U.S. President's Emergency Plan for AIDS Relief (PEPFAR): Impact and Challenges in an "Amer

The President’s Emergency Plan for AIDS Relief (PEPFAR) is the predominant program targeting HIV in Uganda. Proposed by President George W. Bush in January 2003, PEPFAR was created to target the global AIDS crisis in 15 “focus countries,” including Uganda, and remains the largest initiative to fight a single disease. The effort, which includes mass treatment, prevention, and care, was continued and expanded under President Barack Obama. Since 2003, PEPFAR funding has totaled more than $70 billion, and now represents roughly 62% of U.S. global health funding. Today, PEPFAR-support efforts can be found in 58 countries across the globe. However, despite having found widespread success in combating the global AIDS crisis, recently proposed budget cuts by President Donald Trump's administration have called into question PEPFAR's future. In addition, the budget has raised concerns over the uncertain impact of decreased global heath funding on countries such as Uganda.

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Out of the more than $840 million in U.S. assistance provided to Uganda in 2016, $371 million was specifically dedicated to addressing the HIV/AIDS epidemic through PEPFAR. Since 2003, PEPFAR has directed this aid towards providing service delivery and technical assistance in coordination with the Government of Uganda, and development partners including the Global Fund to Fight AIDS, Tuberculosis and Malaria. Within 2016, PEPFAR-support programs provided approximately 850,000 Ugandans with antiretroviral (ARV) therapy, or roughly 94% of HIV-positive Ugandans. Additionally, PEPFAR initiatives helped to test 8.1 million Ugandans for HIV/AIDS, and have promoted efforts to increase voluntary medical male circumcision (VMMC). As the Ugandan Government continues to build upon its health infrastructure, PEPFAR funding remains a crucial component of the HIV/AIDS response.

PEPFAR funding has also been targeted to address vulnerable populations within Uganda. Many studies have demonstrated the increasing rates of infection among young women and girls throughout the country. Overall, the HIV/AIDS epidemic disproportionally impacts women and girls, as females are twice as likely to contract the disease than males of the same age. In response, PEPFAR and its private sector partners have created the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) partnership to reduce new HIV infections in adolescent girls. In Uganda, the $31 million program intends to reach 335,000 young women through initiatives addressing gender-based violence, condom use and availability, and educational and economic opportunities. PEPFAR's DREAMS initiative remains one of the largest programs addressing women and girl's access to HIV/AIDS related services.

Despite the growing need for global health programs like PEPFAR to combat the global AIDS crisis, President Trump's proposed budget cuts will reduce the impact PEPFAR can make. to U.S. bilateral HIV/AIDS programs, with an additional $225 million cut for the Global Fund. As Congress continues to debate the 2018 budget, advocates including President George W. Bush have voiced strong support for PEPFAR’s work, and the need to continue funding the HIV/AIDS response.

A report by the ONE Campaign, a nonprofit focused on poverty and preventable diseases, indicates that President Trump’s budget would rollback progress on HIV/AIDS, “[leading] to the first global increase in new HIV infections since 1995.” In addition, the Kaiser Family Foundation found that 800,000 fewer people would be placed on treatment in the first year of the new strategy, with 2.7 million fewer by 2020. Another study estimates that 26 million additional AIDS infections and 4 million more preventable deaths will occur over the next 15 years, given the projected decrease in U.S. funding. The SAIS Human Right's Clinic also found these projections echoed on the ground in Uganda, with many organizations arguing that a decrease in funding would essentially offer a death sentence to many in need of services provided by international programs.

Looking further into the country-specific impact of the budget cuts, PEPFAR funding will be fully eliminated to seven countries including Brazil, Djibouti, Liberia, Mali, Nepal, Senegal, and Sierra Leone. Funding will be reduced in 17 additional countries, as the Department of State’s new Epidemic Control Strategy prioritizes resources for 13 “priority countries,” including Uganda, as well as Kenya, Zambia, Malawi, Lesotho, Cote d’Ivoire, Botswana, Namibia, Swaziland, Haiti and Rwanda. The Department’s new Epidemic Control Strategy is aimed at strengthening cooperation within these high-priority areas, in areas related to HIV testing and treatment, prevention programs for young women and men, and renewed engagement with faith-based organizations and the private sector. Resources will be concentrated on scaling-up successful programs such as DREAMS, and VMMC.

It is difficult to overstate the impact that programs like PEPFAR have had on the fight against HIV/AIDS across the world. U.S. leadership in global health has become a cornerstone of American foreign policy, and a key component of American soft power. Addressing the HIV/AIDS epidemic has not only been a humanitarian success for the U.S., but has also bolstered strategic objectives by reducing the destabilizing effects of the epidemic on U.S. allies. However, the more that an “America First” philosophy comes to define U.S. foreign policy, the less likely it is that successful PEPFAR programs will be maintained in the long-term. In fact, the administration's 2019 budget demonstrates even deeper cuts to global health funding, despite the U.S. committing to the goals of diagnosing and treating 90% of people with HIV, and reducing the number of annual new infections to 500,000 by 2010. Despite a momentary reprieve for “high-priority” countries such as Uganda, it is unclear for how much longer the U.S. will continue to serve as an international leader in global health.