By now, most readers know that PEPFAR—the U.S.’s global HIV program—was shut down soon after President Trump put a 90-day freeze on all foreign aid the day he was sworn into office in January. Despite a “waiver” for lifesaving resources, most of PEPFAR’s operations remain closed, prompting fear and confusion over what could happen to domestic HIV programs such as Ryan White, and the Ending the HIV Epidemic initiative, which was started during the first Trump administration.
Apart from the court battles to preserve foreign aid, PEPFAR is at the mercy of several deadlines as Congress wrangles with the federal budget. Lawmakers must come up with a fiscal 2025 federal budget, or at least a temporary budget—known as a continuing resolution, or CR—by March 14 to avert a government shutdown. If any part of the government is still funded by a CR by April 30, mandatory across-the-board spending cuts, known as “sequestration,” will kick in.
PEPFAR faces its own deadline for renewal. Congress must reauthorize the program by March 25, or PEPFAR’s budget could be cut by as much as 25% and have severe limitations placed on its mission. In fiscal 2024, PEPFAR’s budget was $6.5 billion.
To understand the implications of these challenges, POSITIVELY AWARE spoke with Jirair Ratevosian, who became chief of staff for PEPFAR in 2022. After leaving PEPFAR to run for Congress in 2023, he is now a senior associate of the Global Health Policy Center at the Center for Strategic and International Studies. Ratevosian had also served as a legislative director to U.S. Representative Barbara Lee (D-California), helping to establish the bipartisan Congressional HIV/AIDS Caucus in 2011.
© Sean Black
What does the road ahead look like for PEPFAR and U.S. HIV programs in general?
We need to be clear-eyed in understanding that foreign aid will not be the same and PEPFAR will not be the same in the future. Funding levels will likely not be the same as they were before—PEPFAR funding had been stagnant for at least 10 years. This Congress is in cost-cutting mode. They’re going to be taking billions out of the budget for domestic and global HIV programs without any understanding of the consequences. It’s going to be on us to explain the ramifications of those efforts, but then also be smart about responding in a way that protects all the things that we know are working that are keeping people alive.
I think we’re facing a future where we’re not going to be able to to put every person who needs HIV treatment on treatment. We're not going to be able to rapidly broaden PrEP access in the way it needs to. These will be missed opportunities as a result of shortsighted foreign aid freeze.
It’s challenging, because we have prevention options that are highly effective, easy to tolerate and are desired by people, like injectable PrEP that are hopefully a few months away from FDA approval. [While Apretude is an FDA approved injectable form of PrEP, consisting of two shots administered every two months, lenacapavir, a drug already approved as a component of HIV treatment for heavily-treatment-experienced patients, has been tested for PrEP as a shot given every six months and is expected to be approved later this year.] PEPFAR signed a supply agreement with Gilead Sciences [the maker of lenacapavir] in December to supply lenacapavir, after FDA approval, to PEPFAR countries. That was a remarkable breakthrough. Lenacapavir was going to be available to PEPFAR programs at the same time as it would be available in the United States. At the moment, I’m unsure if that’s realistic given how the administration is handling the foreign aid freeze.
Can PEPFAR, or the U.S., back out of its lenacapavir agreement?
If there's no HIV prevention happening, then there's no implementation of a supply agreement. That’s the reality. I’m hopeful that coming out of this 90-day review period, there will be a realization that prevention efforts are critical to controlling the HIV epidemic. Public health officials already know this. We need to convince administration leaders and more policymakers. I'm hopeful that after the 90-day review period, which is around the same time that PEPFAR needs to be reauthorized, that we not only continue prevention efforts, but we double down on prevention because we need PrEP access to triple if we want to make an impact on incidence.
What are the chances of PEPFAR being reauthorized?
Last year, we got a one-year PEPFAR reauthorization. Before then we that, we had received two five-year reauthorizations. I continue to remain hopeful, based on the statements we've heard from congressional leadership, that PEPFAR reauthorization will be prioritized. This is an opportunity for us to to have a hard look at the program and to emphasize the things that are working and drive the reforms that will be necessary to sustain the program for the future.
Even if it’s not reauthorized, it doesn't mean the program is going to stop. [The] Ryan White [HIV/AIDS Program] has not been reauthorized for a number of years, but the services continue.
What would PEPFAR look like if it’s not reauthorized?
It would lose its budget earmarks, controls on its budget that set its priorities. For example, 50% of PEPFAR’s budget is earmarked for HIV treatment and related services—that earmark condition would not be extended. Part of PEPFAR’s reauthorization is also related to its contribution to The Global Fund, which is the multilateral HIV, TB and malaria effort that PEPFAR and the United States Government contributes towards. But for the most part, PEPFAR operations will continue so long as there's congressional appropriations for the program. But there are major questions about what levels of funding PEPFAR, or any global health program, will receive. Anyone who's observing Capitol Hill can tell you that we're entering a budget-cutting environment where it's conceivable that PEPFAR could be cut by $1 billion, if not more.
U.S. Rep. Jamie Raskin addresses demonstrators at a rally in front of the now-shuttered USAID headquarters. (photo: Jirair Ratevosian)
Has bipartisan support of PEPFAR in Congress changed?
There are a number of Republican senators who have come out in support of PEPFAR in recent weeks. Some of them have had positive statements about PEPFAR and its lifesaving mission. What I think has changed is the number of bipartisan members who are willing to speak up. I think that's shrinking, and that's worrisome, because the number of members of Congress who were around when PEPFAR started [in 2003], that's gone down to only a handful now. There are less and less people who understand its real impact to save lives.
There’s less awareness about how foreign aid in general greatly benefits us. Foreign aid spending pays off in dividends that are multifold in the sense that we put people on lifesaving treatment, we keep kids alive by nutritional support, by malaria-preventing efforts like bed nets and we support humanitarian efforts around the world. All of that helps advance foreign policy and helps advance diplomacy. It’s soft power that has influence that military spending can’t buy. You get all that for less than 1% of the federal budget. I don't think there's any other budget element that has those kinds of dividends.
AIDSWatch [the HIV lobbying effort to Capitol Hill organized by AIDS United] is coming up at the end of March. Are you going?
I've been going for many years. I think it's going to be the biggest and probably most impactful AIDSWatch in a long time. A couple years ago, Republicans in Congress had proposed nearly $800 million in cuts to the Ryan White program. Because of the power of AIDSWatch, advocates were able to reverse that. I'm excited to see the reenergizing of HIV activists in Washington now.
I hope that we take a broad view in terms of the kinds of conversations that we want to have with lawmakers. Focus on engaging all lawmakers—new lawmakers, in particular, from conservative states. Talking about why these programs are important to their states, and how they save lives and how they're efficient, will be important. We also have to do a better job of talking about the importance of the private sector, in not only enabling an effective HIV response, like with new innovations, but also how our HIV programs support U.S. business interests. We shouldn't be ashamed to say that, because that's the truth. And as an HIV community, we have to break down the silos between global HIV advocates and domestic HIV advocates. We're all one. HIV is our common denominator. When we go into those congressional offices, we should be talking about Ryan White and PEPFAR in the same sentence.