Pepfar Watch

COVID-19 Emergency Supplemental Spending and the U.S. Global AIDS Response

Original blog available on the Health GAP website here

Summary: As of September 30, 2020, PEPFAR was supporting access to HIV treatment for nearly 17.2 million people, has enabled 2.8 million newborns to be born HIV-negative, and in 2020 supported HIV testing and counselling for nearly 50 million people. PEPFAR has the power to help deliver the end of the AIDS pandemic by 2030 if it is fully funded and held accountable to the goals and priorities of civil society. At least $1.4 billion for PEPFAR and $4 billion for the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund)​ is needed as part of the COVID-19 Supplemental Spending Bill, to ensure rapid restoration of HIV prevention and treatment services to levels seen prior to COVID-19 to mitigate the harms COVID-19 responses have already caused.

“While PEPFAR and partner programs have shown remarkable resilience in the context of COVID-19, its impact on HIV, tuberculosis (TB), and malaria prevention programs has been devastating. These programs were among the first and hardest-hit by COVID-19, and the pain has been particularly acute for women and children as well as other vulnerable and marginalized populations.” — PEPFAR World AIDS Day Statement, December 1, 2020

The Intersection of the COVID-19 and HIV Pandemics

UNAIDS estimates COVID-19 responses have resulted in at least a 50% decline in the rate of HIV treatment scale-up.1​ ​Even before the COVID-19 pandemic, nine years of virtually flat funding to PEPFAR has​ ​undermined the scale-up​ ​of evidence and human rights-based treatment and prevention programs. The decisions of the new Congress over the next four years represent the last chance to put the AIDS response on track in order to attain the global goal of eliminating HIV as a global public health threat by 2030.

COVID-19 has had far-reaching implications for PEPFAR and Global Fund-funded responses to global AIDS. The number of new people enrolled in treatment during FY19 Q3 compared with FY20 Q3 declined by 20%.

Evidence from PEPFAR Quarterly program performance data as well as community-led monitoring (CLM) reveals further serious disruptions to HIV treatment and prevention as well as a range of harms to communities most affected by HIV. These include attacks on LGBTQ communities, sex workers, and people who use drugs2​ ​under the guise of COVID-19 control measures; spikes in maternal deaths;3​ ​and dramatic increases in cases of violence against women and girls.​4

A recent assessment carried out on the effects of the COVID-19 response in Uganda on pediatric HIV treatment access reveals grave strain on caregivers who were unable to feed their families, get medicine refills, or seek care at clinics because of movement restrictions enacted with little or no support for people living with HIV. Many HIV positive women reported treatment interruptions as a result. Between Quarter 2 and Quarter 3, there was a 24% increase in the number of people treatment facilities reported having lost clinical contact with, a​ 31% drop in HIV treatment initiation, and a drop-in community viral load suppression from 67% in Q2 to 62% in Q3.​ ​5​ In Kenya, Zimbabwe, Uganda, and many other countries, governments’ COVID-19 responses interrupted healthcare access for pregnant and breastfeeding women, with dire consequences ranging from unsafe delivery to preventable maternal and newborn death. The withdrawal of community support services provided through PEPFAR-funded DREAMS programs in Kenya have increased the vulnerability of young women seeking effective HIV prevention services and support.

COVID-19-Proofing the HIV Response

Although in some countries COVID-19 restrictions have eased, access to COVID-19 vaccines is far off for most PEPFAR countries, and “COVID-19-proofing” the HIV response is still required for adults and children. Across sub-Saharan African countries, communities are reeling from the impact of COVID-19 induced economic hardship. They require unprecedented support in order to be able to prioritize their health needs. In addition, restrictions could surface again at any time—and programs must invest in more robust and accountable responses that preserve and protect treatment and prevention access, instead of putting adults and children with HIV in harm’s way.

HIV testing under PEPFAR is down nearly 40% over 2019, and in some countries have seen a 25% decline in the number of HIV positive pregnant women accessing services to prevent HIV transmission to their newborns. We’ve also seen a worrying 25% decline in HIV treatment initiation across many age groups. Voluntary Medical Male Circumcision (VMMC) over one year fell 74% due to the lockdowns and we are seeing similar declines in DREAMS programming for adolescent girls. The situation is dire, particularly as FY21 will be the first full year we will feel the impacts of COVID-19 on life-saving HIV programs. PEPFAR programs are resilient and yet the financial programs that support them are not.

When properly resourced, PEPFAR also holds great promise as a platform that can provide uninterrupted essential HIV prevention, testing, and treatment services while also supporting countries’ COVID-19 responses. PEPFAR can mitigate some of the adverse effects of COVID-19 on HIV services and PLHIV themselves by building upon lessons learned through 17 years of hard-fought gains. Its responsive, data-driven efforts are saving lives — but they require sufficient funding to continue to do so.

1 ​UNAIDS. ​Prevailing against pandemics by putting people at the centre — World AIDS Day report 2020

2 ​See: ​Ugandan LGBTI community left vulnerable in pandemic lockdown​ and
Uganda’s COVID-19 Response is Terrorizing Women with Arbitrary Detention, Blackmail, and Violence
3 ​HIV and Human Rights Activists’ Open Letter to the World Bank: COVID-19 Response in Uganda is Killing Pregnant Women
4 See: ​Is Covid creating human rights crisis in Uganda?​ and ​A transport ban in Uganda means women are trapped at home with their abusers

5 Presentation: “PEPFAR Uganda FY30 Quarter 3 Performance Highlights.” Slides 18-19.