As a political appointee, Ambassador John Nkengasong, head of the US President’s Emergency Plan for AIDS Relief (PEPFAR), said that he will be obliged to resign when President-elect Donald Trump is inaugurated on 20 January.

“The rules that govern a transition are that all the political appointees have to resign on the 20th and then their resignation is either accepted or they are asked to stay,” Nkengasong told a Global Fund media briefing on Monday.

However, he stressed that PEPFAR has been a bipartisan programme since its inception in 2003 when it was launched by Republican President George W Bush.

“It has since enjoyed the support of all administrations,” said Nkengasong, the US Global AIDS Coordinator in the Bureau of Health Security and Diplomacy.

Nkengasong was appointed by President Joe Biden, confirmed by the US Senate in May 2022, and he started work the following month. 

Nkengasong is a Cameronian-born US citizen, who first attracted global attention as the first head of the Africa Centres for Disease Control and Prevention (Africa CDC), where he led the continent’s response to the COVID-19 pandemic. Prior to that, he had worked for the US Centers for Disease Control and Prevention, as well as at the World Health Organization. 

“We should always think about PEPFAR, not the individual – 26 million lives saved over the last 21 years,” Nkengasong stressed at the briefing, although his re-appointment prospects are regarded as slim.

“PEPFAR was reauthorised [by the US Congress] for one year last year. That reauthorisation expires in March, and we are hoping that we’ll get a clean five-year reauthorisation going forward,” he added.

But this may not be plain sailing. PEPFAR has come under attack from US and African conservatives who claim – incorrectly – that some aid recipients are promoting abortion. This is why the programme only received a one-year extension rather than the usual five years.

Trump has made cutting government spending and opposing abortion cornerstones of his election campaign, which does not augur well for the campaign to end AIDS by 2030.

HIV money is drying up

HIV is incurable but thanks to antiretroviral (ARV) drugs, it has become a controllable chronic disease and if people living with the virus have an undetectable viral load, they don’t transmit HIV.

As many as 25 million people depend on PEPFAR and the Global Fund to subsidise their ARVs, which they need to take for life. 

Yet money is drying up. About 60% of the HIV response is paid by domestic finances, and this fell for the fourth consecutive year, with a 6% drop in 2023. Meanwhile, donor resources for HIV dropped by 5%, UNAIDS Deputy Director Christine Stegling told the briefing.

Global Fund executive director Peter Sands said that global overseas development assistance is under pressure, and health has lost its “prime spot” to both climate change and conflict.

“There is a particular issue with funding for HIV/ AIDS, which is that we run the risk of being a victim of our own success. Because the number of people dying has dropped so much, and because HIV/ AIDS is no longer seen as that much of a threat in donor nations themselves, it’s dropped off the radar screen and seems like an old problem; one that’s largely won or gone away,” said Sands.

“But HIV is a formidable adversary. We are nowhere near getting a vaccine, and we don’t have a cure for it yet.”

But the single-minded focus on eliminating HIV has made “extraordinary progress”, Sands added.

“AIDS-related deaths have come down by 51% since 2010 and more than three-quarters of people living with HIV are on treatment, but we still have another nine million people not on treatment and we still have 1.3 million new infections each year,” according to Stegling.

Shift to domestic financing

Economist Professor Dean Jamison, co-chair of the Lancet Commission on investing in health, says it is unlikely that for a better response to funding HIV globally. 

“So that does put greater emphasis on a transition to domestic finance where the reliance has been substantially on donors. It’s not to say that the external finance is likely to go away and then there won’t be important additions to that. I would be looking to parts of Asia for external finance, but on the domestic side, what are the range of options?” asked Jamison, who is an emeritus professor of Global Health Financing at UCSF, UCLA and the University of Washington.

Poor countries would prioritise HIV spending, likely focusing on preventive interventions and treatment. Drawing on private resources, perhaps through payroll taxes, may also be a solution.

Stegling singled out debt, low economic growth and insufficient revenue as the main obstacles to domestic financing for HIV.

“Last year in GDP term, Sierra Leone spent 15 times more on public debt servicing than on health. Chad spent 12 times more on debt servicing than on health,” she noted.

Meanwhile, sub-Saharan Africa loses about $80 billion in uncollected tax revenue.

Debt relief, future financing at affordable rates and better tax revenue collection are the solutions UNAIDS is focusing on.

“These are the issues of the future that we need to look into if we’re talking about self reliance, more resilient systems for health that are financed by countries, by every country themselves,” Stegling noted.

With South Africa being the chair of the G20 next year, she sees “an amazing opportunity” for African leadership debt restructuring and different financing mechanisms. 

What lies ahead?

Stegling says donors are likely to move into “gaps”, such as human rights protections for particular marginalized groups that might not immediately find support from their governments.

Meanwhile, Nkengasong stressed that progress should not be confused with success.

“The progress that we have made is very fragile,” Nkengasong stressed.

PEPFAR did an analysis of 10 to 12 high-burden countries that it supports and found that, to maintain their programmes if PEPFAR was unable to fund them would result in debt risk increasing by 400 percentage point,.

“Are we ready to live with this? We pride ourselves with the success we’ve made over the last 25 years or so against HIV. But the response to HIV is extremely fragile. It’s extremely fragile because it requires that the millions of people that are receiving treatment receive that treatment every day.

“We cannot afford to leave them behind. If we do that, the billions that we’ve put into the fight against HIV AIDS will be completely wasted.”

Image Credits: US State Department.