEPFAR funding reached $18.8 billion (R141 billion). From 2003 – 2009 PEPFAR treatment support is estimated to have saved 3.28 million adult lives. South Africa, the epicenter of the epidemic, receives a substantial amount of its HIV funding from PEPFAR. In fiscal year 2008, South Africa received nearly $590.9 million (R4.43 billion).

South Africa is moving into a new era in its AIDS response. The new government has demonstrated political commitment to meeting the treatment and prevention targets of the National Strategic Plan (2007-2011) (NSP). Targets include providing treatment to 80% of people in need and reducing new infections by 50% by 2011. It would be a great pity if this new era of local political commitment to tackle HIV was undermined by a decline in the international funder commitment.

South Africa will need to double the number of people receiving antiretroviral treatment to meet its NSP targets. The government will be further expanding access to treatment through implementing the changes to the treatment guidelines announced by President Zuma on World AIDS Day and implementing provider initiated testing.

In South Africa a funding cut will mean the government will face an increase in costs with the rapid need for scale up in spending of HIV and at the same time replacing donor funds.

Moreover, other Sub-Saharan African countries with large HIV epidemics are much more dependent on donor funds than South Africa. Unlike South Africa, countries like Malawi, Namibia and Zambia have little prospect of finding alternative finance if PEPFAR funds decline and any contraction of PEPFAR would mean less money for HIV treatment and prevention programmes. This will mean more infections and more deaths.

Unfortunately, several very vocal economists and public health officials, with little understanding of the crisis HIV presents for Sub-Saharan Africa, have been calling for reduced funding for AIDS because, they argue, donor money should rather be directed towards building health systems. This argument fails to consider:

(1) the massive negative impact of the HIV epidemic on life-expectancy and the economic potential of young adults in Sub-Saharan Africa;
(2) the benefits to programmes fighting TB and malaria (the two other largest causes of infectious disease deaths in the world) of increased AIDS spending;
(3) the improvements to health systems that are occurring because of AIDS programmes, in part because of the unprecedented community involvement in the HIV epidemic in Sub-Saharan Africa compared to other diseases; and
(4) the positive changes to patient-health worker relations in many poorer countries that the global response to health that HIV has caused.

We urge the United States not to turn its back on universal access to HIV treatment at this vital time.