美國總統愛滋病緊急救援計畫 (PEPFAR) 的重新授權懸而未決
www.thelancet.com/hiv Vol 10 September 2023
自2003 年美國總統喬治·W·布希 (George W Bush) 創建以來，美國總統愛滋病緊急救援計畫(PEPFAR) 一直是全球愛滋病應對行動的重要組成部分，支持受愛滋病毒/愛滋病影響最嚴重的低收入國家的愛滋病毒計畫。 PEPFAR 超過 1,100 億美元的投資從根本上重塑了衛生系統：提高監測能力、創建大型臨床服務設施網絡以及管理藥品供應鏈。 據估計，目前有 2,000 萬人正在接受愛滋病毒治療，其中 150 萬人透過美國總統防治愛滋病緊急救援計畫 (PEPFAR) 獲得了暴露前預防治療。 該計畫已幫助預防了估計 2,500 萬人與愛滋病毒相關的死亡。 還有數百萬人可能從該組織的活動中間接受益，尤其是在 COVID-19 大流行期間，當時為抗擊愛滋病毒而建立和加強的衛生系統有助於應對這一新威脅。美國政府和美國公民有理由為總統緊急救援計畫對全球健康做出的非凡貢獻感到自豪。
過去二十年來，在總統防治愛滋病緊急救援計畫的支持下，監測、治療和預防方面的創新和擴展已幫助世界上一些受災最嚴重和資源最匱乏的國家取得了顯著的成就。 去年，波札納（PEPFAR 最初的重點國家之一）宣布已實現 UNAIDS 95-95-95 目標。在本期中，一項基於馬拉威PEPFAR 支持的基於人口的愛滋病毒影響評估數據的研究顯示，該國實際上有望在2030 年之前實現95-95-95 的目標。
PEPFAR 的第四次重新授權到 9 月 30 日為止即將發生，自該計畫啟動以來每 5 年進行一次，喬·拜登總統已要求為該計畫未來五年提供 68 億美元的資金。 要達成於 2030 年減少愛滋病毒/愛滋病負擔的雄心勃勃之全球目標，有制定長期計畫的能力至關緊要。總統防治愛滋病緊急救援計畫每五年更新一次，歷來得到兩黨的支持，為各國提供了穩定，並使這些國家愛滋病毒/愛滋病計畫能夠提前規劃。但這是第一次，重新授權受到威脅。
來自新澤西州的共和黨代表、眾議院外交關係小組委員會（負責監督總統防治愛滋病緊急救援計畫）主席克里斯·史密斯反對重新授權，除非包括限制措施以阻止資金流向提供或支持墮胎服務的團體。 儘管PEPFAR資金不用於提供墮胎，但反對提供全面的性健康和生殖健康服務的共和黨人擔心，一些提供墮胎的設施可能會從PEPFAR資金中受益。此類限制將類似於拜登總統在 2021 年擔任總統的第一周所廢除的全球禁言規則，因此不太可能得到民主黨或現任總統的支持。採取敷衍了事態度，幾名共和黨政客正在尋求實施為期一年的續約，向支持墮胎的團體凍結資金提供，希望他們的政黨能夠贏得明年的總統選舉，從而擁有更多的權力來決定未來總統防治愛滋病緊急救援計畫的方向。如果未能重新授權該計畫，不僅會讓人對總統緊急救援計畫所支持的計畫之未來產生懷疑，並限制受助國家計畫提前規劃的能力，而且還會導致一些有時限的規定終止。其中包括要求將 10% 的資金用於支持受愛滋病毒影響的孤兒和兒童。 對重新授權的懷疑也將危及最近宣布的安全分娩健康嬰兒之倡議：這是一項為期兩年、耗資 4000 萬美元的努力，旨在加快進展，消除愛滋病毒高負擔國家的垂直傳播。正如本週《剌胳針》發表的通訊文章所強調的那樣，PEPFAR 可以拯救兒童的生命，如果不完全重新授權將會導致生命損失。是無需闡明的殘酷諷刺。
2022 年，約翰·恩肯加松 (John Nkengasong) 成為非洲大陸第一位掌管總統防治愛滋病緊急救援計畫 (PEPFAR) 的人。 現在，在其成立20 週年之際，Nkengasong 應該與各國合作，期待美國總統防治愛滋病緊急援助計畫(PEPFAR) 工作方式的轉變，在已經取得的令人印象深刻的成果的基礎上，繼續制定可持續之計畫，並在增加捐款的同時增強其自力更生的能力，並幫助愛滋病毒計畫在 COVID-19 大流行之後的重建。未能重新授權該計畫或將其限制成為每年度之週期，將帶來不穩定並阻礙制定成功計畫所需的長期保證。我們希望那些試圖破壞總統防治愛滋病緊急救援計畫（PEPFAR）運作的人能夠聽取理性意見，並重新全面授權該計畫。 ■ 刺胳針愛滋病毒
PEPFAR reauthorisation hangs in the balance
www.thelancet.com/hiv Vol 10 September 2023
Since its creation by US President George W Bush in 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has been a crucial component of the global HIV response—supporting HIV programmes in low-income countries hit hardest by HIV/AIDS. Over US$110 billion of investment through PEPFAR has radically reshaped health systems: increasing surveillance capacity, creating large networks of clinical service facilities, and managing drug supply chains. An estimated 20 million people are currently on HIV treatment and 1·5 million have access to pre-exposure prophylaxis thanks to PEPFAR. The programme has helped to prevent an estimated 25 million HIV-related deaths. Many millions more have likely benefited indirectly from the organisation’s activities, not least during the COVID-19 pandemic when health systems built and strengthened to combat HIV were instrumental in tackling the new threat. The US Government and US citizens can justifiably be proud of the extraordinary contributions to global health that PEPFAR has made.
Innovations and expansion in surveillance, treatment, and prevention deployed with PEPFAR’s support over the past two decades have helped some of the world’s hardest hit and least resourced countries make remarkable achievements. Last year, Botswana, one of the original PEPFAR focus countries, announced that it had achieved UNAIDS 95-95-95 targets. In this issue, a study based on data from the PEPFAR-supported Population-based HIV Impact Assessment in Malawi shows that the country is realistically on track to achieve 95-95-95 targets before 2030.
