A financial cliff edge for U.S.-funded global programs is rapidly approaching, leaving millions of people with HIV/AIDS, many in Africa, facing an uncertain future. In September, 120 US Centers for Disease Control grants for HIV/AIDS efforts are set to expire, with no concrete replacement system in place.
The program serves more than 8.7 million patients worldwide, but it is unclear what will happen to many patient services behind the scenes on October 1, analysts said.
The move comes as the U.S. State Department is restructuring the CDC’s work on global health initiatives to take on greater control, according to internal guidance released by the department in May, a copy of which was obtained by CNN.
The new guidance offers a “streamlined” approach to the United States’ long-running HIV/AIDS initiative, called the President’s Plan for AIDS Relief (PEPFAR), established by the Bush administration in 2003. PEPFAR is considered a flagship global health initiative and is credited with saving more than 26 million lives and preventing millions of infectious diseases, primarily in Africa.
Previously, PEPFAR was jointly managed by the United States Agency for International Development (USAID), the CDC, and other agencies, and was overseen by the Department of State. But the new plan would quickly transfer more authority to the State Department. Multiple critics and experts told CNN that while they support the idea of streamlining PEPFAR — efforts to make it more efficient have already begun — they believe this new approach will significantly reduce the effectiveness of the effort and sideline CDC health experts.
The 120 U.S.-funded awards to PEPFAR’s CDC branch are expected to end within weeks without an alternative mechanism in place, according to a recent analysis of public data by the Academy for Healthcare Safety Policy, a U.S.-based think tank.
“The result could be a second global medical wood chipper, with the sudden destruction of the operating systems that patients, clinics, healthcare workers, laboratories, and health ministries still rely on,” the analysis’s authors wrote.
The impact is expected to vary widely by country. Mozambique, Tanzania and South Africa will be particularly hard hit by the funding cliff this year, according to the analysis.
The award will fund a wide range of services including community testing, HIV clinical services, HIV testing services, pre-exposure prophylaxis (PrEP) medication, and more. Funding is typically renewed on a five-year cycle, so many expiring overseas programs have been in place for 15 or 20 years.
In addition to not renewing U.S. funding programs that expire in 2026, the State Department also plans to replace some of the CDC’s other remaining awards and has directed the CDC to cancel some public funding opportunities, one CDC official said.
“It really feels like the end of PEPFAR,” a CDC official who was not authorized to speak on the record told CNN. “In many cases, the State Department mechanisms are not yet established. So this is not about passing it from one expert to another; it’s about taking it away from one expert and putting it in a big box with a question mark.”
Another part of the new strategy, launched in May, is the move to a system in which partner countries choose from a “menu” of services and pay a la carte for their desired CDC services. Analysts say this will force U.S. health agencies out of the driver’s seat and turn them into contractors of sorts.
The CDC official added that Trump administration political appointees have made it clear that they are no longer interested in funding certain organizational projects, such as health surveillance systems, certain testing operations, and training for health care workers, the CDC official added. As for the parts of the PEPFAR program that he wants to keep funding, such as health workers and medicines, “that’s really only for another year or two, after which we’ve already told some countries that we’re going to stop working.”
But the State Department said operational funding would increase as it moves toward a so-called “America First Global Health Strategy.” The changes to PEPFAR are part of a broader strategy that would see U.S. aid funneled through a new system of one-on-one memorandums of understanding (MOUs) with countries, rather than being distributed through international aid partners and organizations.
“The State Department expects funding for CDC’s overseas operations 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 maintaining and enhancing PEPFAR’s lifesaving effectiveness, maintaining CDC’s world-class technical role, and ensuring that U.S. assistance produces lasting results,” a State Department spokesperson said. They said recipient countries are currently working on implementation plans for the MOU agreement and that CDC remains the “preferred provider of all technical services to recipient countries.”
A spokesperson for the U.S. Department of Health and Human Services, which oversees the CDC, said, “Suggestions that the America First Global Health Strategy will ‘degrade’ global health programs ignore CDC’s decades-long commitment to building sustainable public health capacity around the world,” adding, “CDC continues to implement global health programs funded by Congressional appropriations.”
The State Department’s reorganization of PEPFAR has drawn widespread criticism from experts, members of Congress, and former CDC officials who worked under both Republican and Democratic administrations.
In an essay published in the health news outlet Stat in May, eight former CDC directors warned that the State Department’s strategy, “if rushed as currently planned…will destroy PEPFAR and undermine health security around the world and in our country.” They added that a paid service menu “risks uprooting the scaffolding and expertise” of the program before effective alternatives can be introduced.
Former CDC directors called on the State Department, CDC, and Congress to work together on a more stable transition plan.
Meanwhile, a bipartisan group of senators sent a letter to the Senate Appropriations Committee asking for a direct increase in funding to the CDC’s Global Health Account, arguing that “we must be honest stewards of taxpayer dollars spent on foreign aid, and PEPFAR is one of the most cost-effective foreign aid programs and provides a tremendous return on investment.”
The group of 23 senators, led by Rev. Raphael Warnock (D-GA) and Dr. Bill Cassidy (R-LA), said the CDC has a “track record” of successfully implementing the U.S. global effort on HIV/AIDS.
“The real challenge with this proposal is that it really treats global HIV action and global health action as part of an MOU agreement, transactional,” said Dr. Michel Montandon, a former leader of the CDC team working to prevent mother-to-child transmission of HIV who was fired last year. “There’s really a lack of focus on the health impacts, saving lives and keeping Americans safe.”
Mr. Montandon expressed concern about the continuation of accountability, transparency, and strong data collection, long considered keys to PEPFAR’s success, as the new system of bilateral MOU transactions is implemented.
“We know that if you ask countries to meet certain metrics, people are likely to tell you what you want to hear. So we need a lot of data quality systems in place, on-the-ground visits, and oversight to make sure the data is accurate,” she told CNN.
Regarding the expiring award, Montandon added: “It will be very difficult to transition support to 8 million people within a few months without creating major disruptions…When people can’t get treatment, they get AIDS. Babies get HIV and people die.”
CDC officials added that staff within the agency have long worked to improve PEPFAR’s efficiency and strengthen partner government engagement to ensure that the funds the United States spends on the HIV/AIDS response are better utilized. The official argued that PEPFAR’s restructuring actually impeded efficiency.
“Ironically, we are actually going backwards,” the source said. “Because of these changes, we’re making a lot less money per dollar than we were two years ago.”
