Millions who rely on US-funded HIV/AIDS programs face uncertainty as financial cliff looms

By Lauren Kent, CNN

(CNN) — Millions of HIV/AIDS patients, many of them in Africa, face an uncertain future as a financial cliff-edge for US-funded global programs fast approaches. In September, 120 funding awards for HIV/AIDS work carried out by the US Centers for Disease Control are set to expire, with no concrete replacement system in place.

The programs provide services to more than 8.7 million patients worldwide, analysts say, and it’s unclear what will happen to many patient services on the other side of October 1.

It comes as the US State Department is restructuring the CDC’s work on global health initiatives to assume greater control, according to internal guidance published by the State Department in May, of which CNN obtained a copy.

The new guidance lays out a “streamlined” approach to the United States’ long-running HIV/AIDS initiative, called the President’s Emergency Plan for AIDS Relief (PEPFAR), which was established by the Bush administration in 2003. Considered a flagship among global health initiatives, PEPFAR is credited with saving more than 26 million lives and preventing millions of infections, mostly in Africa.

Previously, PEPFAR was jointly run by the US Agency for International Development (USAID), CDC and other agencies, and overseen by the State Department. But the new plan will swiftly move much more control to the State Department. Multiple critics and experts have told CNN that they support the idea of streamlining PEPFAR – work to improve its efficiency was already underway – but they believe this new approach will severely diminish the initiative’s effectiveness and sideline the health experts at CDC.

The 120 US-financed awards for the CDC branch of PEPFAR are expected to end within weeks without replacement mechanisms in place, according to a recent analysis of publicly available data by the Health Security Policy Academy, a US-based think tank.

“The result could be a second global health woodchipper: the abrupt destruction of operating systems that patients, clinics, health workers, laboratories, and ministries of health still depend on,” wrote the authors of the analysis.

The impacts are expected to vary greatly from country to country. Mozambique, Tanzania and South Africa will be hit particularly hard by the funding cliff this year, the analysis shows.

The awards fund a range of services including community testing, HIV clinical services, HIV lab services, Pre-Exposure Prophylaxis (PrEP) medication and more. Many of the expiring overseas programs have been running for 15 or 20 years, since the funding was typically renewed in five-year cycles.

In addition to not renewing US-funded programs that happen to expire in 2026, the State Department is also planning to replace some of CDC’s other remaining awards and has told CDC to cancel some open funding opportunities, according to one CDC official.

“It really does feel like the end of PEPFAR,” the CDC official, who was not authorized to speak on the record, told CNN. “In a lot of cases, the State Department mechanism is not set up yet. So, this isn’t handing it from one set of experts to another – this is taking it away from one set of experts and putting it in a big box with a question mark.”

Another part of the new strategy launched in May is transitioning to a system in which partner countries choose from a “menu” of services, paying à la carte for which CDC services they want. Analysts say that will take the US health agency out of the driver’s seat and turn it into a contractor of sorts.

Trump administration political appointees “have been pretty clear the overall funding is going way down,” the CDC source added, saying that State Department officials have made clear that they are no longer interested in funding certain systemic work, such as health surveillance systems, certain laboratory work and health workforce training. For the parts of PEPFAR programs that they do want to keep funding, like health workers and medications, “it’s really just for one or two more years, and then they’ve already told some of the countries we’re pulling the plug.”

The State Department though has said that funding for operations will increase, as it transitions to what it’s calling the “America First Global Health Strategy.” The changes to PEPFAR are part of that broader strategy, in which American aid will be funneled through a new system of one-on-one Memoranda of Understanding (MOU) with individual countries, rather than distributed through international aid partners and organizations.

“The State Department expects CDC overseas operating funding to increase – not decrease – under the America First Global Health Strategy,” a State Department spokesperson said in response to questions from CNN.

“The Trump Administration is preserving and strengthening PEPFAR’s lifesaving impact, maintaining CDC’s world-class technical role, and ensuring US assistance is producing durable results,” the State Department spokesperson said. They said that each country receiving aid is now working through a plan for implementation of the MOU agreements and that the CDC remains “the preferred provider for all technical services to recipient countries.”

A spokesperson for the US Department of Health and Human Services, which oversees CDC, said: “The suggestion that the America First Global Health Strategy will ‘deteriorate’ global health programs ignores decades of CDC’s work to build sustainable public health capacity around the world,” adding that “CDC continues to implement global health programs funded through Congressional appropriations.”

Bipartisan criticism

The State Department’s restructure of PEPFAR has drawn widespread criticism from experts, members of Congress and former CDC officials who worked under both Republican and Democratic administrations.

In an essay published in the health news outlet Stat in May, eight former CDC directors warned that the State Department strategy, “done in haste as currently planned… will destroy PEPFAR and undermine health security around the world and in our own country.” They added that the fee-for-services menu “risks pulling out the scaffolding and expertise” of the program before an effective alternative is in place.

The former CDC directors urged the State Department, CDC and Congress to work together on a more stable transition plan.

Meanwhile, a bipartisan group of senators has sent a letter to the Senate Appropriations Committee urging a direct increase in funding for CDC’s global health account, arguing that “while we must be conscientious stewards of taxpayer dollars spent on foreign assistance, PEPFAR is one of the most cost-effective foreign assistance programs, delivering an immense return on investment.”

CDC has a “proven track record” of successfully implementing the US’ global work on HIV/AIDS, said the group of 23 senators, led by the Rev. Raphael Warnock (D-GA) and Dr. Bill Cassidy (R-LA).

“A real challenge with this proposal is that it’s really viewing global HIV work and global health-response work as transactional, as part of these MOU deals,” said Dr. Michele Montandon, the former leader of the CDC team working to prevent mother-to-child transmission of HIV, who was laid off last year. “There’s really a lack of focus on health outcomes, saving lives, keeping Americans safe.”

Montandon expressed concerns about the continuation of the accountability, transparency and strong data collection that have long been considered the keys to PEPFAR’s success, as the new system of bilateral MOU deals is implemented.

“When you require countries to meet certain indicators, we know that people are more likely (to) tell you what you want to hear. And so you need a lot of data quality systems in place, and site visits, and oversight to make sure that the data are accurate,” she told CNN.

Regarding the expiring awards, Montandon added: “It’s really hard to transition the support for 8 million people in a couple months’ time without having major disruptions… When people lose their access to treatment, they get sick with AIDS. Babies get HIV. People die.”

The CDC official added that staff inside the agency have long been working to improve PEPFAR’s efficiency and bolster the involvement of partner governments, in order to help ensure that the money the United States spends to combat HIV/AIDS goes further. The source argued that the restructure of PEPFAR is actually inhibiting efficiency.

“The irony is, we’re actually moving backwards,” the source said. “We’re getting far less per dollar than we were two years ago because of these changes.”

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