PEPFAR Cuts Threaten Goal of AIDS-Free Generation

With the release of President Barack Obama's 2015 Global AIDS Funding budget, leading global health experts have voiced their concerns about the effects of the President's proposed cuts, and are calling on bipartisan members of Congress to increase funding for the response to the global AIDS crisis and continue to scale-up lifesaving prevention and treatment programs.

"We are concerned about the budget that has been put out this year, and the effect it will have on global HIV," said amfAR's Vice President of Policy Chris Collins, who moderated a recent conference call on the issue. "The new budget would flat-fund PEPFAR after years of cutbacks, despite the fact that achieving an AIDS-free generation was a goal the president underscored in his State of the Union address last year."

amfAR's conference call featured panelists Professor Jeffrey Sachs, Earth Institute, Columbia University; Rochelle Walensky, MD, PhD, Professor of Medicine, Massachusetts General Hospital, Harvard Medical School; Shepherd Smith, Institute for Youth Development; and Matthew Kavanagh, Senior Policy Analyst, HealthGAP, Mumford Fellow at the Center for Public Health Initiatives, University of Pennsylvania.

Members of Congress are also expected to scrutinize the President's FY 2015 budget request for the President's Emergency Plan for AIDS Relief (PEPFAR), which was not restored in this year's budget and has seen a cut of over $600 million since FY 2010. Additionally, the President's budget request for the Global Fund to Fight AIDS, TB, and Malaria was reduced by $300 million, which will be placed into a contingency matching fund that is also at risk of being lost from the global AIDS response.

News Daunting in Face of Cure

And, fresh off of the 2014 Conference on Retroviruses and Opportunistic Infections conference held in Boston from March 3-6, researchers must put aside their excitement around increasing hope for a cure for HIV, to deal with the realities of funding cuts.

"It was incredibly inspirational for these 4,000 HIV researchers to convene in Boston," said Walensky. "The cure is at the top of the agenda. We saw data on a second baby cured of HIV. We have MSM who are showing zero transmission and ART regimens that you can give people once a month. A study in JAMA shows that ART prevents death by 16 percent, and people are not dying in PEPFAR countries. We are saving lives, preventing infections, and might even be saving money. Now is not the time to pull back."

Collins said that advocates have signed on to a joint letter to the Administration for a bold new target for PEPFAR, to get 12 million people on treatment by 2016. Secretary of State John Kerry is leading this charge, and testified before the House Appropriations Subcommittee on the State Department budget on March 12.

Promised PEPFAR Increases Dwindle

When the Obama Administration brought a leader to the White House whose father was Kenyan, HIV activists thought that it signaled a new era for funding to end HIV. The faith community was brought to the forefront to support legislation around PEPFAR, and people were excited that the budget would be more robust and move forward aggressively.

The 2008 Congress authorized $48 billion for the next four years. But that first year, instead of a billion dollars, PEPFAR got $135 million. Harvard students protested the cuts, asking the president to keep the promises he had made. But it was to no avail.

"It was very discouraging to those working in the field, to those in Africa," said Smith. "People were very worried whether they would be able to retain treatment, or if those in care would ever get treatment. They didn't know whether resources would be there to support the program."

But now, said Smith, it seems as though there is almost an intentional effort to dismantle PEPFAR. Kavanagh said that while 700,000 people were added to ARV treatment between 2009-2011, the 2012 budget was disappointing, and is causing big rollbacks.

"There is a deep interest, but a major problem with funding," said Kavanagh. "It means we won't meet our AIDS-free generation goal without additional funding.

While earlier scale-up was possible due to pipeline funding and lower drug costs from $650 to $338 per patient per year, this year's PEPFAR funding is the lowest in its history, allowing only 339,000 new people into treatment next year.

Kavanagh said that if we get at least $400 million in funding this year, then 1.7 million new patients could be added next year to the treatment rolls. If we get $600 million in new funding, we can add 2.6 million patients to the rolls.

"Instead, over $600 million has been cut from bilateral programs since 2011; Congress needs to act," said Kavanagh. "Where are our political leaders at a time when we know if we invest a small amount of money now, we will get huge returns in the future?"

Scaling Back is Wrongheaded

Having watched the battle against AIDS from the very start, from pre-PEPFAR days and the emergence of global funds in 2001, Professor Sachs believes that this is a fight for primary health, here and internationally, that includes fight against malaria and other disease part of global effort for past 14 years.

He recalls that when the scale-up effort started, President George Bush made it clear that money would not be the obstacle to scaling up. Advocates overcame tremendous skepticism over scaling up in sub-Saharan Africa, battling fears of resistant strains or lack of adherence.

"The same thing was said about malaria. But the fact of the matter is the fight against AIDS, malaria and other diseases in the past 14 years has proven to be remarkably successful, beyond the expectations of anyone," said Sachs. "But around 2010, the administration seems to have decided they were topping this off, because funding has been flat or declining since then. A wrongheaded decision has been taken."

From the point of view of human and epidemic poverty, we are reaching the point where treatment as prevention is the single most powerful tool we have. People's viral loads are dropping so profoundly that they are not infective to others.

Walensky noted that although domestic Ryan White funding for mother-to-child funding has been cut, the international prevention of MTC transmission was "one of our most successful programs, and we are aiming to have zero transmission by 2015, and are well on our way to achieving that goal."

Sachs said that Obama and Bush should be celebrating these achievements in the streets, instead of making cuts. He notes that HIV funding via PEPFAR is not a partisan issue; Republicans won't object to funding, because it was their initiative at the start. Still, activists must resign themselves to signing a strongly worded letter to Obama, calling for additional funding.

"It is surprising and disappointing that we're at this point," said Sachs. "The ability to expand coverage is up against the wall, just at the time when the epidemic could be over, if we get more people into treatment. I cannot for the life of me believe that this is what the American people really want."