Uncertainty around PEPFAR program puts millions at risk

“More than three weeks since the US government froze PEPFAR funding, there is still widespread confusion and uncertainty as to whether this critical lifeline for millions of people has been cut off,” says Avril Benoît, chief executive officer of MSF USA. 

“Despite a limited waiver covering some activities, what our teams are seeing in many of the countries where we work is that people have already lost access to lifesaving care and have no idea whether or when their treatment will continue. MSF is calling on the US government to immediately resume funding for the full range of PEPFAR operations as well as other critical health and humanitarian aid.”

Impact on lifesaving programs

On 1 February, after over a week of chaos and a freeze of activities, the US government issued a limited waiver allowing for the resumption of some programming with specific guidance for HIV. However, that guidance was unclear, and it did not immediately reach PEPFAR country teams. Across our broad network, MSF did not see a single organisation able to resume work as a result of this limited guidance on waivers. On 6 February, the US government issued clarified guidance on HIV care and treatment and prevention of mother to child transmission (PMTCT) programs.

However, we remain concerned that key areas of HIV prevention, treatment, care, and support are not included in this additional guidance, such as pre-exposure prophylaxis (PrEP) for all vulnerable groups, including LGBTQ people and sex workers, specific interventions for adolescent girls and young women in high prevalence countries, and community-led monitoring programs. These services are essential to ensuring a successful response to the epidemic.

While MSF does not accept US government funding and will not be directly affected by cuts or freezes to PEPFAR, many of our activities are contingent on the programs that have been interrupted. In some places we’ve had to adapt and change our activities and the indirect effects of these freezes have already been felt in our projects in various parts of the world.

In Sub-Saharan Africa, where MSF runs several HIV/AIDS and related health programs, we are already witnessing impacts on patients. In South Africa, many clinics providing HIV services, including testing, treatment, and PrEP through PEPFAR-funded organisations have been shuttered, leaving people confused and distressed about where to access their critical medication. In Mozambique, a major partner organisation of MSF that provided comprehensive HIV services had to stop activities completely. In Zimbabwe, most organisations providing HIV services have also stopped work, disrupting in particular the DREAMS program aimed at decreasing new HIV infections in adolescent girls and young women.

“Any interruption to HIV services and treatment is deeply distressing to people in care and an emergency when it comes to HIV treatment,” says Tom Ellman, director of the South Africa Medical Unit at MSF Southern Africa. “HIV medicines must be taken daily or people run the risk of developing resistance or deadly health complications.”

In Democratic Republic of Congo, the aid freeze was already affecting the most successful model of antiretroviral drug distribution ever implemented in the capital city of Kinshasa: the community-run free distribution and peer support points, known locally as "PODIs." In a country where stigma against people living with HIV is massive and poverty remains a barrier to care, PODIs have proven to be a medically necessary approach for addressing delays or therapy abandonment. With PEPFAR-supported points of care now closed and other activities frozen, thousands of people were left without support and with a high risk of developing advanced HIV. MSF teams supporting advanced HIV disease care in Kinshasa might not be able to meet the increased demand if disruptions persist.

In South Sudan, approximately 51 per cent of people living with HIV know their status, and 47 per cent are on treatment. A discontinuation of this program will have devastating effects on thousands of people and their communities.  MSF has worked alongside PEPFAR providing essential HIV care in this context and has seen firsthand how this program saves lives. The support of PEPFAR in this country is critical.

PEPFAR-supported programming is deeply interconnected with and reliant on other components of the US foreign aid system, specifically implementation support provided by USAID and technical and other assistance provided by the US Centers for Disease Control and Prevention (CDC). Given that the foreign aid freeze and stop-work orders continue to affect these other agencies, and staff from these agencies have been put on immediate leave or recalled, it is unclear when and how even the limited activities now allowed will be able to restart.

“These disruptions will cost lives and upend years of progress against this virus,” says Benoit. “Every day that passes is an emergency for millions of people for whom PEPFAR is a lifeline.”

PEPFAR-supported programming has been heavily integrated into key aspects of the broader health systems of partner countries over the last 20 plus years and as a result the consequences of these disruptions have been far-reaching. For this reason, some of the services affected go beyond purely HIV treatment and prevention, such as in Uganda, where PEPFAR-funded aspects of infectious disease surveillance and response, including for Ebola virus, have been stopped.

“When MSF first started treating people with HIV/AIDS in South Africa 25 years ago, there were no ARV medicines on the shelves, every diagnosis felt like a death sentence, and communities were desperately trying to curb the virus’ spread,” says Ellman.

Since then, PEPFAR support has helped save more than 25 million lives and encouraged the fight against HIV to be a truly global one. But continued success relies on continued access to the full range of HIV-related programs, services, and goods including prevention services and treatment, population-specific and targeted programs, programs related to gender-based violence, and other critical areas, said MSF.  

As health care providers, we are deeply concerned by these disruptions to this lifesaving program.

“Even temporary interruptions to key components of PEPFAR will harm people at risk of acquiring HIV and people living with HIV,” said Benoît. “We urge the US government to immediately resume all funding of critical humanitarian and health aid, including the full range of PEPFAR operations.”