Is There a Price and Time Limit on Human Justice, Freedom, and Dignity? | Opinion

On Sept. 30, Congress was supposed to reauthorize U.S. President's Emergency Plan for AIDS Relief (PEPFAR) funding. Partisan infighting and politicking derailed its full-fledged reauthorization, scapegoating accusations of PEPFAR "hijacking" to funding distribution concerns regarding reproductive health care in the Reimagining PEPFAR's Strategic Direction. Instead of a 5-year reauthorization, the House passed a 1-year funding provisional extension, which is feared to not pass in the Senate.

PEPFAR provided $100 billion over two decades to support HIV care globally, including antiretrovirals (ARVs) to 20.1 million people living with HIV (PLWH); 25 million lives were saved. As an infectious diseases physician and clinical trials investigator, I witnessed firsthand benefits of PEPFAR, which should have been reauthorized without provisions, expanding wide-reaching HIV care.

I know intimately how novel HIV pre-exposure prophylaxis (PrEP) and therapeutics transform lives. In the U.S., long-acting injectables that prevent and treat HIV are readily available. Yet, numerous barriers remain—from development, manufacturing, approvals, to implementation—between when ARVs are market-ready in the U.S. versus resource-limited countries.

What also remains are fiscal, infrastructural, geopolitical oceans separating developed versus underdeveloped health care systems. Despite PEPFAR's progress, globally 10 million PLWH were not on ARVs in 2021. While in 2022, 76 percent of PLWH accessed ARVs—increased from 24 percent in 2010—57 percent of children younger than 15 and 72 percent of men 15 years and older with HIV had access. The Reimagined PEPFAR Strategic Direction has goals to address gaps in HIV care. These aims include achieving 95-95-95 treatment targets, reducing incident HIV, addressing societal barriers, and strengthening governmental and health care systems.

While providing medical care, conducting research, teaching trainees, and cultivating infectious diseases fellowship programs in Rwanda and Liberia, I am entangled in global under-resourced health care systems. Whether working on the wards globally or domestically, as I have for a decade, when I sit at bedsides of healed patients or deathbeds of humanity, what else could I see? Impassioned vulnerability. Unfair loss. Ineffable truth. These truths changed me, but I refused to let them break me. PEPFAR accelerates hope that global health equity is possible.

I have lived a thousand lives through my patients. From hospitals in the fields of Rwanda, to the capital of Liberia, to deep rural South Africa, to Chicago, Baltimore, New Haven, I witnessed patients with HIV fight to eventually survive or die. Novelist Romain Gary once reflected: "Our needs—for justice, for freedom, and dignity—are roots of heaven that are deeply embedded in our hearts, but of heaven itself men know nothing but the gripping roots." After all, I unequivocally believe that my patients' faces, voices, lived experiences are the "roots of heaven." PEPFAR provides justice, freedom, and dignity for PLWH; Congress should provide these principles for PLWH, optimizing—not filibustering—PEPFAR's agenda.

I observed stark differences in PEPFAR's regionally dependent impact, which should be addressed for more equitable PEPFAR funding distribution. In Liberia, relatively sparse PEPFAR funding exists and the HIV care continuum (treatment cascade) is relatively sparse. I recall a patient with AIDS whose visage was paralyzed along with the leg, unable to walk. The AIDS-associated JC virus caused a debilitating neurologic syndrome, progressive multifocal leukoencephalopathy, necessitating a faithful bedside caretaker.

In Rwanda, where PEPFAR funding relatively abounds, the HIV care continuum relatively abounded. Nevertheless, I encountered a patient with AIDS whose intracranial pressure was so high the patient became obtunded. The opportunistic fungus caused florid cryptococcal meningitis, umbilicated skin lesions throughout. Emergently, a lumbar puncture was performed for decompression.

When I stared into the patient's then hollow but once glowing eyes, it didn't break me—it made the "roots of heaven" for human justice, freedom, and dignity grow stronger. Those entangling moments forced me to acknowledge what I do not believe—"geography is destiny." Instead, those moments transformed me, proving I was willing to do everything to defy that broken philosophy. It is my vision that "geography is not destiny." PEPFAR rewrote history, demonstrating that geography is not destiny.

I am a doctor by trade, but an anthropologist by blood. My vulnerability—a "dangerous idealism" that global health equity should be pursued—is my superpower. It is my honor, my misfortune, to practice medicine and witness destruction in, respectively, unequal health care infrastructures.

PEPFAR could have been fully reauthorized; yet, it was not—a critical misstep in principle, symbolism. In the future, I call on Congress to reauthorize PEPFAR for a 5-year period as before. PEPFAR should be expanded without provisions, addressing HIV service gaps and funding disparities globally.

We foresee that HIV's prevalence will increase, until perhaps a cure or effective vaccine for HIV is developed. Thankfully, HIV epidemic control has been achieved in some regions; yet, rates have not been stably driven down to the point that HIV is no longer a pandemic. Thanks to PEPFAR, today we can discuss this problem—a "side effect" of being better than we would have been without it.

Jessica Tuan, MD, MS, AAHIVS is an assistant professor of medicine in the Section of Infectious Diseases & Department of Internal Medicine, and associate director of the Yale Antivirals & Vaccines Research Program at the Yale School of Medicine. She is a Public Voices Fellow with The OpEd Project in partnership with Yale University.

The views expressed in this article are the writer's own.