PEPFAR Article in Devex
Bob Noziglia
By Michael Igoe // 19 June 2023
https://www.devex.com/news/can-john-nkengasong-save-pepfar-from-the-culture-wars-104909
The 2022 International AIDS Society conference in Montreal, Quebec, last July was a big moment for Dr. John Nkengasong.
The highly respected Cameroonian virologist had been officially sworn in as U.S. global AIDS coordinator just one month earlier, and for the gathering of nearly 13,000 HIV advocates and experts, it marked a public debut for his leadership vision for PEPFAR, the U.S. government’s flagship global HIV/AIDS initiative.
Among those eager to get the ambassador’s ear were government ministers from PEPFAR’s partner countries. Nkengasong met with nearly a dozen of them over the course of the long weekend, and they all asked him some versions of the same question:
Is the U.S. government going to end PEPFAR?
The U.S. President’s Emergency Plan for AIDS Relief is celebrating its 20th anniversary this year. While the initiative occupies a rare bright spot of bipartisan endurance in American politics, it is also facing questions about its future.
In recent months those questions have lurched from a strategic conversation about how the U.S. government and partner countries can find a sustainable pathway to ending the AIDS epidemic, to an all-hands-on-deck effort to rescue PEPFAR from America’s pervasive culture wars.
In their uncertainty about PEPFAR’s future, the ministers in Montreal now appear alarmingly prescient.
Nkengasong has tried to keep the sustainability conversation more nuanced, emphasizing shared responsibility and shared accountability among the U.S. government and its partner country governments.
“When you use the word ‘sustainability,’ it’s not about handing over to you and running away,” Nkengasong said earlier this month at the Center for Global Development in Washington, D.C.
PEPFAR, which currently spends about $5 billion a year on bilateral HIV programs, could be a victim of its own success. Forged from devastation, the initiative is credited with saving 25 million lives, particularly in Africa. It is routinely held up as one of the U.S. government’s greatest foreign policy achievements. HIV is no longer the death sentence it was 20 years ago, and other health threats such ash COVID-19 have shaken up the sense of priority some leaders attach to a virus that once threatened their nations’ survival.
When Nkengasong speaks to presidents and ministers in PEPFAR’s partner countries, “the discussion doesn’t start with HIV/AIDS. It starts with a security threat,” he said. “It’s either a COVID threat, an Ebola threat, or a massive cholera outbreak.”
Progress in the global fight against HIV has “inadvertently lowered the visibility of HIV in the competing radar screen of the political leadership,” he said.
Still, the AIDS crisis continues. In 2021, 1.5 million people contracted HIV, and 650,000 people died from it.
Global health institutions are collectively pushing to reach a trio of targets set by the Joint United Nations Programme on HIV/AIDS for 2030, by which time 95% of people living with HIV should know their status, 95% of those diagnosed with HIV should be receiving antiretroviral therapy, and 95% of those receiving therapy should be virally suppressed.
According to UNAIDS, the aim is “nothing less than the end of the AIDS epidemic by 2030.”
Nkengasong has tried to be unwavering and proactive in his messaging: “We are committed to the end, and we are committed past 2030.”
But he has also pushed leaders in PEPFAR’s partner countries to think in more concrete terms about what a “road map” to sustainable HIV financing might look like.
“These people are all playing with fire, and they’re playing with people’s lives, and there can only be one reason: political motivation to kill PEPFAR.”
— Mark Dybul, former U.S. global AIDS coordinator
In February, at the African Union summit, he asked for a speaking slot during a private session with African heads of state. He spoke extemporaneously, but according to his own account he asked leaders to recommit to spending greater portions of their public budgets on health, as they pledged to do 22 years ago in the Abuja Declaration.
“If we have the right dialogue, countries begin to see this as a source of pride in taking care of their own people,” Nkengasong said at CGD earlier this month.
‘Playing with fire’
Before taking charge of PEPFAR — which is headquartered at the U.S. State Department in Washington, D.C. — Nkengasong served as the first head of the Africa Centres for Disease Control and Prevention. He became a beacon of African health leadership during a global COVID-19 response that largely neglected the continent — and an advocate for enhancing Africa’s self-reliance in global health.
As the first African-born U.S. global AIDS coordinator, Nkengasong appeared uniquely well-positioned to steer delicate conversations about budgets, foreign aid, and PEPFAR’s future around potential pitfalls and misinterpretations.
But in the last few months, his job has gotten harder.
What many expected would be a rubber stamp process in the U.S. Congress to reauthorize PEPFAR for another five years before the fiscal year ends in September has instead devolved into a culture war battle over abortion and gender identity that some worry poses a threat to PEPFAR’s basic survival.
Some of PEPFAR’s closest observers believe that a handful of politically-motivated critics are using divisive misinformation to undermine the bipartisan coalition of supporters that has allowed the initiative to weather two decades of political turbulence and four presidential administrations.
“These people are all playing with fire, and they’re playing with people’s lives, and there can only be one reason: political motivation to kill PEPFAR,” said Mark Dybul, who served as U.S. global AIDS coordinator under President George W. Bush.
PEPFAR is legally prohibited from funding abortion by multiple provisions in its authorizing legislation. Abortion is also illegal or heavily-restricted in all but four countries that receive significant PEPFAR funding, and the initiative is required to follow the laws where it operates. Nkengasong has publicly stated that PEPFAR does not fund abortion, and he has distributed documents to country teams in U.S. embassies reminding them of the initiative’s legal obligations, according to people familiar with the situation.
