(Originally posted on Medium.com)
President Donald Trump included a chilling proposal last week in his request for the as yet unresolved 2017 federal budget: slash funding for the wildly successful and bipartisan-backed President’s Emergency Plan for AIDS Relief (PEPFAR) by $300 million and "begin slowing the rate of new patients on treatment in FY 17." While many policymakers are dismissing the possibility that this proposed budget will pass through Congress, advocates nevertheless have every reason to be deeply concerned. This dangerous proposal is likely a harbinger of more grave harm to come. What could be a worse strategy for combatting the world’s leading infectious disease killer than slowing the expansion of treatment that not only saves lives but also prevents HIV transmission?
After the White House 'skinny budget' for Fiscal Year (FY) 2018 appeared to spare global AIDS programs, this bait-and-switch sends a strong signal: PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria are far from safe from Trump’s attacks. Nevertheless, despite the mixed message the White House is sending to lawmakers, funding levels are ultimately decided by Congress, and AIDS advocates must demand they publicly reject this deadly policy shift.
This mirrors one of the biggest mistakes of the early Obama administration, when officials started talking about HIV treatment as a "mortgage" that needed to be curtailed. As we documented at the time, the administration pulled back from investing in HIV treatment and we lost significant ground -- leading not only to many avoidable deaths, but to many new infections. In 2009, PEPFAR directed service providers in Uganda, for example, to cap new HIV treatment enrollment, resulting in treatment wait lists and catalyzing a crisis in the AIDS response. This came even as evidence increasingly showed that HIV treatment is among the most effective methods of preventing HIV transmission -- as effective as using condoms. This failed policy contributed to a stalling of the response and, for the first time in several years, new infections globally did not decrease at all. After strong protests by AIDS activists, students, and clinicians in the U.S. and Uganda, a year later the deadly policy was reversed.
Now Trump is proposing to repeat these mistakes. The global AIDS response is finally within sight of halting the disease, with new infectious dropping in large part because of the increasing portion of people living with HIV who are on effective antiretroviral treatment, which halts HIV transmission. Trump’s proposal to slash PEPFAR’s current year budget signals a dangerous diversion in the global AIDS response that will come at a great cost - in lives and in dollars. In May, the White House will issue its full budget proposal for the 2018 budget, and the language in its ‘skinny budget’ proposal that PEPFAR should be funded to “maintain the current treatment levels” points to a surely significant slash in PEPFAR funding for the needed continued expansion of people in HIV treatment.
Not only would denying lifesaving treatment for people with HIV be immoral, it would also be fiscally irresponsible. A $300 million cut translates to roughly 600,000 fewer people getting into treatment this year alone and the epidemic would continue to rise, just when we can end it within 15 years with a modest scale-up. In South Africa alone, according to projections by Dr. Rochelle Walensky, Professor of Medicine at Harvard Medical School, a $300 million or 7.5% cut would translate to 900,000 additional deaths and 500,000 new HIV infections. This approach is completely paradoxical to the strategy required to save both lives and money.
Instead, we need to implement UNAIDS’ globally endorsed strategy to ensure 90% of people living with HIV are diagnosed, 90% have treatment, and 90% achieve viral suppression. In Malawi, Zimbabwe, and Zambia, for example, new evidence shows this approach is working--with lower rates of HIV than expected due to high HIV treatment coverage. To achieve this strategy, we need to close a global funding gap of $6 billion per year, and continue our historic leadership by providing one-third of the necessary increase - an increase of $2 billion per year by 2020. In South Africa alone, this investment would result in 2 million fewer HIV transmissions, and 2.5 million fewer deaths relative to current funding rates.
The choice is clear: we can end the HIV epidemic by 2030, or we can forever keep underfunding the effort, costing millions more human lives and billions of dollars.
Once again, as we have in the past, AIDS activists need to come together to push Congress to vocally reject both the FY 17 White House request now, and any future treatment caps from the full 2018 White House request expected in May. This is a key moment to show our power as a movement. Congress will take a two week recess from April 10-21. We need to show up at local offices and demand that they follow through on the U.S. commitment to end the epidemic. To lead or join a district level contingent demanding a meeting and a promise to fully fund PEPFAR, please sign up here. We cannot stand by and let people die when we have the tools, the science, and the resources to end AIDS.