Anti-gay law erodes Uganda’s gains in HIV fight ­PEPFAR chief

It has been 20 years since President George W. Bush announced PEPFAR during his 2003 State of the Union address, as a global effort to combat HIV and the largest global health programme devoted to a single disease. What have been the achievements of PEPFAR in those 20 years?
 
In 20 years, it has saved over 25 million lives and prevented 5.5 million children from being born with HIV. PEPFAR has provided lifesaving therapy to more than 30 million people, provided more than 65 million tests so that people can know their HIV status and has supported about 3 million adolescent girls and young women mainly across Africa to avoid being infected with HIV. Institutionally, about 3,000 laboratories, 70,000 health facilities and 340,000 health workers have been trained and these assets have also been used to fight other emerging pandemics such as Ebola, Marburg, and Covid-19. 

However, that is not to say that the HIV epidemic is over. Last year, about 1.2 million new infections were recorded world over. So, while we have made a lot of progress, a lot of work still needs to be done to maintain the fragile gains that we have made.

2030 is projected to be the year when HIV will stop being a public health threat. How do you hope to achieve this landmark with the high number of new infections globally?

The United States is committed to working with the world and partner countries to bring HIV to an end as a public health threat. There are things we need to focus on if we are to sustain the gains so far achieved beyond 2030. One is political sustainability; we need to make sure HIV is brought back up the radar screen of the political leadership in partner countries. We also need financial sustainability if we are to increase funding of the HIV response. 

When President Museveni signed into law the Anti-Homosexuality Act 2023, there was a lot of talk about PEPFAR cutting funding to Uganda. Don’t you think this will reverse the gains you have made in this country? Why target people living with HIV, who had nothing to do with the passing of this Act?

Uganda has been a leader in the fight against HIV since the beginning and President Museveni has been an exceptional leader in that regard, and it is thanks to his openness about the disease. Political leadership matters in fighting any pandemic. Our concern with that Act, though, is that the gains that have been made in the country over the years in fighting HIV. You know what the prevalence of HIV in Uganda was in the mid-90s. You saw first-hand how the coffin market was flourishing.
 
Now, the fight against HIV will not be won unless all populations in the country have the right to access HIV services and the law (Anti Homosexuality Act) will do just the opposite. It is going to inhibit priority populations that should have the right and priority to access quality services. As PEPFAR was in the process of organising Uganda’s Operational Plan, we became aware that the Bill was going to Parliament.

 We felt it safe to first pause and see what the Bill would look like. Now, we know what the Act looks like and it is regrettable that the President signed it. Together with the Global Fund and UNAIDS, we sent a letter to the President expressing our deep concerns and regrets. 
We will continue to review our actions in the context of the US government’s response to what that Act means. So, we are not penalising people. We are taking steps to make sure that our actions are aligned with those of the US governments.

What challenges is PEPFAR facing? 

As we approach the last mile (2030), the big challenge is the young people who think they cannot get HIV. They did not see the ugly face of HIV in the 1980s and 1990s. Most of the new infections are among young people in Africa. Outside Africa, the highest infection rates are among young men who are having sex with men. However, HIV is not only a health issue. It is also a developmental issue because over the last 20 years, countries that have taken HIV seriously and worked with PEPFAR have seen their GDP increase by 2.1 percent. HIV is also a security issue because it is mainly affecting young people.  If the young people are taken away by this disease, who will develop the continent?

We are also now facing the challenge of structural barriers and policies across Africa, like these laws in Uganda, which are making it difficult for people to access treatment and services. We had a similar problem in South Africa some years ago, with (former) President (Thabo) Mbeki and his Minister of Health, (Mantombazana) Shabalala preaching the use of garlic (and beetroot) to treat HIV. That was the darkest moment in the fight against HIV. That negative influence on the neighbouring southern African countries where the burden of HIV was massive had a generational effect. 

 What lessons PEPFAR has learned so far?

Over the years, we have learned that good politics and good public health programme implementation save lives. It has taken at least two decades to transform and shape the way we respond to this terrible disease. We should always be prepared for the long haul because it is all about partnerships with the US and other governments.