US AIDS program in Africa: ‘massive entitlement’ or biggest success of 50 years?

Fifteen years ago, there was no shortage of ways to measure the growing scale of the HIV crisis here. It was visible in the country’s spiraling death toll and its overburdened hospitals, in the sputtering proclamations from the country’s president and health minister claiming that HIV drugs were “poison,” and in their recommendations of a treatment of rest and good diet.

But for David Clark, a South African doctor and HIV researcher, there was perhaps no starker measure of the epidemic’s destructive path than the rapid growth of the massive cemetery hugging one of Johannesburg’s major highways, where he watched new graves shoot up like wildflowers and the soil become pockmarked with dozens of gaping holes – a queue of newly dug graves waiting be filled.  

“The weekly advance of that cemetery in those years was absolutely tangible,” says Mr. Clark, now CEO for southern Africa at the Aurum Institute, which works on HIV treatment and prevention in the region. “You could see the march of those gravestones visibly every time you passed.”

A decade and a half later, however, South Africa, once ground zero for the disease, has become one of the world’s great HIV success stories. The disease now accounts for less than one-third of all deaths in the country, down from half in 2005, and life expectancy has climbed by nearly a decade. In a brisk turnaround from its denialist days, the country also now has by far the largest public antiretroviral treatment program in the world, serving more than 3 million people.

And the country owes those successes at least in part to a massive George W. Bush-era aid program known the President’s Emergency Plan for AIDS Relief (PEPFAR), which since 2003 has funneled more than $72 billion into the fight against HIV globally, and nearly $5 billion into South Africa alone. 

Although PEPFAR has attracted significant criticism over the years – much of it around the moralizing bent of some of its early funding provisions  – it is nearly universally regarded, even by detractors, as a turning point in the AIDS epidemic here.

“It’s not every day in global health where a program gets to essentially say they’ve turned the tide on an epidemic, and that’s what PEPFAR has done,” says Sharonann Lynch, HIV and TB policy adviser for Doctors Without Borders' access campaign. “When PEPFAR was announced, you didn’t have anyone talking about ending AIDS – and now that’s exactly what the US and other governments have committed to. They can see it in sight.”

It is, says Clark, “the single most important health care intervention in the world in the past 50 years.”

Provocative questions

But the Trump Administration has expressed divergent views about the program, leaving beneficiaries across the continent uncertain about its future at a crucial junction in the global fight against HIV.

During Rex Tillerson’s confirmation hearing for secretary of State, for instance, he called PEPFAR “one of the most extraordinarily successful programs in Africa.” But in a questionnaire about US-Africa policy distributed by Trump’s transition team to the State Department earlier this month and later obtained by The New York Times, Trump officials appeared to express concern over the size and scope of PEPFAR going forward.

“Is PEPFAR worth the massive investment when there are so many security concerns in Africa?” the questionnaire asked. “Is PEPFAR becoming a massive, international entitlement program?”

For the Trump team, the provocative framing of those questions may simply have been an attempt to boldly challenge assumptions about the utility of America’s aid programs in Africa.

But for many living and working in the epidemic’s heart, the queries felt simplistic – at times, even condescending. If PEPFAR was saving millions of lives, what did it mean, they wondered, to ask if the investment was “worth” it?

“We have made incredible progress, but now we must be very careful not to reverse it,” says Linda-Gail Bekker, president of the International AIDS Society and a professor of medicine at the University of Cape Town in South Africa. “If we turn our backs now, we’re going to look back in 15 years and ask how, just when we were beginning to claw our away out of this tragedy, we let it slip away.”

Casting PEPFAR as an entitlement program, meanwhile, struck many here as far too narrow.

“This disease knows no borders, so to look at PEPFAR as an entitlement program that only benefits Africans [and other direct PEPFAR beneficiaries] would be a huge mistake,” says Olive Shisana, a South African scientist who has directed several HIV research organizations and projects. “We live in an integrated world. Bringing an end to HIV benefits the health of the US as well.”

That perspective, she adds, obscures the work that African activists, researchers, and governments have done over the past decade to push PEPFAR to become more collaborative, responsive not just to the interests of politicians in Washington, but also those living in the eye of the storm.

In the early days of the program, for instance, PEPFAR often seemed to approach AIDS as “a moral issue as much as a public health issue,” says Kikonyogo Kivumbi, executive director of the Uganda Health and Science Press Association, a network of LGBT health activists.

In line with the social conservatism of George W. Bush Administration, early PEPFAR regulations stipulated that one-third of all PEPFAR money spent on HIV prevention efforts must go to teaching abstinence, and forced recipient organizations to sign an anti-prostitution pledge.

“You were telling people how they had to behave if they wanted to live,” Mr. Kivumbi says.

But over time, activists in both the US and Africa pushed back against the stipulations, with the restrictions eventually ending. “We fought a long fight to contest those kinds of exclusions,” he says, adding that the program is better for it. (Recent research has shown that the $1.4 billion spent by PEPFAR on abstinence education, for instance, almost universally failed to reduce HIV prevalence. PEPFAR’s most recent description of its work, meanwhile, claims “we will work to leave no population at greatest risk behind.”)

In recent years PEPFAR has largely pivoted toward bulking up local health systems in AIDS-affected countries and training local personnel. 

 Sisonke Msimang, a South African writer and activist who previously ran the HIV and AIDS program at the Open Society Foundation for Southern Africa, says the Trump Administration’s views on PEPFAR "aren’t entirely wrong … the development paradigm is broken," and needs rethinking, in part because of the imbalance in power relationships that aid may foster.

African governments must ask themselves difficult questions, she says, about how they can grow more self-sufficient in funding and developing HIV treatments and prevention strategies. That’s a process that will require both “better and bolder activism from above – from African and US governments – and from below, from African people,” she says.