How the US came to fund global treatment for HIV/AIDS
A health worker examines a man during an HIV/AIDS awareness campaign on the occasion of World AIDS Day at the Kuchingoro IDPs camp in Abuja, Nigeria December 1, 2018. REUTERS/Afolabi Sotunde
What’s the context?
Before the PEPFAR programme, millions in Africa were deprived of lifesaving treatment. Experts now fear for its future
- HIV diagnosis was ‘death sentence’ in Africa in 1990s
- PEPFAR helped reduce drug prices dramatically
- Activists worry funding for AIDS plan may decrease under Trump
NAIROBI - At the height of the HIV/AIDS crisis in the 1990s, getting diagnosed with the virus in Kenya meant bracing for the worst.
"We were pretty much giving people a death sentence," recalls Lilian Otiso, a doctor who was a medical intern at the time at Kenyatta National Hospital, Kenya's largest referral hospital.
Highly effective antiretroviral therapies (ARVs) had reduced AIDS deaths by 47% in the United States in the year after they became available in 1996. But they cost more than $10,000 per patient annually —far out of reach for most patients in Africa.
Even by 2002, only 50,000 people in Africa were receiving ARVs, a mere 0.1% of the nearly 30 million HIV-positive people on the continent. The average life expectancy had fallen to 47 years, compared to a projected 62 years without AIDS.
This meant medical personnel like Otiso could only help people diagnosed with the disease to manage the inevitable.
"We walked them through how to break the news to family and get their affairs in order. Support groups and nutrition advice were all we could offer," said Otiso, who is now the executive director of LVCT, a Kenyan nongovernmental organisation that provides testing, counseling and support for HIV/AIDS patients.
The launch of the President's Emergency Plan for AIDS Relief (PEPFAR) in 2003 changed everything. The world's largest health programme targeting a single disease, PEPFAR has provided $120 billion in funding over 20 years, delivering life-saving treatment to millions in over 50 countries.
But the programme's future is at risk. President Donald Trump ordered a 90-day pause in foreign development assistance on Jan. 20, the day he took the oath of office.
This included stopping the supply of lifesaving drugs for HIV, malaria and tuberculosis, as well as medical supplies for newborn babies, in countries supported by USAID around the globe, a memo reviewed by Reuters showed.
This follows a rocky period, where PEPFAR failed to secure a five-year funding authorisation in 2023 for the first time in its inception, when the U.S. Congress granted only a one-year extension.
The road to PEPFAR
When AIDS emerged in the mid-1980s, the public health sector in Uganda was already strained by war. In the 1990s, the government established a Joint Clinical Research Centre to study the disease, which had spread within military ranks.
"Uganda was importing these very expensive ARVs, and deciding who received them was essentially a military decision," Ugandan journalist Daniel Kalinaki told Context/the Thomson Reuters Foundation in an interview. Kalinaki is the co-author of "Open Secret: People Facing Up to HIV and AIDS in Uganda."
In 2000, South Africa faced a lawsuit from 39 pharmaceutical companies seeking to block legislation that would allow imports of low-cost generic drugs to treat HIV and AIDS. The companies argued that this violated international patents.
The standoff centred around intellectual property rights. By the late 1990s, Western companies continued to protect their patents, so that only they could manufacture the drugs.
But some countries began producing generic versions by reverse-engineering the active ingredients in antiretroviral drugs, which help suppress levels of the virus and prevent its transmission.
"The West built a medical moat around themselves at the time," says Kalinaki. "When India and Cuba started producing generics, the debate shifted from cost to intellectual property. Do you have the right to copy something you didn't invent? But can you - should you - stop someone from copying something that will save millions of lives?"
Pharmaceutical companies also claimed Africa lacked the infrastructure to manage ARVs effectively.
"Western drug companies presented all sorts of arguments—some based on real challenges but not aimed at solving the problem," says Kalinaki.
"They cited lack of refrigeration, inadequate knowledge and even claimed African patients couldn't take pills properly because they were too poor and hungry."
Andrew Natsios, then-head of the United States Agency for International Development went further, testifying before Congress in 2001 that Africans couldn't adhere to treatment regimens because "they do not know what watches and clocks are" and marked time with the sun and so would struggle to take medication on a schedule.
