[KIGALI, SciDev.Net] Global health leaders cautiously welcomed a decision by US lawmakers to restore funding for the President’s Emergency Plan for AIDS Relief (PEPFAR), stressing the need for more sustainable funding amid broader aid cuts.

Proposed cuts of US$400 million to PEPFAR were spared from the Trump administration’s efficiency drive following votes in the Senate on Tuesday (15 July) and House of Representatives on Friday (18 July).

The funding was part of a US$9.4 billion finance package already allocated to projects including media and foreign aid programmes that the Trump administration was seeking to claw back under its “America-first” agenda.

The revised package also spares some funding for maternal health, malaria and tuberculosis.

Since its inception in 2003, PEPFAR has provided 20 million people with antiretroviral drugs and saved an estimated 25 million lives.

“PEPFAR has been one of the greatest success stories in global health, transforming the HIV response,” said Beatriz Grinsztejn, president of the International Aids Society (IAS) at its flagship conference in Kigali, Rwanda, last week.

“Global advocacy played a crucial role in persuading US lawmakers to protect this vital programme, reminding them that decisions about PEPFAR shape the health and futures of people around the world.”

Grinsztejn, however, warned that “uncertainty remains, with ongoing threats to global health funding”.

“We must stay vigilant,” she added.

In Uganda, where over 1.5 million people are living with HIV, the US had invested US$3 billion in the PEPFAR programme since 2004. As a result, 742,000 HIV-positive people are receiving antiretroviral drugs, while 6 million pregnant women were tested for HIV last year.

“The decision to restore PEPFAR funding is a major boost for Uganda’s public health,” Daniel Kyabayinze, the country’s director of public health, told SciDev.Net.

“This programme has been the backbone of our HIV/AIDS response for two decades.”

Kyabayinze noted that since its establishment in Uganda, the programme has led the country’s HIV response, supporting prevention and treatment, and strengthening health systems to put Uganda on track to meet the UN’s 90-90-90 targets for ending AIDS as a public health crisis by 2030.

But he says the PEPFAR funding freeze implemented by the US in January as part of a 90-day suspension of US foreign aid funding was a wake-up call, exposing Uganda’s fragile health programmes.

“The impact of even the threat of withdrawal was severe,” added Kyabayinze.

“We were forced to reprogram parts of our domestic health budget and pause low-priority activities.

“It challenged us to think about how to make our HIV response more sustainable.”

For 23-year-old Gyslain Masonga from Nyamirambo, Kigali, the decision by US lawmakers could not come too soon.

For the last two years he has depended on the preventative medication PrEP for protection because his girlfriend is HIV positive.

However, after the PEPFAR funding freeze, Masonga could only take his medication when he could afford to buy it himself.

“I love my girlfriend so much, I can’t leave her. Doctors told me that I have to take my pills … or else I will also get the virus,” Masonga told SciDev.Net during a field visit to the Health Development Initiative in Rwanda, a healthcare non-profit organization, this week.

Masonga said he used to get the drug free of charge but that changed in March due to the funding cuts. He now spends 3,000 Rwandan Francs (US$3) a week on the drugs – a large sum for a casual worker in Rwanda.

The bipartisan removal of the PEPFAR cuts marks a significant policy reversal according to global health experts at the IAS conference.

The IAS welcomed the decision and called for swift action to protect essential HIV services. It urged all country leaders to ensure continued investments to save lives and support global health.

IAS president-elect Kenneth Ngure emphasised the importance of the decision for the African continent.

“PEPFAR is a lifeline for communities across Africa,” he said ahead of the final vote. “Restoring this funding would mean hope for people living with and affected by HIV.

“But African leadership must remain at the centre of shaping our response, and we need to keep advancing conversations about sustainable financing — including stronger domestic investments and strategies to reduce dependence on global donors.”

Linda-Gail Bekker, former IAS president and director of the Desmond Tutu HIV Centre at the University of Cape Town, in South Africa, said PEPFAR’s preservation is likely to save 600,000 South African lives from HIV infection in the next ten years.

“This is the best news ever,” she told the conference.

“I’ve said this before, and I’m going to say it again, PEPFAR is the most important and consequential contribution to public health, certainly in my lifetime, and probably ever. That it is not going away in its entirety is a victory for all who’ve advocated for it.”

She urged countries to safeguard the last mile activities of finding people who are not yet in healthcare services, and to ensure that people who are already in treatment programmes can access their treatment without interruption.

“And it’s very important not to leave behind key and vulnerable populations, because these are the components of this epidemic that will continue to undo our goal to end the epidemic as a public health threat,” Bekker added.

This piece was produced by SciDev.Net’s Global desk.