PEPFAR: Learn how to combat pandemics, not raid AIDS resources

The President’s Emergency Plan for AIDS Relief (PEPFAR) — one of the most successful development programs in U.S. history — may be poised to become a victim of its own success.

PEPFAR has saved 25 million lives over the 20 years since its inception, prevented millions of HIV infections, and helped more than 50 countries make progress against the global HIV/AIDS pandemic. Moreover, the health networks it built have allowed these countries to respond better to other diseases, including COVID-19 and Ebola.

Leaders in Washington have taken notice of this phenomenal track record: The State Department is now considering expanding PEFAR’s mandate, pending congressional approval, to coordinate all U.S. government activities in global health preparedness and response.

While that’s a compliment to PEPFAR’s achievements, it will hurt PEPFAR’s core mission if the proposed new Global Pandemic Response Bureau doesn’t receive additional funding and personnel. The only way the State Department can fund the new bureau out of existing resources would be to cannibalize PEPFAR. And that would be a disaster for the millions of people around the world who continue to benefit from PEPFAR as well as the American people who garner both international goodwill and medical advancement from the program.

Through PEPFAR, the U.S. government has invested over $100 billion in the global HIV/AIDS response, the largest commitment by any nation to address a single disease in history. I was privileged to work with PEPFAR from the beginning and led it as the U.S. global AIDS coordinator from 2014 to 2021.

PEPFAR taught us some key lessons on how to tackle pandemics that we were able to leverage for COVID-19 beginning when I was the White House coronavirus response coordinator and which we can also use for future pandemics. PEPFAR showed us what the pathway to success looks like.

Effective pandemic control necessitates moving past words. It requires new resources and specific, focused milestones. It links resources to results: Each objective has clear metrics tied to dollars received. PEPFAR also showed us that public-sector investments alone aren’t enough and that to truly move the ball, we need to invest in programming and education at the local level through on-the-ground community organizations that can raise awareness — not just issue mandates.

Beginning in the late 1990s, there was a call to action to address the devastation of AIDS in places with limited resources across the globe. Media sounded the alarm, and leaders around the world endorsed the message. Months and years went by, but nothing changed because their commitment to the crisis was only rhetorical — words without action.

A global consensus emerged around the mantra of “prevent, detect and respond,” but the response was ineffective because the proposals made weren’t funded.

President George W. Bush was the man who acted, moving from talk to response by making the founding pledge of $200 million to what became the Global Fund to Fight AIDS, Tuberculosis, and Malaria in 2001. He followed this up the next year by committing $500 million to reduce the transmission of HIV from mothers to their babies. Then, with huge bipartisan support in the Congress and thanks to the generosity of the American people, he launched PEPFAR in early 2003 with a promise of $15 billion over five years.

This American-led response, grounded in clear outcomes and measurable impact, changed the course of the HIV pandemic. And there’s no reason we can’t do it again. But we must beware of the same traps, including paying lip service to pandemic response while failing to back up the effort with real resources and clear metrics to measure progress across government.

The new State Department proposal is currently an unfunded mandate. And it won’t just be PEPFAR that’s affected if it stays that way.

To support and coordinate a whole-of-government approach and drive policies requires a data-driven approach for decision-making. Resources are needed to develop an integrated strategy and policies, establish clear metrics and ensure progress with agency-specific programmatic funding while avoiding duplication. It’s shortsighted to invest a billion dollars in global health security without tracking every taxpayer dollar to specific outcomes and impacts and supporting constant programmatic improvement.

Moving bureaucratic boxes around won’t create the sustainable roadmap that we need to combat future pandemics effectively, especially if there is no real funding to go with it. What will is ensuring outcomes and impact with transparency and accountability — and coupling intentions with the resources necessary for real action.

Deborah L. Birx, M.D., is a senior fellow at the George W. Bush Institute, where she works on global health issues. She is the former U.S. Global AIDS coordinator and former White House coronavirus response coordinator.