A box of HIV medicine is seen before being given to an HIV positive patient at the IOM treatment centre in Eastleigh, Nairobi, Kenya, November 29, 2018. Picture taken November 29, 2018 REUTERS/Baz Ratner
A box of HIV medicine is seen before being given to an HIV positive patient at the IOM treatment centre in Eastleigh, Nairobi, Kenya, November 29, 2018. Picture taken November 29, 2018 REUTERS/Baz Ratner
Security threat
The United States slowly began to view HIV/AIDS as a danger to political stability in emerging democracies. Former president Bill Clinton declared AIDS a "national security threat," and after the Sept. 11, 2001, attacks on the United States, the stakes became even higher.
According to records from former president George W. Bush's White House archives, he launched PEPFAR as a cornerstone of U.S. foreign policy "to help alleviate despair that allows extremism to take hold."
At the time, Africa not only had the highest HIV prevalence but also the largest number of orphaned children, who were seen as a potential pool for recruitment into militant and criminal groups.
But Bush also framed PEPFAR as a humanitarian response to the HIV/AIDS crisis in Africa, driven by the United States' moral obligation to alleviate suffering and save lives in poorer nations devastated by the epidemic.
Under the programme, ARVs became widely available, providing hope for millions of people who previously would have been condemned to die.
While PEPFAR initially relied on proprietary drugs from U.S. manufacturers, it began approving generics in 2005 following expedited reviews by the U.S. Food and Drug Administration.
By 2008, generics made up 90% of PEPFAR-funded ARVs, which significantly reduced costs.
"PEPFAR came about because of a mix of players—activists pushing hard, people working behind the scenes and a lot of pressure to bring prices down," says Otiso.
As for adherence, African patients defied the stereotypes by demonstrating better adherence to treatment regimens than their North American counterparts.
"What shocked (critics) was that adherence here was better than in the West," says Otiso. "We had radios. We had the 7 o'clock news. Those on treatment adjusted their lives to suit (those markers)."
An HIV adherence counsellor speaks to a woman being tested for HIV at the IOM treatment centre in Eastleigh, Nairobi, Kenya, November 29, 2018. REUTERS/Baz Ratner
An HIV adherence counsellor speaks to a woman being tested for HIV at the IOM treatment centre in Eastleigh, Nairobi, Kenya, November 29, 2018. REUTERS/Baz Ratner
'Foreign policy win’
Since its launch, PEPFAR has provided antiretroviral therapy to more than 20 million people with HIV and saved 26 million lives, according to U.S. government data.
PEPFAR's impact extended beyond HIV, strengthening healthcare systems to address other diseases and improve maternal and child health.
This dramatic shift underscored not just the effectiveness of treatment but also PEPFAR's geopolitical significance.
"I'm not naive enough to think PEPFAR was purely altruistic," says Kalinaki. "It was a defensive mechanism that turned into something good—arguably America's biggest foreign policy win in a long time."
Today, the programme faces growing uncertainty. Anti-abortion groups in the U.S. have claimed that PEPFAR is being used to promote abortion.
A review of service providers funded by PEPFAR in Mozambique found that four nurses performed a total of 21 abortions since January 2021, said three U.S. officials who briefed members of Congress on the matter on Jan. 23 in a bid to show transparency and demonstrate that measures to ensure compliance with the ban on abortions were working.
The officials said it was the first time a PEPFAR-funded provider had been found to have provided an abortion in the program's 20-year history.
However, U.S. laws already explicitly prohibit the use of foreign aid funds for abortion services.
"Given the already existing challenge and standoff with PEPFAR in terms of renewal, we are likely to find ourselves in a difficult place where the imminent threat of PEPFAR not being renewed becomes real," says Catherine Nyambura, director of programmes at the ATHENA Network, a global feminist organisation that works with women and girls to lead and shape the response to HIV and AIDS.
This story is part of a series supported by HIVOS's Free To Be Me programme.
(Reporting by Christine Mungai; Editing by Sadiya Ansari and Ayla Jean Yackley.)
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