U.S. Response to Mpox in the DRC: Leveraging PEPFAR as a Global Health Security Asset

Commentary by Alicia Carbaugh

Published October 28, 2024

Given the multitude of devastating crises unfolding around the world, news of the current mpox outbreak in parts of Africa may not be reaching a wide audience. However, this outbreak-driven by a more contagious and deadly strain of the mpox virus-is important to spotlight given its growing toll and implications for global health security. The U.S. government (USG) has mobilized a multipronged response, of which its billion-dollar global HIV/AIDS program, PEPFAR, is a core element. The President's Emergency Plan for AIDS Relief (PEPFAR) has a unique role to play given the intersection of HIV and mpox, as well as the potential to leverage its platform in the Democratic Republic of Congo (DRC) and in other African countries where mpox cases are being reported. U.S. support for the regional mpox response underscores PEPFAR's importance as a provider of life-saving HIV services in areas facing an emerging health threat, as well as its critical contributions to the USG's global health security approach. This is especially relevant as the program faces another reauthorization in early 2025 amid a potentially unsettled political climate.

Snapshot of Current Mpox Outbreak and Key Challenges

The World Health Organization (WHO) declared mpox to be a Public Health Emergency of International Concern (PHEIC) in July 2022 and again in August 2024, following a similar pronouncement by the Africa Centres for Disease Control and Prevention (CDC). This was in response to increased circulation of the more contagious and deadly strain in the DRC, where mpox is endemic. There have been more than 40,000 suspected cases across Africa in 2024. The epicenter of the outbreak remains in the DRC, but the strain has been identified in numerous other African countries, such as Burundi and Zambia, as well as in countries outside of Africa, including Germany, Sweden, and India.

Mpox is both treatable and preventable, including through vaccines. However, the response in the DRC has been complicated by many factors, including weak health infrastructure, limited access to primary care services for people in affected areas, lack of rapid diagnostics and low testing rates, conflict and displacement of people, as well as stigma and discrimination facing those with the illness.

There have been several international efforts to increase the availability of vaccines in the region. The WHO prequalified Bavarian Nordic's mpox vaccine, which was followed by the announcement of an advance purchase agreement between Gavi, the Vaccine Alliance, and Bavarian Nordic to secure 500,000 vaccine doses. These doses were funded through Gavi's new First Response Fund, created in June 2024, to provide financing for vaccines in health emergencies. Vaccine doses began to arrive in the DRC in early September, but there have been obstacles to getting shots into arms. These include delivery system challenges, lack of awareness, the circulation of misinformation about vaccines, and distrust in health institutions and interventions linked to the country's colonial history. Vaccination of vulnerable groups in high-priority areas in the DRC began during the first week of October.

Additionally, an unintended consequence of the successful effort to eradicate smallpox from the world decades ago is contributing to the outbreak. Smallpox vaccination conveyed immunity to mpox, as the diseases are members of the same family of viruses. As smallpox vaccination efforts ended in the 1980s, there are now generations of people with no immunity to mpox in the DRC, surrounding countries, and the rest of the world.

The Intersection of Mpox and HIV

There are concerns about mpox and HIV coinfection, as uncontrolled HIV can increase the risk of severe mpox disease and death. Additionally, there are parallels to the HIV epidemic given that mpox is an infectious disease that can be sexually transmitted and has impacted marginalized populations, such as men who have sex with men and sex workers. This has exacerbated the stigma and discrimination already facing those with the illness, given its visible lesions and scarring. Stigma and discrimination further complicate efforts to control mpox as people may avoid care, undermining surveillance, prevention, and treatment efforts.

As observed during outbreaks of Covid-19, Ebola, and cholera, the global response to HIV/AIDS offers important lessons and resources-surveillance and laboratory infrastructure, infection control expertise, supply chains, advocacy capabilities, community engagement, and approaches grounded in human rights-that can be leveraged to address other health threats. The Joint United Nations Programme on HIV/AIDS has called for the international community to "draw on the experience of the AIDS movement to ensure a response rooted in solidarity, compassion, inclusion, and equity."

