Beehive State News

Dear Secretary of State Blinken and Ambassador Nkengasong,

On the 20th anniversary of PEPFAR, we celebrate the program’s many successes, including 25 million lives saved and 5 million childhood infections averted. This effort, an example of American generosity and leadership, came at a time when Africa was reeling from the AIDS epidemic. Rising life expectancy over the past two decades can be traced to HIV treatment.

We enthusiastically endorse PEPFAR reauthorization, which benefits from strong bipartisan support. We also support the Administration’s commitment to ending HIV/AIDS as a public health threat by 2030. Accordingly, we want to draw attention to one of the most significant remaining challenges to pandemic control: the continued high rate of HIV amongst pregnant women, and the attendant high rates of vertical transmission of the virus from mother to child.

The numbers are staggering, tragic – and reversible. In 2021, approximately 130,000 newborns were infected with HIV in sub-Saharan Africa. Many of these newborns will die in the first years of life. The rest must endure a lifetime of care, which is expensive and difficult to execute. Nearly 1,000 adolescent girls and young women (AGYW) are infected every day. Only half of infected adolescent girls are on treatment. HIV-infected mothers are five times as likely to die of pregnancy-related causes as their uninfected peers.

The available maternal care is generally so poor and inaccessible that pregnant women in Africa make the usually rational decision not to seek it. Consequently, they do not receive genuine maternal care – and many go through pregnancy with HIV, and transmit the virus to their babies. The Principal Deputy AIDS Coordinator for PEPFAR Deborah von Zinkernagel was correct when she observed in 2014, “It’s no secret that maternal health and HIV are closely linked.”

Despite 20 years of remarkable vision and execution by PEPFAR, these numbers remain stubbornly high. Unless something genuinely different is done, these women will continue to suffer with, die from, and transmit to their babies AIDS.

The lack of quality maternal care in Africa can be fixed – and these mothers and their babies can be saved. The framework is in the Administration’s recently published: “Reimagining PEPFAR’s Strategic Direction” – which identifies AGYW and children as top priority groups. And the tactical way to help them has also been established – through the Saving Mothers, Giving Life (SMGL) program.

SMGL, a successful five-year pilot program implemented during the Obama Administration with PEPFAR funding and infrastructure, offered a package of clinical interventions to address the “three-delays” that prevent pregnant women from receiving quality services: delay in the decision to seek care; delay in reaching care; and delay in receiving quality care.

The impact was so profound and so immediate that Deborah von Zinkernagel remarked in 2014: “…the tremendous strides made through “Saving Mothers, Giving Life” in just one year give me — and all those who work with and support PEPFAR — great hope for our collective ability to improve maternal health as a critical component of achieving an AIDS-free generation.”

And the impact continued. Maternal mortality was cut by 40% – and there was a 71% increase in treatment to prevent vertical HIV transmission. These interventions cost less than $200 per year of life gained – less than the cost of HIV treatment for one year.

A revived program based on the successes of SGML would include accessible and dependable antenatal care, interventions to address the four leading causes of maternal mortality (port-partum hemorrhage, hypertensive disorders of pregnancy, obstructed labor and infection) and comprehensive emergency obstetric and newborn care. PEPFAR support would include medical supplies and consumables, equipment and the training of health workers. PEPFAR, uniquely and fortunately, has the clinical orientation, medical relationships, and reporting and accountability systems to deliver these critical services for these mothers and babies.

The success that PEPFAR should have with implementing such a maternal care program will extend beyond the lives saved and pain ameliorated among African women and children. It will be strategically important to the United States. 40% of the world’s population will be African by the end of the century and our strategic competitors are investing comprehensively in the region. We know that the PEPFAR program remains one of our most potent soft power assets on this front. In a 2021 analysis in the US Army War College Journal, Chief Nursing Officer Michael Wissemann wrote: “Countries in sub-Saharan Africa with a PEPFAR program, compared with those countries that do not have the program, demonstrated three times the growth in UN human development index scores. They also showed a significant increase in opinion of the United States and a 40 percent reduction in political instability and violence. These effects are tied directly to the aid provided to 7.7 million Africans, through antiretroviral treatments.”

We thank you for your resolute commitment to the PEPFAR program and your consideration. We are confident that the clinical approach as outlined above will result in enormous numbers of pregnant women being treated for HIV and in their babies being born healthy – with humanitarian and strategic benefits for decades to come.