Key Issues and Questions for PEPFAR’s Future

The Biden administration has inherited PEPFAR at a critical time for the program and the fight against HIV, and PEPFAR is at a turning point. Much has changed since the program was created in 2003, including important shifts in global HIV burden, a substantial expansion of the array of validated HIV prevention and treatment tools, and notable changes in the global health and development landscape. In addition, the program awaits the nomination by the President of a new Coordinator, is preparing a new five-year, Congressionally-mandated strategy, and, in two years, is due to be reauthorized by Congress. At the same time, the fight against HIV/AIDS is far from over and the COVID-19 pandemic has presented new health and economic challenges for PEPFAR countries.

This policy brief explores key issues and poses questions regarding PEPFAR’s future, providing a roadmap for the major decisions ahead for the program. It identifies eight key, interrelated issues facing the administration, Congress, and other PEPFAR stakeholders, as follows:

1. Addressing the short- and long-term impacts of COVID-19 on PEPFAR and the HIV response. COVID-19 continues to have profound health and economic effects in the countries that receive PEPFAR support and there is uncertainty about the future. While early actions by PEPFAR appear to have helped minimize treatment disruptions, COVID-19 has also presented the program with new challenges and questions, including the extent to which COVID-19 might set back PEPFAR’s progress, administrative and legislative actions that can be taken to mitigate impact and make-up lost ground, and whether the PEPFAR platform can be used more directly to address COVID-19 through vaccine delivery and other interventions.
2. PEPFAR funding and bipartisan support. PEPFAR funding has been mostly stagnant for more than a decade, even as the number of people needing HIV treatment has increased and new infections remain high. In addition, other donors have reduced their HIV funding in recent years and countries that receive PEPFAR support have faced challenges in mobilizing domestic HIV resources. Whether funding for PEPFAR will be increased, or even sustained, will in part depend on its ability to maintain bipartisan support, which has been one of its hallmarks to date. Ultimately, many of the decisions facing the program will hinge on future funding levels, as well as the broader HIV financing landscape.
3. PEPFAR’s geographic footprint, service portfolio, and population focus. Among the main programmatic levers available to PEPFAR to address the HIV epidemic are its geographic focus, the set of interventions it supports, and the population groups it prioritizes. Decisions in these areas have reflected a variety of factors over time, including HIV epidemiology, scientific advances, political and diplomatic considerations, and funding. Going forward, many of these same factors will likely affect PEPFAR’s strategic choices in these three interrelated areas. Other considerations may also come into play, including, for example, the extent to which a focus on promoting equity in access to HIV services might be incorporated into such decisions.
4. The role of community and civil society in PEPFAR and the HIV response. Since the onset of the HIV epidemic, communities, including people living with HIV, have played a key role in the HIV response – as advocates, providers of services, and accountability watchdogs. The participation of civil society in PEPFAR’s policy development and programming has a long history, one which has increased and become more formalized over time and is unique among other areas of global health and development. In addition to strengthening PEPFAR’s immediate efforts, the inclusion of community and civil society could affect the longer-term sustainability of programs in countries. As such, how PEPFAR seeks to further build upon and sustain its support for community-led HIV responses will have important implications for the program’s future.
5. PEPFAR, epidemic control, and the long-term sustainability of the HIV response. Although PEPFAR was designed from the outset as an emergency response, the importance of building sustainable capacity in countries was recognized as a priority at its early stages and has been underscored over time. Still, how best to define and sustain long-term success remains a challenge for PEPFAR, as well as for other HIV donors. It is not yet clear what the scope and nature of U.S. assistance might be after a country achieves epidemic control or other program targets or how to sustain progress and guard against shocks. Ultimately, how best to promote sustainability and country ownership, including whether PEPFAR should consider instituting formal transition plans or criteria for determining when and at what pace to draw down support, are key questions for the future.
6. PEPFAR’s role in global health security and broader health systems strengthening. The COVID-19 pandemic has intensified attention to shoring up U.S. global health security efforts and creating more resilient health systems. It is unclear what this will mean for PEPFAR, and any major actions could pose both opportunities and risks for the program. As the first and largest U.S. global health program specifically designed to address a pandemic, PEPFAR could offer key lessons for broader U.S. pandemic preparedness efforts and potentially be integral to such efforts. However, an increased focus on health security more generally could conceivably crowd out other global health investments and reduce the emphasis on HIV, even when tremendous need still exists.
7. PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The U.S. has played an integral role in the Global Fund since its inception, including providing the Global Fund with its founding contribution, serving as its single largest donor, and being active in the organization’s governance and oversight. The Global Fund, in turn, extends the reach of PEPFAR into more countries and populations. PEPFAR and the Global Fund work quite differently, however. Given how critical both PEPFAR and the Global Fund are to the HIV response, there may be opportunities for the U.S. government to rethink and strengthen their relationship going forward, including through more proactive and strategic coordination, particularly given concerns about future financing for HIV.
8. PEPFAR’s structure and location within the U.S. government’s global health architecture. When PEPFAR was first created, locating it at the State Department and providing its Coordinator with the power to oversee all U.S. global HIV investments, as specified in its authorizing legislation, marked a departure from the way in which U.S. global health programs had been previously structured. Some have argued that PEPFAR’s location and structure should be reconsidered to further its transition from an “emergency” program to one more focused on long-term development and to better integrate activities across the U.S. global health portfolio.¹ Others, citing the program’s broadly recognized positive impact on the HIV response, have argued that it is important to keep the current structure, and that moving PEPFAR would present significant risks, including threatening the HIV response and diluting PEPFAR’s diplomatic role.² Whether or not PEPFAR’s structure is reconsidered by policymakers, particularly in the context of an increasing focus on global health security, is likely to remain a key question facing the program’s future.