Global HIV Programs at a Critical Juncture: Report of the CSIS Working Group on Reinvigorating U.S. Leadership on HIV/AIDS

Commentary by Katherine E. Bliss

Published December 2, 2024

More than two decades since the launch of global programs dedicated to bringing prevention, diagnostic, and treatment services to people at risk of, or living with, human immunodeficiency virus (HIV), the international commitment to end HIV as a public health threat by 2030 is at a critical juncture.

At least three-fourths of the 40 million people currently living with HIV benefit from antiretroviral therapy; the number of new infections among children has declined by nearly 40 percent over the last 10 years; and long-acting prevention tools that have been approved or are in advanced stages of development offer people at risk of HIV the promise of a life without the persistent concern of infection.

But despite enormous progress since the early 2000s in preventing, diagnosing, and treating HIV, there were still more than 1 million new cases of HIV worldwide in 2023. Nearly half of all new cases of HIV globally are among women and girls, with adolescent girls and young women in sub-Saharan Africa making up more than three-quarters of new infections in youth between the ages of 15 and 24. Recently implemented laws, such as the 2023 Anti-Homosexuality Act in Uganda, make it dangerous for people at risk of or living with HIV to seek health services, undermining decades of HIV-focused efforts.

At the precise moment when the global community has the tools and knowledge to make significant strides in eliminating HIV as a public health threat, there are multiple pressures to move on from it. Pandemic fatigue stemming from the Covid-19 crisis, along with the shift of donor focus from HIV and global health to other global challenges, means there is stiff competition for scarce health and development funds. Populist movements in many regions emphasize support for domestic social programs over providing funding for foreign assistance initiatives. In the United States, which, through the President's Emergency Plan for AIDS Relief (PEPFAR) and its commitments to the Global Fund to Fight AIDS, Tuberculosis and Malaria, has been the largest international funder of HIV programs, the historic bipartisan commitment to HIV in Congress has been severely tested, as evidenced by the struggle to reauthorize PEPFAR earlier this year that resulted in a short-term, one-year authorization expiring in March 2025.

In 2023 the CSIS Bipartisan Alliance for Global Health Security convened a working group to assess the ways in which U.S. investments in HIV services had also contributed to health systems strengthening and outbreak response. Its first report, Centering PEPFAR in U.S. Global Health Security Strategies, published in October of 2023, called for the U.S. government to re-prioritize a focus on HIV and enhance coordination between PEPFAR and other U.S. global health security initiatives to ensure a unified and complementary approach.

Following a second year of discussion about the place of HIV programs within U.S. foreign assistance and national security initiatives, the CSIS Working Group on Reinvigorating U.S. Leadership on HIV/AIDS argues that for the United States to lose focus on HIV now, when the potential for significant progress in ending HIV as a global public health threat is so great, would be extremely shortsighted. Instead, as the American people await the inauguration of a new president and installation of a new Congress in 2025, there is an urgent need for the United States, working closely with global health partners, to maintain support for bilateral and multilateral HIV programs and reinforce a vision for their sustainability over time; advance a focus on equity within HIV service provision; and deepen coordination with local and multilateral partners to strengthen health systems, accelerate progress in reaching global HIV goals, and protect global health security.

Looking ahead to the expiration of the current one-year PEPFAR authorization in March 2025, the Working Group recommends that the incoming administration should adopt the following as priority measures:

1. A vigorous campaign is needed to ensure a multi-year reauthorization of PEPFAR, reassuring Congress and the American people that PEPFAR is collaborating with implementing countries to chart a clear path towards program sustainability, with a vision of increasing domestic financing and reducing donor funding over time.

   Since the passage of the United States Leadership Against Global HIV/AIDS, Tuberculosis, and Malaria Act in 2003, Congress has reauthorized PEPFAR for five-year increments three times, in 2008, 2013, and 2018, with both Democrat and Republican sponsors. While U.S. support for global programs can continue even without a formal PEPFAR renewal, the failure of Congress to pass a multi-year reauthorization of PEPFAR at the end of September 2023 highlighted the tensions undermining the bipartisan support the program has traditionally enjoyed. Congress's inability to move forward with a five-year reauthorization last year centered around false allegations that PEPFAR funds were supporting abortion services overseas, it was also the case that many longstanding members of Congress who championed PEPFAR or supported previous reauthorizations had retired from office, with recently elected lawmakers less informed about the benefits of the 20-year-old program than their more seasoned counterparts and uncertain as to whether HIV should remain a foreign policy priority of the United States.

