Is PEPFAR Leaving Behind Key Populations?

MSMGF expresses deep concern about the new PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) launched last week by US Secretary of State, Rex Tillerson

The President’s Emergency Plan for AIDS Relief (PEPFAR) is one of the largest donors to the global fight against HIV, and it is widely seen as one of the most effective and strategic programs the U.S. has ever undertaken. Combined with its investment in global health made to the Global Fund, the United States has a deeply rooted bipartisan, forward-thinking commitment to global HIV treatment and prevention.

While the Trump administration’s proposal of over $1 billion arbitrary cuts to global HIV programs, including PEPFAR, has been rejected so far by the Congress, we are deeply worried that leadership from the U.S. on ending HIV is weakened by a troubling trend to deemphasize key populations disproportionately impacted by the epidemic, including gay men and other men who have sex with men, people who use drugs, sex workers, and transgender people.

The same day that President Trump made remarks praising PEPFAR at the UN last week, Secretary of State Rex Tillerson launched the new PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020). In this publication, Tillerson outlines plans to support a total of 50 countries and to accelerate implementation of the HIV response in a subset of 13 high-burden countries that have the greatest potential to achieve epidemic control by 2020. Notably absent from the strategy is an explicit and tailored plan for curbing the epidemic among key populations.

Key populations are rendered vulnerable to HIV by punitive and discriminatory laws and politically driven policies, creating stressors that exacerbate risk for acquisition and make the problem of HIV worse. The absence of protective laws and policies enable unchecked stigma and discrimination in healthcare and social service settings to persist, and seriously undermine the promise of exciting new developments in the field. Studies have shown that PEPFAR has missed opportunities to explicitly address the role of criminalization in supporting blanket approaches and feeding stigmatizing attitudes; unfortunately, the new PEPFAR Strategy will continue to miss these opportunities.

The 13 prioritized “high impact” countries are Botswana, Cote D’Ivoire, Haiti, Kenya, Lesotho, Malawi, Namibia, Rwanda, Uganda, Swaziland, Tanzania, Zambia, and Zimbabwe. Tillerson’s plan aims to reach 95 percent of people living with HIV who know their status, 95 percent of people who know their status accessing treatment, and 95 percent of people on treatment having suppressed viral loads in these 13 countries over the next three years.

In the 9 of these 13 priority countries, same-sex acts are criminalized, fueling the epidemic by dissuading gay men and other men who have sex with men from seeking treatment and inhibiting health care providers from offering necessary services. Tillerson’s plan for PEPFAR is yet another example of how key populations continue to be left behind in the HIV response. Key populations represent 50% of people living with HIV who are not yet on treatment and collectively comprise 45% of new HIV infections globally in 2015.

 “Meeting accelerated global HIV targets requires targeted investment in programming for key populations. We need PEPFAR to continue playing its crucial role in driving down incidence and enhancing prevention and treatment coverage. The U.S. has a unique role to play in tearing stigma and discrimination, which continue to undermine access to critical HIV services for key populations. At this stage of the global AIDS response, we can’t afford to have the U.S. shrink away from its responsibilities in ensuring NO ONE gets left behind.”  – Dr. George Ayala, Executive Director, MSMGF

Additionally, the list of 13 priority countries selected for additional investment excludes important countries like Mozambique, South Africa, South Sudan, Nigeria, and the Democratic Republic of Congo, which all have significant HIV incidence rates and are dependent on substantial PEPFAR resources for support. The significant gains that these countries have made in recent years will be lost if funding and other resources are diverted just as they are reaching the tipping point towards epidemic control.

PEPFAR must continue to support countries with concentrated epidemics among vulnerable communities outside of the 13 new priority countries. There is little evidence to suggest that local governments will fill in the gap to address the needs of gay men, people who inject drugs, sex workers, transgender women, who are most at risk of HIV. PEPFAR has historically been a substantial and often only supporter of targeted funding for key populations; this must continue in order to achieve the 90-90-90 targets and end the epidemic by 2030.

Finally, and as our partners at Health Gap pointed out in a recent statement, the new plan for PEPFAR is also worrying in that:

  • It does not highlight the dangerous impact of expanding the Global Gag Rule to PEPFAR…
  • It does not call on Congress to increase funding for the global AIDS response…
  • It does not include a human rights component…
  • It calls for increasing engagement with faith-based organizations, which have historically rejected evidence-based strategies…”

In order for PEPFAR funding to be most effective, it is of utmost importance that key populations including gay men and other men who have sex with men have a voice in shaping policy priorities, developing programmatic responses, and ensuring equitable distribution of targeted resources in the 50 + countries where PEPFAR is currently active.


MSMGF has been working towards ensuring that key population communities are always at the decision-making table. We work to identify opportunities to showcase the impact communities are having on the ground, to build strong working relationships with the Office of the U.S. Global AIDS Coordinator and Health Diplomacy (OGAC) and senior advisors in PEPFAR, and to share opportunities for communities to engage. We continue to support community partners in national HIV planning processes across sub-Saharan Africa, Eastern Europe and Central Asia, and Southeast Asia in their push for community-led, evidence-informed, and rights-based programs.

Learn More About PEPFAR 

New Publication on PEPFAR & Anti-Homosexual Legislation in Africa

Setting Advocacy Priorities: PEPFAR Country Operational Plans 2017