But Nkengasong’s status as a Washington outsider, a potential asset for the program’s relationships with partner governments, now risks becoming a liability on Capitol Hill, where the initiative’s fate depends on political savvy and Washington relationships.
“I hate to see this happening to him because he’s new to it,” said a person familiar with the situation, who spoke on condition of anonymity to avoid making a tenuous situation worse.
One relationship looms particularly large.
Rep. Chris Smith, a Republican from New Jersey, devout Catholic, and leading anti-abortion voice in Congress, has been a key PEPFAR ally. While Smith has pushed hardline policies to restrict U.S. funding for groups that support abortion, he also co-sponsored PEPFAR’s reauthorizing legislation during the last round in 2018 and has been a lynchpin in the initiative’s faith-based coalition.
But Smith’s support has been shaken by vague allegations from conservative activists who argue that the Biden administration is using PEPFAR funds for abortion and other activities that reflect a “radical social agenda.”
“President Biden has hijacked PEPFAR … in order to promote abortion on demand,” Smith wrote in a letter to his colleagues on the House Foreign Affairs Committee earlier this month.
“Any multi-year PEPFAR reauthorizing legislation must ensure that Biden’s hijacking of PEPFAR to promote abortion be halted,” he wrote.
PEPFAR’s advocates have mobilized to push back against the allegations and to send a message that the initiative is still backed by a broad bipartisan coalition. This month Nkengasong met privately with representatives from faith-based organizations to shore up their support for reauthorizing the program.
The problem, according to people worried about PEPFAR’s future, is that while this kind of outreach might have worked in the past, those making allegations this time seem more interested in inflicting political damage against the Biden administration than with resolving genuine concerns about the initiative.
“It’s not about reality. It’s about using dog whistles to try to kill a program,” Dybul said.
None of the allegations conservative critics have made point to specific instances where PEPFAR violated any of the laws that govern its own funding and operations. Their chief complaint is that a small group of organizations that do provide abortion care with their own funding have also received funding from the U.S. government to carry out other activities.
“Literally tens of millions of peoples lives put at risk over what no one’s proven could be happening in four countries,” Dybul said.
The failure to reauthorize PEPFAR would not immediately doom the initiative, but it would send a harmful signal to partner countries, particularly at a time when the United States is competing for influence in Africa with China and Russia, Dybul said.
PEPFAR’s advocates remain hopeful that Smith and others facing pressure from anti-abortion groups will undertake a good faith review of the initiative’s programs that will either surface concrete evidence of violations, or restore their confidence in the program.
“The bipartisan coalition of sensible people needs to be restored, and facts need to start taking over from vitriol and personal attacks,” Dybul said.
A premature victory
Within the context of the global fight against HIV, there is another alarming reason to worry about a political squabble that sounds uniquely American and mostly procedural:
The testing and treatment targets set by UNAIDS might not be working.
The underlying assumption behind these targets is that if 95% of people living with HIV know their status, 95% of those diagnosed with HIV receive treatment, and 95% of those on treatment achieve viral suppression, incidence of HIV will decrease to a point of epidemic control.
But according to Chris Beyrer, that does not appear to be happening. He is the director of the Duke Global Health Institute, former president of the International AIDS Society, and an advisor to multiple global health programs including PEPFAR.
Numerous medical trials — including the recent HIV vaccine trials that ultimately disappointed — have revealed that while HIV therapies are very effective at preventing people from dying, testing and treatment have not produced the anticipated decline in new infections, Beyrer said.
“It’s not about reality. It’s about using dog whistles to try to kill a program.”
— Mark Dybul, former U.S. global AIDS coordinator
The 2030 targets replaced a similar set of 90-90-90 goals that UNAIDS established for 2020.
“I think the science is suggesting that this whole 90-90-90 approach is problematic. We are declaring premature victory, and that shapes the way the whole PEPFAR program, and in fact, the whole epidemic is understood,” Beyrer said.
“The treatment burden is growing. It’s not shrinking,” he added.
That does not mean the HIV epidemic has not evolved. New infections are increasingly concentrated among so-called key populations. These include men who have sex with men, sex workers and their clients, and people who inject drugs.
For those watching both the politics and the epidemiology of HIV, that points to a daunting tension at the center of Nkengasong’s tenure.
It is not only in the United States that the global AIDS coordinator will have to overcome divisive politics in order to safeguard the future of America’s global fight against HIV. While anti-abortion culture warriors hold PEPFAR’s reauthorization hostage at home, rising conservative forces in PEPFAR’s partner countries also threaten its ability to operate in the culturally-sensitive terrain where the battle to defeat AIDS will ultimately be won or lost.
There is no better — or worse — example, Beyrer said, than the law recently approved by Ugandan President Yoweri Museveni, which makes same-sex intercourse between consenting adults punishable by life imprisonment and imposes a potential death penalty on those who transmit diseases including HIV/AIDS through gay sex.
Other countries including Kenya and Ghana are considering similar discriminatory laws and could be emboldened by Uganda’s example.
Those leveling criticism at PEPFAR from Washington are also trying to align with conservative groups in the countries where it operates.
The same day Chris Smith wrote his letter to congressional colleagues in Washington, more than 100 African parliamentarians and religious leaders sent their own letter to U.S. lawmakers raising “concerns and suspicions” that PEPFAR might be supporting activities that violate the group’s “core beliefs concerning life, family, and religion.”
“The social and structural challenges to reaching where the epidemic is going are getting harder, not easier,” Beyrer said.
“John Nkengasong has to deal with this both on the African political front and on the U.S. front,” Beyrer said. “And that is not easy.”
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