   The installation of a new cohort of representatives in Congress in January 2025 offers the incoming administration the opportunity to educate members and staff about PEPFAR's achievements, demonstrate PEPFAR's clear contributions to reaching U.S. foreign policy and national security objectives, and counter misinformation related to PEPFAR's use of program funds. The new administration should communicate how PEPFAR investments strengthen U.S. alliances and reinforce U.S. interests in economic and political stability overseas. It should also articulate the steps PEPFAR, in collaboration with global partners, such as the Global Fund and the Joint United Nations Programme on HIV/AIDS (UNAIDS), is taking to help countries deepen the expertise of locally-based organizations and chart a path towards greater self-financing and program management through the development of sustainability roadmaps.

   It will be important for the new administration to convey clearly to lawmakers what aspects of data analysis, disease surveillance, and delivery of services may be most smoothly transitioned from PEPFAR support to country management and which aspects of the global HIV response the United States may need to support for a longer period. While program transformation and progress toward sustainability may look different in different countries, the next administration should carefully explain to Congress and the American people why reauthorizing PEPFAR while enabling countries and local organizations to assume a greater role in financing and program management is the best path towards 2030 and beyond. With polling from October of 2023 suggesting that two-thirds of people surveyed were in favor of continued leadership by the United States in supporting the global HIV response, the new administration, in advocating for a multi-year program renewal, can point to solid public opinion in favor of continued PEPFAR programs.

2. It is crucial to remind Congress, the American people, and partners overseas why equity must be at the heart of HIV prevention and treatment approaches and how there will be no end to the threat posed by HIV to health security until all people at risk are reached with quality health services.

   Tackling the social challenges of stigma and discrimination that undermine access to HIV prevention, diagnostic, and treatment services has been a prominent aspect of PEPFAR's work since its launch in the early 2000s. U.S.-supported programs have focused intensively on collecting data to track trends in new infections, consider the access of diverse populations to health services, and assess the quality of care to ensure that all people at risk of HIV are able to access prevention, diagnosis, and treatment to improve their health, reduce the odds that they will transmit the virus to others, and protect health security.

   PEPFAR support has underpinned enormous progress in reaching people living with HIV with testing and treatment. Yet there are still gaps in service coverage that undermine the efficacy of the overall initiative and imperil the goal of ending HIV as a global public health threat in the next five years. Children remain highly vulnerable to HIV and are at a significant disadvantage when it comes to accessing treatment. Thanks to increased testing and initiation of pregnant women on antiretroviral therapy, the number of children born with HIV has decreased considerably since 2010. However, the uptake by pregnant or breastfeeding mothers of antiretroviral therapy has plateaued at around 80 percent, making a focus on accelerating the access of women to mother-to-child prevention programs paramount. At the same time, there is a gap between adults and children in treatment access, with just slightly over half of children living with HIV on antiretroviral therapy, compared to more than three-fourths of adults. One important step is PEPFAR's "Safe Births, Healthy Babies" initiative, a two-year effort to ignite progress in preventing mother-to-child transmission and reduce the number of babies born with HIV by one-third, but identifying and providing treatment to children living with HIV remains a persistent challenge.

   Evidence also suggests that the incidence of new infections remains stubbornly high among key populations, as well as adolescent girls and young women, in sub-Saharan Africa and elsewhere. In July, prior to the International AIDS Society conference in Munich, PEPFAR released a new Action Plan to address HIV-service equity gaps for key populations. With the U.S. Department of State's Bureau for Global Health Security and Diplomacy having recently released a five-year strategy that identifies closing equity gaps "for vulnerable populations, including key populations, adolescent girls and young women, and children," the incoming administration has an opportunity to mount an energetic diplomatic strategy on equity, antidiscrimination, and community engagement, both in PEPFAR-supported countries and in encouraging other donors to support work on HIV.

   There is also an opportunity for the next administration, working with Congress, to advance equity in reducing the incidence of HIV cases, including among key populations and adolescent girls and young women between the ages of 15 and 24, who remain highly vulnerable. In formulating PEPFAR budget requests, the new administration should share a compelling vision about the opportunities presented by new long-acting biomedical prevention options if they are made widely available in a timely manner and explain why investing in effective HIV prevention protects existing program achievements, and underpin program sustainability in that reducing new infections avoids adding to the number of people who must be on lifelong treatment. The new administration should articulate how it will support countries in developing plans for purchasing and distributing the new products while working with community organizations to promote awareness and uptake.

3. Reinforce the importance of U.S. investments in global HIV programs, including PEPFAR as well as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, in protecting U.S. and global health security, including by supporting outbreak response and strengthening critical aspects of health systems.

   In advocating for a multi-year reauthorization of PEPFAR, the incoming administration should emphasize how U.S. investments in bilateral and multilateral HIV activities do much more than support work on HIV in that they strengthen and reinforce the abilities of local health providers to respond to the needs of their populations, thereby improving outbreak response and protecting the American people from public health threats originating overseas. The new U.S. Global Health Security Strategy released in April of 2024 highlights the role PEPFAR and other infectious disease efforts, such as the President's Malaria Initiative (PMI), have contributed to global health security, principally through strengthening the health workforce, building laboratory and disease surveillance capacity, enhancing infection prevention and control measures, and engaging with communities to inform and advocate for quality services.

