The future of millions of people receiving HIV/AIDS treatment through US-backed health programmes is increasingly uncertain as a major funding deadline approaches, raising fears of widespread disruption to lifesaving services, particularly across Africa.
More than 120 funding awards supporting HIV/AIDS programmes managed by the US Centers for Disease Control and Prevention are due to expire in September, with no fully established replacement system ahead of October 1.
According to analysts, the affected programmes currently provide services to more than 8.7 million patients globally, leaving uncertainty over whether many of those services will continue once the existing funding ends.
The looming funding gap coincides with a broader restructuring of the President’s Emergency Plan for AIDS Relief (PEPFAR), under which the US State Department is taking greater control of the programme from the CDC.
Established in 2003 during the administration of former President George W. Bush, PEPFAR has been widely regarded as one of the world’s most successful global health initiatives.
The programme is credited with saving more than 26 million lives and preventing millions of HIV infections, with much of its impact recorded in Africa.
Until now, PEPFAR has been jointly implemented by the CDC, the US Agency for International Development and other agencies under the oversight of the State Department.
However, new guidance issued in May outlines a streamlined structure that significantly expands the State Department’s authority over the programme.
Although many public health experts support efforts to improve PEPFAR’s efficiency, several have warned that the new arrangement could weaken the programme by reducing the CDC’s role despite its long-standing technical expertise.
A recent analysis by the Health Security Policy Academy, a US-based think tank, found that the 120 CDC-funded awards are expected to lapse within weeks without replacement mechanisms in place.
“The result could be a second global health woodchipper: the abrupt destruction of operating systems that patients, clinics, health workers, laboratories, and ministries of health still depend on,” the authors of the analysis wrote.
The impact is expected to differ across countries, with Mozambique, Tanzania and South Africa identified among those likely to face the greatest challenges.
The expiring awards support a wide range of HIV services, including community testing, clinical care, laboratory services and access to Pre-Exposure Prophylaxis.
Many of the programmes have operated continuously for 15 to 20 years through successive five-year funding renewals.
Beyond allowing expiring programmes to lapse, the State Department is also reportedly planning to replace some remaining CDC awards while directing the agency to cancel certain open funding opportunities.
“It really does feel like the end of PEPFAR,” a CDC official, who was not authorized to speak on the record, told CNN. “In a lot of cases, the State Department mechanism is not set up yet. So, this isn’t handing it from one set of experts to another – this is taking it away from one set of experts and putting it in a big box with a question mark.”
As part of the restructuring, partner countries will also begin selecting services from a menu-based system, paying for specific CDC support they require.
Analysts argue that this effectively shifts the CDC from leading programme implementation to serving as a technical contractor.
The CDC official said political appointees in the Trump administration had indicated that overall funding would decline significantly, with reduced support for public health surveillance, laboratory systems and workforce training.
“have been pretty clear the overall funding is going way down,” the CDC source added, saying that State Department officials have made clear that they are no longer interested in funding certain systemic work, such as health surveillance systems, certain laboratory work and health workforce training. For the parts of PEPFAR programs that they do want to keep funding, like health workers and medications, “it’s really just for one or two more years, and then they’ve already told some of the countries we’re pulling the plug.”
The State Department has rejected suggestions that support for global HIV programmes is being reduced, insisting that operational funding will increase under its new America First Global Health Strategy.
Under the strategy, US health assistance will be delivered through individual Memoranda of Understanding negotiated directly with recipient countries instead of relying on international aid partners.
“The State Department expects CDC overseas operating funding to increase – not decrease – under the America First Global Health Strategy,” a State Department spokesperson said in response to questions from CNN.
“The Trump Administration is preserving and strengthening PEPFAR’s lifesaving impact, maintaining CDC’s world-class technical role, and ensuring US assistance is producing durable results,” the State Department spokesperson said. They said that each country receiving aid is now working through a plan for implementation of the MOU agreements and that the CDC remains “the preferred provider for all technical services to recipient countries.”
A spokesperson for the US Department of Health and Human Services, which oversees the CDC, also defended the reforms.
“The suggestion that the America First Global Health Strategy will ‘deteriorate’ global health programs ignores decades of CDC’s work to build sustainable public health capacity around the world,” the spokesperson said, adding that “CDC continues to implement global health programs funded through Congressional appropriations.”
The restructuring has also attracted bipartisan criticism from former CDC leaders, lawmakers and global health experts.
In a May essay published by Stat, eight former CDC directors warned that the planned transition could significantly damage the programme.
“done in haste as currently planned… will destroy PEPFAR and undermine health security around the world and in our own country.”
They further cautioned that the fee-for-services approach “risks pulling out the scaffolding and expertise” of the programme before an effective alternative is established, urging the State Department, CDC and Congress to work together on a more stable transition.
Meanwhile, a bipartisan group of 23 senators has urged the Senate Appropriations Committee to increase direct funding for the CDC’s global health budget, describing PEPFAR as one of the most cost-effective US foreign assistance programmes.
They said the CDC has a “proven track record” of successfully delivering the country’s global HIV/AIDS response.
Dr. Michele Montandon, the former head of the CDC’s programme to prevent mother-to-child HIV transmission, also questioned the new approach.
“A real challenge with this proposal is that it’s really viewing global HIV work and global health-response work as transactional, as part of these MOU deals,” she said. “There’s really a lack of focus on health outcomes, saving lives, keeping Americans safe.”
Montandon also expressed concerns that accountability, oversight and data quality could suffer under the new bilateral agreements.
“When you require countries to meet certain indicators, we know that people are more likely (to) tell you what you want to hear. And so you need a lot of data quality systems in place, and site visits, and oversight to make sure that the data are accurate,” she told CNN.
Commenting on the expiring funding awards, she warned: “It’s really hard to transition the support for 8 million people in a couple months’ time without having major disruptions… When people lose their access to treatment, they get sick with AIDS. Babies get HIV. People die.”
The CDC official maintained that the agency had already been working to improve PEPFAR’s efficiency and strengthen local government participation long before the restructuring.
“The irony is, we’re actually moving backwards,” the source said. “We’re getting far less per dollar than we were two years ago because of these changes.”
