Who Will Suffer Most if US AIDS Funding Ends

Abstract

The President's Emergency Plan for AIDS Relief (PEPFAR) is among the most successful US global health programs. It has moved HIV/AIDS from a certain death to a treatable disease. PEPFAR is now in danger of not being renewed. This perspective seeks to highlight the voice of perinatally HIV-infected Tanzanian youth.

Sitting in a conference room in the shadow of Mount Kilimanjaro in northern Tanzania, we cautiously asked a group of young Tanzanians who are living with HIV to contemplate the unthinkable: What if PEPFAR ends?

It is a question many Americans may not have considered. PEPFAR, the President’s Emergency Plan for AIDS Relief, is arguably the US government’s most successful global health program, credited for preventing an estimated 25 million deaths from AIDS since its start in 2003. Now, after decades of wide bipartisan support, the program is in serious danger, as some Republicans in Congress are threatening to hold up its reauthorization over baseless claims it funds abortions [1].

Those debates seem incomprehensible to the young people with whom we work [2]. For them, PEPFAR has been their lifeline. When they were born, half of HIV-infected infants died before their second birthday [3]. Many watched their biological mothers die of AIDS. They have endured traumatic home transitions, extreme stigma, poverty, and hopelessness.

They are the generation PEPFAR sought to save. And it has. US funding has made antiretroviral therapy widely accessible in countries such as Tanzania, turning HIV infection from a near-certain death sentence to a treatable infection that can be successfully managed with medication. PEPFAR has supported education programs to teach people living with HIV that they can keep the virus suppressed, and that they can have children without transmitting HIV to their babies. It has lifted them from suffocating despair and has enabled them to have hope for their future.

There is a Swahili expression, “Tumia dawa kutimiza ndoto,” that means, “Take your medicine to achieve your dreams.” This is the contract PEPFAR has offered a generation of Africans living with HIV. But the contract goes both ways. Why would the US government do so much to give these young people hope, only to take it away?

Twenty years ago, President George W. Bush had the moral courage to propose a big idea. Dr Anthony Fauci and Dr Mark Dybul were tasked to put together a plan to address AIDS in Africa. They became the architects of PEPFAR. The devastation they witnessed on the African continent was horrifying. Though many infections prey heavily on extremes of age, infants, and the elderly, AIDS was killing those in the prime of their lives. An entire generation of parents were dead, leaving behind millions of orphaned children and HIV-infected babies. While medicines to control HIV were becoming available in the United States and other wealthy nations, the toll of AIDS in sub-Saharan Africa was staggering.

In 2002, more than 40 million people were living with HIV, the incidence rate and death toll rising, predicted to reach over 100 million deaths if action was not taken [4]. Hospitals were overwhelmed, households and towns run by orphans, their parents dead. Life expectancy dropped by 20 years in the most severely affected countries and in some countries more than 40% of pregnant women were living with HIV [5]. Fauci proposed a $500 million investment to address mother-to-child HIV transmission. In response, President Bush urged him to “Think Big” and create a game-changing program that was feasible, implementable, with measurable outputs, and for which African governments would be partners with accountability [6].

In 2003, the US government chose to come together, to not look away, and to create PEPFAR, a life-saving program that has been sustained under four presidents and both Republican- and Democratic-led Congresses. Its success is undeniable. AIDS deaths in infants and young children in sub-Saharan Africa have fallen by 80% [7]. More than 5.5 million babies with HIV-infected mothers have been born HIV free [8]. Twenty million people have received life-saving medication.

And yet the program’s indispensable work is far from finished. Only half of children under 14 years of age living with HIV in sub-Saharan Africa have access to treatment [9]. This is due in part to gaps in HIV testing of pregnant women and children, delay in test results, and HIV-related stigma, all issues PEPFAR helps address through successful government partnerships.

Failing to reauthorize PEPFAR would also threaten the progress made in protecting adolescent girls and young women, who are up to 14 times more likely to become HIV infected than their male counterparts. In Tanzania, over 200 000 Tanzanian girls have engaged in a PEPFAR-supported program that provides mentoring and education to help them avoid HIV infection [10].

The beauty of PEPFAR is that it was conceived as a true partnership with international governments. Funding is tied to specific gaps in outcomes in each country that participates, which has allowed countries to invest in new health infrastructure and training for healthcare workers. It has created rare employment opportunities for youth who live with HIV to work as peer navigators and in home-based care. Creating jobs and strengthening healthcare systems globally in turn advances US national security and diplomacy.

Though it can be difficult to see the effects of a government program that helps lives elsewhere, to us and the people we work with, PEPFAR’s impact is very real. The generation saved by PEPFAR has not only survived, but thrived. They have become peer and community leaders and made plans for their futures. Many have started families of their own and dream about what life will be like for their children.

Undoubtedly, this is why when we asked them about a possible end to PEPFAR, they fell silent. Their heads went down. Eventually, one youth, full of emotion, spoke in Swahili: “Mzazi hali ili mtoto ashibe,” or, “A parent will starve for their child to survive.” Before PEPFAR they saw their parents die, while they lived. Losing access to medications and not being able to take care of their children would be history repeating itself. It would be the end of life as they know it.

The moral imperative that brought PEPFAR to life has not changed, nor should our commitment to its renewal. Our African partners have kept their end of the commitment. Seeing how far we have come, how can we in good conscience risk another generation—their families, their futures, and their dreams? Simply put, we cannot.