The US Legacy in HIV is Unraveling
*This article, authored by AVAC Executive Director, Mitchell Warren, originally appeared on DevEx.
With PEPFAR facing precarious uncertainty, shifting priorities and dwindling expertise raise alarms. Will the U.S. Congress intervene?
Right now, the U.S. global AIDS response could best be described as rearranging deck chairs while the ship drifts entirely off course.
We are not witnessing bold reform, but an intentional unraveling of America’s legacy in global health. And it’s happening without the congressional engagement that has, historically, yielded such remarkable success.
Reimagining and realigning global health programs is not inherently bad. In fact, it was a spirit of reimagination that led to the creation of the President’s Emergency Fund for AIDS Relief, or PEPFAR, the most successful global health program in our country’s history. But we were off track on global targets related to HIV before Jan. 20. To right the ship requires a thoughtful, intentional strategy. That is not what is happening.
Before Donald Trump’s second presidential inauguration, we were lagging behind in progress toward established HIV targets due to COVID-19, among other factors. But now, we are in a parallel universe entirely.
Once upon a time, when Rubio supported PEPFAR
In the original PEPFAR legislation, Congress intentionally included a direct line of accountability from the global AIDS coordinator, who oversees the program, to the U.S. secretary of state. That structure mattered — both for U.S. credibility abroad and for effective, data-driven results at home.
In his hearings on Capitol Hill last week, Secretary Marco Rubio shared details around the administration’s proposed plan to restructure the State Department. These changes would marginalize the program, moving it to report to the under secretary for economic growth, energy and environment oversees. This creates an additional, wasteful, and ineffective layer of bureaucracy. It also consolidates authority under a State Department with diminishing health expertise, due to the dismantling of the U.S. Agency for International Development, which means the intellectual capital of hundreds, if not thousands, of global health experts has been lost.
Again, realignment is not a bad thing. But there are core principles that must guide any change to PEPFAR’s structure — sustainability, local ownership, transparency, and comprehensive prevention. Once we have aligned around these principles, only then can we have conversations about the right level and structure of the program. Conversations around both principles and structure must include Congress.
PEPFAR’s incontrovertible success has been possible only through bipartisan and bicameral support. The program has been upheld for more than two decades through rigorous congressional oversight. Members of Congress — Republican and Democrat — have long demanded accountability, performance, and results. And they got them.
Ongoing assessment is built into the very fabric of the program. Throughout its 20 years and across multiple presidential administrations, PEPFAR’s strategy, operations, and impact have continually been evaluated to ensure it remains successful. Each global AIDS coordinator has talked about going to Capitol Hill to defend PEPFAR’s budget. And, every year, that defense was successful, including during Secretary Rubio’s tenure on the Senate Foreign Relations Committee.
In fact, no one knows better than Secretary Rubio — who served on the U.S. Senate Foreign Relations Committee from 2011 until his confirmation as secretary of state — what it means to be a member of the committee overseeing PEPFAR’s impressive data. Then Sen. Rubio has said of PEPFAR: “The dividends it pays from a human element are extraordinary, and you need to look no further than Africa, where millions of people are alive because the United States pays for their antiviral medication.”
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