Report Shows Negatives of Removing Global AIDS Coordinator

Moving the Office of Global AIDS Coordinator, which oversees and manages the President's Emergency Plan for AIDS Relief (PEPFAR), out of the U.S. State Department would likely provide little benefit and could have a profoundly negative impact on its ability to effectively lead the global fight against HIV/AIDS, concludes a report with input from leading global health experts and former officials from both Republican and Democratic administrations.

The findings, issued today in a report published by the O'Neill Institute for National and Global Health Law at Georgetown University, represent the first analysis from the global health community and experts in PEPFAR operations to examine proposals to reorganize the State Department and USAID.

In March of this year, President Trump issued an "Executive Order on a Comprehensive Plan for Reorganizing the Executive Branch." Secretary of State Rex Tillerson has stated that the redesign of the State Department and USAID is a top priority and recently submitted a redesign proposal to the Office of Management and Budget, which is now considering changes.

The O'Neill Institute-led group of experts reviewed various reports by other groups recommending that the Office of the Global AIDS Coordinator be moved from the State Department to USAID.

"We are concerned that some proposals for reorganizing U.S. diplomatic and aid structures offer little benefit but bring serious risks for the Global HIV response," says Matthew M. Kavanagh, Ph.D., director of Global Health Policy and Governance Initiative at the O'Neill Institute, and author of the O'Neill Institute report. "Significant input was missing from those with a global health background who are well versed PEPFAR's operations and the role of the U.S. Government in addressing the HIV epidemic."

According to the O'Neill Institute report, "The PEPFAR program has been singularly successful at a monumental task-halting and reversing a global pandemic virus that has no cure or effective vaccine." It notes that, "Today the epidemic stands at an exciting but tenuous stage. Major investments are paying o with falling new infections and deaths as treatment and prevention services reach tipping-point levels -- with new technologies and new evidence, the HIV response is succeeding in PEPFAR countries and new HIV infections and AIDS deaths both falling significantly. But progress is incredibly fragile, and failure to continue strategically could result in HIV resurgence."

Kavanagh says advances in science and medicine must be translated into policy if they are to make an impact.

"One of the reasons we are seeing the falling infection and death rates is because of the effective use of diplomacy via the Global AIDS Coordinator's office and U.S. Ambassadors to engage directly with national political leaders to support science-based policies," he explains. "Removing the Global AIDS Coordinator Office from the State Department is risky, and could diminish program's effectiveness here and abroad."

The PEPFAR program was structured to facilitate a "whole of government" response different from traditional development goals, combining medical, public health, development, and diplomatic capacities of the U.S. government to address the AIDS crisis. A global AIDS coordinator position created at the State Department with the rank of Ambassador to manage the multiple interlocking streams of work across agencies.

To date, PEPFAR has invested $72 billion in fighting HIV/AIDS. The vast majority of PEPFAR funds are appropriated to the State Department and then disbursed to implementing agencies -- largely USAID and the Centers for Disease Control and Prevention (CDC) -- for programming. The U.S. Global AIDS Coordinator is charged with coordinating the AIDS response across eight agencies to ensure these and all U.S. funds to fight global AIDS are managed for greatest impact.

"The U.S. global AIDS response through PEPFAR, as well as the Global Fund, have succeeded because of continuous White House leadership across administrations, bipartisan congressional mandates that have supported the program across ideological lines even in periods of hyper-partisanship, and the empowered authority of the U.S. Global AIDS Coordinator," notes the report.

"There is much that can and should be strengthened in U.S. global AIDS programs -- especially moves to increase human-rights based programming and ensure funding effectively reaches the front-lines of the AIDS response. But the well-conceived structure has performed far better than what came before, and now is not a time to undermine what is working," notes Kavanagh.

"Today the AIDS response is at a critical juncture -- impact against the epidemic is both inspiring and fragile. Interrupting the structures of accountability that make U.S. global AIDS programs uniquely effective just when we need clearer-than-ever focus would be a mistake," the O'Neill Institute report concludes.

The full report titled "Reorganization and the Future of PEPFAR: Implications of State and USAID Reform" is available online.