US State Department officials are developing a plan to transform the President’s Emergency Plan for AIDS Relief (PEPFAR) from an entity that tackles HIV to one that is broadly focused on protecting and promoting American interests.

This is according to a report in the New York Times on Thursday, based on leaked planning documents that map out their vision for PEPFAR’s transition in in the next few years.

“It would be replaced by ‘bilateral relationships’ with low-income countries focused on the detection of outbreaks that could threaten the United States and the creation of new markets for American drugs and technologies,” the newspaper reports.

This is in keeping with the focus of the Trump administration’s first meeting with African health leaders after the US paused all foreign aid for 90 days in January.

During the meeting between leaders of the US Centers for Disease Control and Prevention (CDC) and their counterparts in Africa CDC in March, the US officials indicated that they were interested in African business opportunities for American companies.

Africa CDC official Dr Ngashi Ngongo told journalists after the meeting that the Trump administration “would like to see health more as a business, rather than something that functions on grants,” and is interested in “exploring how can we go into a partnership that translates into health as a business”.

Aggressive transition planning

Dr Jirair Ratevosian, a global health expert at Duke and previous PEPFAR chief of staff, said that the Trump administration has “made it very clear that they want to carry on with aggressive transition planning” for PEPFAR.

“Transition planning is not a bad idea, but it must be done right, with timetables, developing indicators, matching government buy-in, getting community input etc,” Ratevosian said.

While he has not seen the documents referred to by the New York Times, Ratevosian is concerned that the transition plan is being written in Washington rather than in and with the African countries most affected by  PEPFAR’s transition.

“There needs to be realistic timetables, careful planning and resources to successfully make the transition of HIV programming [from PEPFAR] to national control,” said Ratevosian. 

“Congress has made clear it rejects the administration’s rushed approach to PEPFAR’s transition, signalling bipartisan concern about protecting the program’s legacy and impact.”

He added that the US State Department should also develop plans for US companies to sell their antiretroviral drugs to African countries, the largest market for these products.

Brief defunding reprieve

Last week, there was a brief moment of hope for PEPFAR recipients after the US Senate  agreed to exempt the programme from a planned $400 million reduction, which had been included in a $9.4 billion rescission package put forward by President Donald Trump.

The rescission package seeks to claw back federal funds from various programs, including approximately $900 million in global health allocations.

Disruptions to US aid for global health including for PEPFAR programmes, have placed millions of lives at risk, particularly in countries heavily dependent on US-supported HIV infrastructure.

Carolyn Amole, Clinton Health Access Initiative vice-president for HIV, hepatitis and TB, said PEPFAR’s funding cuts had disrupted commodities procurement, essential systems such as human resources, supply chains, and data infrastructure.

Millions more AIDS deaths, infections projected

An additional six million new HIV infections and four million AIDS-related deaths could occur between 2025 and 2029 if US-supported HIV treatment and prevention services collapse, according to UNAIDS.

“This is not just a funding gap. It’s a ticking time bomb,” said UNAIDS Executive Director Winnie Byanyima at the launch of the organisation’s 2025 global AIDS update earlier this month.

“We have seen services vanish overnight. Health workers have been sent home. And people – especially children and key populations – are being pushed out of care.”

“Key populations” refer to people most vulnerable to HIV infection, including sex workers, men to have sex with men, people who inject drugs and young women.

Some of the immediate effects of the US withdrawal of funds since Donald Trump assumed the presidency in January include the closure of health facilities, healthworker job losses, and disrupted treatment, testing and prevention services.

Image Credits: The Global Fund/ Saiba Sehmi, UNAIDS.