Missing the forest for the trees

December 1, 2017

The United States is the largest bilateral donor in the global fight against HIV and AIDS. Since the launch of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, the U.S. has progressed from an initial emergency response commitment of $2.27 billion in 2004 to $6.8 billion for long-term sustainability in 2017. Arguably, PEPFAR has changed the global development landscape, not just for AIDS and tuberculosis programs, but for creating sustainable health systems and strategies more broadly.

Today, we’re entering a new phase of the historic program, which enjoys broad bipartisan support in Congress. In September, Secretary of State Rex Tillerson announced PEPFAR’s new Epidemic Control Strategy, PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017–2020). Touted as “a bold course for achieving control of the HIV/ AIDS epidemic,” the strategy focuses on 13 priority high-burden countries that are leading the way in epidemic control and provide the best chance of achieving UNAIDS’ 90-90-90 framework by 2020.

On paper, the strategy is sound. It focuses and aligns U.S. Government resources and activities, which are dispersed across agencies and departments, from State and USAID to the Department of Defense and Centers for Disease Control and Prevention. It is data focused, using Population-Based HIV Impact Assessments for evidence-based decision-making. The strategy prioritizes partnerships and collaboration with country governments, the private sector and faith-based organizations for a more coordinated, improved response.

Where we miss the mark is not in the strategy itself, but in the vacuum in which it lives. In the absence of a much-needed global development strategy that links our HIV targets, our development goals and our national security, we hamstring our HIV efforts by considering them in isolation from the broader development and foreign policy agendas.

HIV and AIDS persist because of social determinants and forces such as poverty, marginalization and inequality. Without addressing these root social and structural causes of the disease, we won’t be successful in ending the epidemic. The U.S. Government is already working across the world to address many of the drivers of the epidemic, from poverty reduction and economic inequality to good governance and humanitarian response. Yet, a coordinated strategy that links these interrelated issues remains missing.

Representing the lion’s share of global health funding in FY17, it is critical to align PEPFAR with these broader frameworks. Doing this will identify synergies and conflict, increase efficiencies in programming, including personnel and budget, and integrate sometimes seemingly disparate foreign assistance programs into an articulate, systemic U.S. strategy for global development.

Secretary Tillerson, USAID Administrator Mark Green, Members of Congress and Administration officials should prioritize a comprehensive global development strategy that feeds into a broader national security strategy, alongside diplomacy and defense. It is imperative to the success of programs like PEPFAR and shows responsible, thoughtful use of American taxpayer money.