Trump pauses global funding for key health programme but allows HIV drug access: What is PEPFAR, how does it impact India?

This is significant considering that the PEPFAR programme directly supports the treatment of over 20 million people — nearly two-thirds of all the people living with HIV globally — across 55 countries. Most of the countries that receive support for continued anti-retroviral therapy (ART), a combination of drugs that prevent the HIV virus from replicating in the body and allowing the immune system to repair itself, are in Africa.

While the US programme also works with India’s National AIDS Control Organisation, it does not support key interventions such as testing and treatment. Experts, therefore, say that the impact is unlikely to be significant within India.

First, what is PEPFAR?

PEPFAR is a US initiative that works with partner countries towards achieving HIV/AIDS control through various interventions such as providing life-saving ART, increasing testing, educating people and strengthening health systems. The programme was launched during the tenure of George W Bush in 2003 but has enjoyed bipartisan support so far. It has so far invested $100 billion in global HIV response. “PEPFAR is the largest commitment by any nation to address a single disease in history,” according to its website. Other than providing ART to 20.6 million people, the programme has also provided HIV testing services to 83.8 million.

Importantly, the programme has provided access to pre-exposure prophylaxis — a medicine that can prevent HIV infection — to 2.5 million people globally. PEPFAR accounts for nearly 90% of PrEP initiations globally, including through its programme SafeZindagi in India.

Why was the programme halted?

The 90-day funding freeze was meant for all foreign assistance from the US, not just PEPFAR. The Department of State says it is meant for evaluating the efficiency of such aid programmes. “The 90-day pause in United States foreign development assistance is for assessment of programmatic efficiencies and consistency with United States foreign policy,” the executive order said.

Will there be an impact in India?

Yes, but not widespread. PEPFAR funding in India comes mainly through projects such as Accelerate, Sunrise and Sunshine. Launched in 2016, project Sunrise has been supporting the activities of the State AIDS Control Societies of the northeastern states. The project also demonstrated innovations that were later included in the national programme, such as revamped strategies for reaching out to the high-risk group and lower threshold for providing opioid substitution therapy to injection drug users.

“Almost all of the ART and testing services in India are provided by the government through domestic funding, so these services are unlikely to get affected. PEPFAR usually runs trial projects and tests innovative strategies. They also provide technical assistance to the programme — this is where an impact might be felt if the funding is stopped,” said an official working with the country’s AIDS control programme. Another expert agreed, stating that the impact will mostly be restricted to trials and surveillance activities.

The Accelerate programme works on engaging vulnerable populations and connecting them to the preventive and treatment services in 33 districts across six states — Maharashtra, Andhra Pradesh, Manipur, Mizoram, Nagaland, and Telangana. A virtual outreach SafeZindagi, supported by Accelerate, was connecting people to at-home testing, public and private testing centres near them, pre-exposure prophylaxis, as well as treatments at public and private ART centres. The website, which could be used to order home testing kits, is “temporarily unavailable” at present.

Project Sunshine was launched in 2020 with the aim of implementing innovative strategies to scale up treatment and prevention to achieve epidemic control in the states of Manipur, Mizoram, and Nagaland, according to the latest available 2021-22 report of NACO.

“Though India is not exclusively on PEPFAR funding for its HIV/AIDS programmes, unlike the African countries, any freeze in global health funding can have sizeable ripple effects on ongoing efforts to control and reduce the spread of HIV,” said Dr Ishwar Gilada, Consultant in HIV and Infectious Diseases and a Governing Council Member, International AIDS Society and its lead for Asia and the Pacific.

What about funding for India’s AIDS programme?

“When it comes to India’s HIV/AIDS budget, the PEPFAR’s contribution is minuscule and the Indian government can overcome the impact by allocating little extra in the forthcoming budget session,” he adds. While latest figures are unavailable, a break-up of the funding for the HIV/AIDS programme in 2017-18 shows that 72.2% came from the government of India, 5.6% from PEPFAR, and 22.2% from the global fund.

However, Dr Gilada anticipates that the cost of ART will go up. “About 90% of ART medicines provided to high-burden countries in sub-Saharan Africa come from Indian pharmaceutical companies. Since the batch size of the medicines will be reduced, the cost of ART medication is likely to go up,” he says.

What is the burden of HIV?

Over 25.4 lakh people in India were living with HIV, according to the latest India HIV Estimates 2023. The incidence — or the number of new HIV cases — has dropped to 0.05 per 1,000 uninfected population. There were an estimated 68,451 new HIV cases in 2023, showing a decline of 44% between 2010 and 2023. There were 35,866 AIDS-related deaths in the country in 2023, a decline of 79.2% between 2010 and 2023, according to the report.

The highest incidence of HIV was in Nagaland, Tripura, Punjab, Meghalaya, and Arunachal Pradesh.