   The contribution of PEPFAR to U.S. health security goals is also clearly articulated in the Department of State's new global health security and diplomacy five-year plan, which makes ending HIV/AIDS as a public health threat by 2030 the first of four high-level goals. PEPFAR investments have been leveraged for outbreak response during the Ebola outbreaks in West Africa in 2014-2015, during the Covid-19 pandemic, and in the recent response to mpox in the Democratic Republic of Congo and beyond. The pillar on public health systems and security within PEPFAR's 2022-2026 strategy emphasizes health worker training, optimization of regional supply chains to ensure access to critical commodities and build local manufacturing capacity, improving patient-centered care, and alignment of HIV initiatives with other U.S. global health security programs.

   Building on these strategic objectives, the incoming administration should also reemphasize the important role U.S. support for and coordination with multilateral programs, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, plays in protecting global health security. A key partner in the fight against HIV, the Global Fund, will be entering its 8th replenishment round in 2025, seeking funds for the next three-year cycle of work. The United States has historically been the largest donor to the Global Fund. With PEPFAR reauthorization language typically limiting the total U.S. contributions to one-third of the total donations, U.S. pledges have frequently served to leverage funds from other donors. In a period of flagging contributions to global HIV initiatives, the United States should engage diplomatically with donors and Global Fund-eligible countries to fortify support for the Global Fund and provide clear evidence of the impact of the fund in advancing innovative financing approaches, responding to countries' needs, strengthening health systems, and building resilience against other global challenges.

While the pressure to move on from HIV and, indeed, from global health in favor of other crises is enormous, the incoming administration should communicate clearly that the United States remains committed to HIV as a priority global health security issue, with equity and strengthened health systems at the heart of a vision for sustainability. Transparency, both about what is possible with sustained attention to prevention, diagnosis, and treatment and what is at stake if U.S. leadership declines and global commitments to HIV/AIDS stagnate, jeopardizing more than twenty years of global health investments, must be a clear priority in the push for a new multi-year reauthorization from Congress and a renewed focus on HIV and health security through bilateral and multilateral programming and diplomatic engagement.

Katherine E. Bliss is a senior fellow and director of Immunizations and Health Systems Resilience with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C.

This publication conveys a majority consensus of the signatories, who are participating in their individual capacity, not as representatives of their respective organizations. No expert is expected to endorse every single point contained in the publication. In becoming a signatory, experts affirm their broad agreement with the publication's findings and recommendations. Language included here does not imply institutional endorsement by the organizations that working group members represent.

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About the CSIS Bipartisan Alliance for Global Health Security

The CSIS Bipartisan Alliance for Global Health Security convenes an esteemed group of members of Congress, senior leaders, and subject matter experts to advance a concrete, forward-leaning agenda for U.S. global health security strategy. It prioritizes coherent, sustained U.S. leadership, ensuring success in the major institutional reforms under way across the executive branch, integration of effort with strong accountability measures, enhanced global coordination, and building new partnerships and alliances through strengthened U.S. diplomacy that systematically advances U.S. national interests, amid intensifying geopolitical competition. Equally critical is building the correct institutional arrangements, including adequate private sector incentives, to bring forward the next generation of technological innovation. The alliance is developing concrete options to strengthen core pandemic preparedness and response capabilities, while exploring the untapped opportunities to better align capabilities across traditional infectious disease programming including on HIV/AIDS, routine immunization, and antimicrobial resistance, among other priorities. Building on the record of prior CSIS initiatives, the alliance delivers recommendations on global health security policy and programs to key decisionmakers in the U.S. Congress, the executive branch, and nongovernmental organizations.

The two-year effort, running from spring 2023 through the end of 2024, is cochaired by Senator Richard Burr, principal policy advisor and chair of the Health Policy Strategic Consulting Practice at DLA Piper and former senator from North Carolina, and Julie Gerberding, MD, MPH, CEO of the Foundation for the National Institutes of Health and former director of the CDC. J. Stephen Morrison, PhD, senior vice president and founder/director of the CSIS Global Health Policy Center, sets the alliance's strategic direction and directs its work on pandemic preparedness and response. Katherine E. Bliss, PhD, senior fellow and director of immunizations and health systems resilience with the CSIS Global Health Policy Center, directs its work on HIV and routine immunization. Michaela Simoneau, associate fellow, leads the alliance's secretariat. More information on the alliance can be found on its website at https://www.csis.org/programs/global-health-policy-center/csis-bipartisan-alliance-global-health-security.

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