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Rex Tillerson shouldn’t cut global AIDS funding. Here’s why.

By Pranay Sinha

“A model for us to look to as we’re thinking about other ways to project America’s values, project our compassion…” was how Secretary of State Rex Tillerson described the President’s Emergency Plan for AIDS Relief (PEPfAR). Bewilderingly, this unequivocally successful program finds itself on the chopping block.

Some history: in the wake of widespread devastation due to HIV, President Bush committed billions of dollars to AIDS relief in the form of PEPfAR. He justified the spending in his 2003 State of the Union address, saying “… seldom has history offered a greater opportunity to do so much for so many.” The trajectory of the epidemic changed rapidly for countries receiving aid. President Barack Obama expanded the program. PEPfAR has also partnered with the Global Fund to address related concerns such as the tuberculosis (TB) epidemic.

Robust funding has allowed individuals in remote parts of the world to get the HIV and TB care. Photo by Pranay Sinha.

Just last year, the program brought life-giving anti-HIV drugs to 11.5 million adults and children, saved 2 million babies from HIV transmission at birth, and supported 6.2 million orphans and vulnerable children. In addition to these humanitarian achievements, PEPfAR has been an enduring diplomatic asset for the United States. Shortly after instituting the program, the favorability ratings for the U.S. skyrocketed in the countries receiving aid. Economies that slumped in the midst of the HIV epidemic began, once again, to rise. Political unrest quieted down.

PEPfAR at work in South Africa

These statistics came to life when I spent six weeks at the Church of Scotland Hospital (COSH) in KwaZulu-Natal, South Africa. COSH is located in a sleepy town where cattle often impede traffic and goats wander fearlessly on the hospital campus. Although the city boasts a modern mall, a thin haze of dust engulfs pedestrians when trucks rumble past on unpaved roads. Zulu-style huts dot the horizon.

The doctors at COSH described a time when they helplessly held the hands of emaciated and sick young men and women as they gasped their final breaths.

The death rate was so high that Philanjalo, an inpatient hospice associated with the hospital, would turn over its entire patient population in a single day. The doctors at COSH watched the decimation of an entire generation by HIV.

The age pyramid was distorted as the loss of young individuals of working age left the populations with a disproportionate fraction of the very young and very old. Predictably, the economy floundered.

Nurses at COSH screening patients for drug-resistant TB. A vast majority had HIV. Photo by Pranay Sinha.

In the mid-2000s, a strong collaboration of the South African and the international community began building South Africa’s capacity to test and treat HIV. PEPfAR played an instrumental role. Between 2004 and 2016, PEPfAR invested 5 billion dollars in South Africa, which provided antiretroviral treatment for 3 million individuals, testing for almost 10 million, and support for 600,000 orphans and vulnerable children. Now the same doctors who had helplessly watched the virus claim millions of young men and women can treat it with just one pill every day. The robust funding means that patients can now be rapidly diagnosed and start HIV treatment before the virus devastates their bodies and their lives. Although almost one in five South African adults live with HIV, South Africa can legitimately foresee an AIDS-free generation where no child gets HIV at birth and any infected person can get treated. The economy is accelerating and the culture remains vibrant.

Proposed cuts to PEPfAR will impact the most vulnerable countries

Secretary of State Rex Tillerson is aware of the transformative effect of PEPfAR funding. It is therefore baffling that Secretary Tillerson now proposes a billion dollar cut to the budget of the State Department, Centers for Disease Control Global Health (CDC Global Health), and United States Agency for International Development (USAID). This entails limiting PEPfAR aid to just eleven countries. Surprisingly, vulnerable countries such as South Africa, Mozambique, Angola, South Sudan, Nigeria, Angola, and the Democratic Republic of Congo did not make the list.

Community screenings like this one identify patients with HIV and TB and link them to care. Photo by Pranay Sinha.

These countries have high burdens of HIV disease and myriad geopolitical barriers to care. For example, despite South Africa’s impressive commitment to HIV programs, one in five South Africans with HIV don’t know that they are infected. In 2015, there were 380,000 new infections. Treatment prevents the spread of the virus. And so it is alarming that 52% of South Africans living with HIV are not on antiretroviral therapy. Globally, the progress is undeniable, but gaps remain. Without U.S. aid, HIV initiatives will lose momentum and the waning HIV and TB epidemics will flare. The virus has been quelled, not vanquished.

In spite of the progress made in South Africa, I caught glimpses of the old world. Skeletally thin men with both HIV and TB still gasp for air. Old grandparents still care for orphaned young children who are emaciated due to complications from HIV infection. But perhaps the most haunting reminder of the legacy of the HIV epidemic was outside the hospital. Most Tugela Ferry storefronts feature faded facades with corrugated metal awnings. Close to the hospital, one store stands out. It stands several feet above its neighbors with marble stairs out front and a glass façade with golden letters that identify it as a funeral home.

The primacy of death is unrivalled in societies that have been plagued by HIV. As Secretary Tillerson proposes cuts to PEPfAR, he should know that the old world looms, ready to return.

About the Author

Pranay Sinha, MD is a physician with clinical and research interests in HIV and Tuberculosis. He received his medical degree at the University of Virginia School of Medicine and completed his residency training at Yale-New Haven Hospital where he specialized in Internal Medicine and received a distinction in global health and equity. Follow Pranay on Twitter @PranaySinha_md.

Discussion
  1. See a recent article and Perspective in PLOS Medicine demonstrating the large-scale effectiveness of foreign aid for malaria control and arguing that effective aid not only reduces the number of children dying in poor countries, but also provides benefits that are likely to return to the US.

    Malaria control adds to the evidence for health aid effectiveness
    Eran Bendavid
    Perspective | published 13 Jun 2017 PLOS Medicine
    https://doi.org/10.1371/journal.pmed.1002320

    The US President’s Malaria Initiative and under-5 child mortality in sub-Saharan Africa: A difference-in-differences analysis
    Aleksandra Jakubowski, Sally C. Stearns, Margaret E. Kruk, Gustavo Angeles, Harsha Thirumurthy
    Research Article | published 13 Jun 2017 PLOS Medicine
    https://doi.org/10.1371/journal.pmed.1002319

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