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International AIDS relief program, at 20, looks to next steps
Saturday marks a major milestone in the global fight to eliminate the AIDS epidemic, as the U.S. President's Emergency Plan for AIDS Relief celebrates its 20th anniversary as the largest commitment by a country to combat a disease.
PEPFAR, launched under then-President George W. Bush, has now spanned four administrations, operates in more than 50 countries, and has helped increase access to HIV prevention tools and treatment.
It's also reduced transmission and progression of the disease and, with the help of new pre-exposure prophylaxis and antiretroviral drugs, reduced deaths globally. Since its inception, the U.S. government has invested more than $100 billion, with the program estimated to have saved 20 million lives globally.
And it's moving the world toward a larger goal: In 2016, United Nations member states, including the U.S., committed to ending the AIDS epidemic by 2030.
Parts of the PEPFAR program are up for reauthorization this year, giving policymakers a new opportunity to examine how to achieve international goals amid competing global health priorities, local policy changes and stigma against at-risk populations. The program has historically seen strong bipartisan support.
In the U.S., the Ryan White Program, housed under the Health Resources and Services Administration, administers HIV programming primarily through state and local grants. It's often touted as the gold standard for domestic health programming.
But the models used successfully in the U.S. may not translate to other countries, and experts acknowledge that there is room to improve the response.
"HIV remains a serious threat to global health security and economic development," wrote Secretary of State Antony Blinken in December as part of a report updating the agency's five-year strategy. "Our progress can be easily derailed if we lose our focus or conviction, or fail to address the inequities, many fueled by stigma and discrimination and punitive laws, that stand in our way,"
The report highlights five main challenges ahead: continuing to identify and treat HIV-positive individuals in the face of changing demographics and populations affected, reducing new HIV infections globally, reducing transmission inequities in PEPFAR-supported nations, improving public health infrastructure and local government partnerships, and combating the effects of other infectious health threats that could thwart progress.
On a Saturday morning in November, the staff at a Bangkok HIV clinic set up for their afternoon stream of patients. Rainbow Sky Association of Thailand, RSAT, is a Thai community group that conducts outreach for populations at-risk for HIV—primarily serving gay men and transgender women.
The group's Bangkok clinic—one of five nationwide—and office are situated in a multistory building on a bustling street. Downstairs, patients can get tested for HIV or referrals for treatment. On the second floor, technicians process tests for HIV and other sexually transmitted diseases.
Phubet Panpet, RSAT's deputy director, speaking through a translator to CQ Roll Call, said the group works with 100 volunteers and uses outreach through social media and advertising in Thailand's gay saunas to advertise that people can get stigma-free health care at the clinics.
In 2021, it saw about 6,000 people—some as young as 15. About 10% of RSAT's clients are migrants from neighboring Myanmar, Laos and Cambodia.
In Thailand, PEPFAR has helped contribute to AIDS-related deaths dropping by 65% and new infections declining by 58% since 2010, according to the Joint United Nations Programme on HIV and AIDS. Thailand in 2016 became the first country in the region to eliminate mother-to-child HIV transmission.
While the RSAT clinic provides other services—condom and harm reduction distribution, STD testing, hormone level testing, counseling groups—Panpet said most patients visit them to access HIV testing and PrEP, which can help prevent HIV transmission.
RSAT has received funds from PEPFAR and United States Agency for International Development as part of Thailand's efforts to reduce HIV transmission. Its goal for 2030 is to reduce HIV transmission to under 1,000 new cases per year, decrease AIDS-related deaths to under 4,000 per year, and counter discrimination against HIV-positive people.
Som, a 38-year-old male sex-worker from Ayutthaya who is being identified under a pseudonym because sex work is illegal in Thailand, moved to Bangkok when he was 19 to attend university. His father pressured him to be a high achieving student, but he slowly shifted to working in bars and using drugs, primarily injectable forms of speed and methamphetamine.
Som has now been HIV-positive for many years and said he initially connected with RSAT for HIV testing, later connecting for treatment through the organization. He now visits with a doctor four times a year for his medications but rarely tells people that he is HIV-positive.
He said he continues to always use condoms with clients—but sometimes clients refuse.
Thailand has reduced its rates of new HIV infections and AIDS-related deaths in part by covering the cost of antiretroviral drugs to HIV positive individuals. But now, groups like RSAT face a new obstacle.
Last November, Panpet said RSAT planned to shift from international funding to using domestic financing from Thailand's National Health Security Office.
But in December, Thailand's Ministry of Public Health announced a new policy to limit the ability of clinics like RSAT from distributing PrEP and PEP, or post-exposure prophylaxis, which reduces transmission after exposure.
PrEP, which the Food and Drug Administration approved in 2012, as well as advancements in and access to antiretroviral treatments like the once daily table Atripla in 2006, were widely credited in reducing HIV-related morbidity and mortality in the U.S.
The Thai policy, which went into effect in January, blocks private health care services from dispensing either of the two drug regimens for free. The medications would still be available at no cost through public hospitals.
All Thai citizens are covered under the country's three-pronged health care system—civil servants and their families are covered through one system, private company workers are covered through social security and most others through its universal coverage program.
But patients who rely on clinics like RSAT and HIV experts worry this new policy change could be a roadblock in the country's HIV-related goals by eliminating this point of access to these medications.
The United States aims to reduce new HIV infections by 90% by 2030. The domestic epidemic disproportionately affects gay and bisexual Black and Latino men, as well as transgender women who have sex with men and users of injectable drugs.
HRSA Administrator Carole Johnson said the agency has been an important PEPFAR partner because of its work implementing the Ryan White program to people living with HIV in the U.S.
"We've had tremendous success in helping people to get to viral suppression," she told CQ Roll Call. "But there are many people who we continue to need to get into care, and so those strategies that we're using domestically are also applicable to the work that we're doing internationally."
In 2016, a consortium of the four historically Black medical schools—Charles Drew University of Medicine and Science, Howard University of Medicine, Meharry Medical College, and Morehouse School of Medicine—established a program to connect hard-hit African nations with some of the best domestic approaches for HIV prevention and treatment.
The partnership is supported through PEPFAR and began implementing HIV services in October 2020 to help Zambia and Malawi reach their UNAIDS targets.
Patricia Matthews-Juarez, senior vice president of the Office of Faculty Affairs and Development at Meharry and project director for the HBCU-Global Health Consortium, said the overall transmission HIV rate for moms and babies in sub-Saharan Africa is about 11%, compared to less than 1% for their four flagship clinics in Zambia. And almost 100% of the moms and babies treated in those clinics are now virally suppressed.
She said the program employs 450 people, including local HIV-positive mothers with little education for peer support.
While HIV-related stigma remains a huge issue globally, it's also an issue domestically.
"I think that public perception might generally be that we have made real progress on stigma in the U.S. and to some degree, we certainly have, but, there are many people who are either HIV-infected or at risk, who are not in care. And some of the reasons that they're not in care is because of stigma," said HRSA's Johnson.
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