In recent months, donor governments, multilateral organizations, and others involved in the global HIV/AIDS response have bolstered efforts to address mpox. For instance, The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), which has disbursed more than $3 billion in grants to the DRC over the past 20 years, is working with the DRC government on its mpox response. The organization has both repurposed resources and committed new funding to address mpox through enhancing elements already in place. These include disease surveillance and laboratory systems, community engagement, partner coordination processes, and provision of health services. Further, The Global Fund has announced support for other African countries as the outbreak spreads, including the repurposing of funds from its COVID-19 Response Mechanism (C19RM) for mpox efforts.

The United States Mpox Response and PEPFAR's Role

The USG has been providing support for mpox efforts in the DRC for years, but work has ramped up since the most recent PHEIC declaration. John Nkengasong, U.S. global AIDS coordinator and senior bureau official for global health security and diplomacy, who formerly helmed the Africa CDC, led a special session of the Foreign Ministry Channel for Global Health Security on August 23 to address the mpox situation in the DRC with representatives from the WHO, the Africa CDC, and the DRC government. In mid-September, the White House held a meeting of key stakeholders to discuss the U.S. mpox response. The White House then released a plan on September 24, outlining its multipronged approach, leveraging existing investments and offering new resources.

The USG has committed to providing "at least $500 million dollars" in assistance as well as 1 million vaccine doses. Support will be provided bilaterally and multilaterally, with partners including the DRC government, WHO, Africa CDC, The Global Fund, Gavi, the Coalition for Epidemic Preparedness Innovations, and UNICEF. PEPFAR is a core element of USG mpox efforts in DRC and the region. According to The White House, ". . . PEPFAR is ensuring program continuity to protect people living with HIV through the use of existing PEPFAR platforms through risk communication, laboratory and surveillance capacity, referral to care, HIV testing, and vaccination delivery to help prevent and respond to mpox." It could be argued that years of PEPFAR investment in the DRC has laid groundwork that will enable the USG to implement the proposed activities mentioned above. The USG has invested more than $800 million in HIV efforts in DRC in the past decade, nearly 40 percent of the $2 billion provided through the U.S. Agency for International Development and the U.S. Department of State for global health efforts in the country.

PEPFAR also plays a significant role in the HIV/AIDS responses in many of the DRC's neighboring countries and elsewhere in Africa, where cases are emerging. Many of these countries, including the DRC, receive both PEPFAR support and enhanced bilateral support for global health security activities from the USG. The leveraging of PEPFAR reflects the USG's plans to enhance its global health security efforts by strengthening linkages between "complementary" programs, as outlined in the 2024 Global Health Security Strategy.

What to Watch

While swift containment of the mpox outbreak is the highest priority, it will be critical for the global health community to glean lessons from the outbreak and response to apply to the next health threat, which may not be far behind. The latest mpox response has been criticized for being slow out of the gate and inadequate, missteps have been reported, and it's not clear to what extent stakeholders are coordinating. For the USG, this could be a test for its leadership on global health, as well as for its new global health security approach. The response also provides an opportunity to spotlight PEPFAR's role in providing life-saving HIV services amid another outbreak, as well as in countering emerging threats by employing the scaffolding, experience, and relationships built over time in the DRC and countries impacted by mpox. In that vein, how PEPFAR's capabilities are leveraged and dovetail with other elements of the USG mpox response, as well as those of key partner organizations, such as The Global Fund, will be important to monitor.

Weaving together key learnings from the mpox response could tell a compelling story about PEPFAR's contributions to HIV and global health security, informing policy debates about the program's future. Next year will include important milestones for USG global health policymaking, including PEPFAR reauthorization in March 2025, at a potentially politically unsettled time. While PEPFAR was ultimately reauthorized for one year with bipartisan support in March 2024, its reauthorization was nearly derailed by abortion-related politics and misinformation. Further, what PEPFAR champions will remain in Congress following the upcoming November election is unclear. This backdrop also could impact the USG's contribution to The Global Fund, which faces its next replenishment in 2025. The USG is the largest single donor to the multilateral organization.

There will be no shortage of health threats in the future, especially as conflict and climate change compound existing health challenges. In fact, the public health community has its eye on a Marburg outbreak in the DRC's neighbor Rwanda. There is an opportunity to demonstrate to policymakers the value of investments in PEPFAR and global health security and ensure that PEPFAR reauthorization discussions do not lose sight of the program's overarching purpose-to reduce suffering, save lives, create diplomatic bridges with countries, and strengthen health security.

Alicia L. Carbaugh is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

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