The America First Global Health Strategy reiterates the objective of ending HIV/AIDS as a public health threat by 2030. Through decades of partnerships, political will, generous but strategic investment, and innovation, the President’s Emergency Plan for AIDS Relief (PEPFAR) has made this long-shot goal an attainable reality. However, the next five years will be critical to ensuring that countries not only achieve internationally agreed targets but sustain these targets for years to come.
As shown in the first iteration of the Bush Institute’s PEPFAR Beyond 2030 series, several countries are close to ending HIV/AIDS thanks to four key tenets: clear, quantifiable goals that dictate strategy; data-driven program management; close collaboration with communities most affected by HIV; and cooperation at national and international levels. Countries across Sub-Saharan Africa have made substantial gains over the last two decades, as several nations have seen their HIV-prevalence rates drop below two percent.
America’s new global health strategy recognizes this progress. The administration is rightfully pushing the governments of partner countries toward self- reliance through long-term financial sustainability and the integration of care for HIV into mainstream health care. Bilateral country memoranda of understanding that span up to five years will be implemented across PEPFAR’s 55 partner countries and regions. These memoranda outline specific U.S. investments and partnerships as well as contributions from national governments and the private sector to ensure that countries can manage and pay for HIV programming on their own by 2030.
However, not all countries will be able to replace PEPFAR support in this time frame. And we must not leave them behind.
History shows us that what happens in the wider world matters here at home. Disease knows no borders, consistently violates state sovereignty, and can easily undermine peace and security. Before the creation of PEPFAR, HIV/AIDS threatened economic, political, and social stability in countries across the globe.
Although the resurgence of an HIV pandemic at the scale of the 1980’s and1990’s would take time, it is not impossible. HIV/AIDS still can wreak havoc in countries, leaving people more desperate and, in turn, vulnerable to insurgencies, security threats, and extremist influence, while undermining opportunities for mutually beneficial investment and trade. Therefore, defining which countries will require PEPFAR support beyond 2030 cannot depend solely on public health metrics. PEPFAR must consider a combination of health and contextual factors.
In planning transitions, PEPFAR must take special care in countries that are experiencing extreme conflict, where violence has decimated health infrastructure and complicated the provision of HIV testing, treatment, and prevention. The African continent has experienced approximately nine coups since 2020. West and Central Africa have seen an increase in democratic backsliding and corruption. Peace agreements, such as those recently concluded between Rwanda and the Democratic Republic of Congo, are fragile and can only come to fully be sustained if countries’ HIV epidemics are controlled.
In these special cases, continuing U.S. engagement in a targeted and cost-effective manner can supplement opportunities envisioned in the America First Global Health Strategy. Countries must maintain a safe environment to attract fruitful partnerships with risk-averse U.S. companies. Mitigating the chances of a resurgent HIV epidemic (along with eliminating malaria) will be an integral component to building successful bilateral partnerships in industries like critical minerals, oil and gas, and pharmaceuticals.
PEPFAR also must consider countries’ financial well-being. Corrupt and kleptocratic actors across many low-and lower-middle-income countries have prioritized personal wealth over their citizens’ well-being. At the same time, across the globe, the ratio of debt to Gross Domestic Product has increased in the last five years, and many African governments spend more on interest payments than on health. It is unrealistic to assume that countries in this situation will be capable by 2030 of absorbing the full ongoing costs of sustaining over 20 years of HIV progress.
Financial assessments also should realistically consider a country’s ability to raise and diversify streams of revenue. While the Member States of the African Union promised in the Abuja Declaration of 2001 to allocate at least 15% of their national budgets to health, few have done so. PEPFAR partner countries South Sudan, Burundi, the Democratic Republic of Congo, Malawi, and Mozambique are among the poorest in the world. Beyond 2030, they will need support from the U.S. and ongoing, coordinated investment from the Global Fund to Fight AIDS, Tuberculosis, and Malaria to ensure the most vulnerable are not left behind.
Finally, PEPFAR must consider the severity of each country’s HIV epidemic. Western and Central Africa have not seen a decline in new HIV infections and are home to around a quarter of the 5.2 million people across the world that are not on HIV treatment. Individuals without consistent access to antiretrovirals are more susceptible to developing drug- resistant strains that are more difficult and costly to treat. Countries that still have an HIV-prevalence rate above two percent by 2030 must continue to receive guidance, monitoring, and oversight from the United States.
Over the past two decades, PEPFAR and its partners have had incredible success. Over 26 million lives have been saved, and a new generation of babies born HIV-free has created a world where ending HIV/AIDS is achievable. National financial and programmatic self-reliance can and should occur by 2030 in many PEPFAR countries. However, PEPFAR must recognize finishing the job will require us not to leave anyone behind – otherwise we risk wasting years of hard work. Targeted, cost-effective engagement in special cases will be critical to making sure we end HIV/AIDS for good.