The fourth reauthorisation of PEPFAR is due to happen by September 30, as it has every 5 years since its inception, and President Joe Biden has asked for $6·8 billion to fund the programme for the next half decade. With ambitious global targets to reduce the burden of HIV/AIDS by 2030, an ability to make longterm plans is essential. The 5-yearly cycle of PEPFAR renewal, which has historically received bipartisan support, provides stability for countries and allows national HIV/AIDS programmes to plan ahead. But for the first time, reauthorisation is under threat.
Chris Smith, a Republican representative from New Jersey who chairs the House Foreign Relations Subcommittee (which oversees PEPFAR), opposes reauthorisation unless restrictions are included to stop funds going to groups that provide or support abortion services. Although PEPFAR funds are not used to provide abortion, Republicans opposed to the provision of comprehensive sexual and reproductive health services are concerned that some facilities that do provide abortions might benefit from PEPFAR funds. Such restrictions would be akin to the global gag rule, which President Biden rescinded in the first week of his presidency in 2021, so will unlikely receive support from the Democratic Party or President. As a sticking plaster, several Republican politicians are seeking to implement a 1-year renewal with blocks on funds to groups that support abortion in the hope that next year their party will win the presidential election and therefore have more power to determine the direction of PEPFAR.
A failure to reauthorise the programme will not only cast doubt on the future of PEPFAR-supported projects and limit the ability of national programmes to plan ahead, but also will see some time-limited provisions come to an end. These include the requirement that 10% of funds be spent supporting orphans and children affected by HIV. The doubt over reauthorisation will also jeopardise the recently announced Safe Births Healthy Babies initiative: a 2-year, $40 million effort to accelerate progress to eliminate vertical transmission in countries with high HIV burdens. As highlighted in Correspondence published in The Lancet this week, PEPFAR saves children’s lives, and failure to reauthorise in full will cost lives. There is no need to spell out the grim irony.
In 2022, John Nkengasong became the first person from the African continent to take the helm of PEPFAR. Now, in the year of its 20th anniversary, Nkengasong should be looking forward to a period of transformation in the way PEPFAR works, working with countries to continue building sustainable programmes with growing self-reliance as they increase their contributions, building on impressive gains already made, and helping the HIV programmes to re-establish themselves after the COVID-19 pandemic. Failure to reauthorise the programme or limiting it to annual cycles will introduce instability and hinder the long-term assurances needed to develop successful programmes. We hope those seeking to derail PEPFAR’s operations will listen to reason and reauthorise the programme in full. ■ The Lancet HIV