Here Are Some Pros and Cons of the PEPFAR Program

For those of us who remember well the 80s and 90s, the current progress made in the battle against HIV/AIDS is nothing short of miraculous. As recently as 1999, the World Health Organization announced that HIV/AIDS was the fourth biggest cause of death worldwide. Since that time, the United States has led global efforts to reduce and eventually eradicate HIV/AIDS. Programs such as the President’s Emergency Plan for AIDS Relief (PEPFAR)—a bipartisan program launched by President George W. Bush and since renewed multiple times—set aside vast sums of money and resources to combat the epidemic. In 2011, these and other efforts paid off when the first person was declared cured of HIV. In President Trump’s recent State of the Union Address, he called for a renewed campaign to end the spread of HIV and declared the end of the epidemic by 2030 a high priority for his administration. While full details of new plans are still emerging, and there are some questions and concerns regarding how the possibility of eradicating HIV/AIDS remains a tantalizing and important global objective.

In December of 2018, President Trump renewed the PEPFAR program through 2023. This program doubles down on the decades’ old efforts to eradicate HIV/AIDS by ensuring billions in annual funding and technical support for proven treatment and prevention efforts. To date, PEPFAR is credited with saving well over one million people and, critically, doing so cost-effectively. PEPFAR is the largest single-disease health initiative in the world and provides support for 14.6 million people currently both in and out of the United States, and its impact cannot be overstated. Between 2004 and 2007, PEPFAR reduced the HIV death rate in supported African countries by 10.5% and did so at the cost of only $2,450 per life saved. But the impact doesn’t stop there. PEPFAR is estimated to have spared 8.9 million children from becoming orphans and has an enormous impact on improving mortality rates globally.

PEPFAR relies on proven, current treatments—such as Antiretroviral Therapy (ART) and Pre-Exposure Prophylaxis (PrEP)—that offer significant breakthroughs both in improving and extending the lives of those infected with HIV/AIDS but also in reducing transmission. PrEP—a once-daily medication taken by uninfected, but at risk, individuals—significantly reduces the risk of infection from infected sexual partners, particularly when that partner is actively using ART medications. However, the proposed changes to Medicare Part D puts progress in these areas at risk.

Changes to Medicare Part D would allow insurers to place additional guidelines and requirements on accessing these vital drugs and could have a negative impact on controlling costs. Under the proposed changes, insurers could require patients to obtain prior authorization before obtaining medications causing delays and additional hurdles for patients in need. Not only could these changes discourage patients from seeking access to medications, but it could also delay the onset of treatment with the compounding effect of delaying viral suppression and therefore potentially boosting transmission rates. Additionally, with greater insurer control over medications and authorization, there is a risk that insurers could require step therapy programs where individuals are required to attempt older, less effective, and less expensive treatments before accessing proven, more up-to-date, and doctor and patient desired approaches. Other programs, such as the Ryan White HIV/AIDS Program that provides support and medical care to low-income people living with HIV who are uninsured or underserved, also find themselves at risk of budgeting constraints and reprioritization efforts that threaten to shift funding to other priorities.

HIV/AIDS remains a critical threat to the global community. Currently, there are approximately 37 million people living with HIV/AIDS with another two million newly infected individuals annually. Even today, roughly 1.1 million people will die from HIV/AIDS this year. While we continue to make significant progress in treatment and prevention with programs such as PEPFAR, there are still underlying risks to changing priorities and guidelines in dealing with the disease. Though the goal of defeating the epidemic by 2030 is admirable and within grasp, it will take the combined will and efforts of all individuals to achieve.

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