Uganda’s anti-homosexuality bill that was signed early this year created funding uncertainty from developing partners. Among them is PEPFAR, The US President’s Emergency Plan for AIDS Relief which has had an unprecedented global impact in the fight to end HIV/AIDS in more than 50 countries, including Uganda. 

John Musenze had an exclusive interview with the US Ambassador to Uganda, William W. Popp, about the future of the PEPFAR programme in Uganda.

The PEPFAR programme recently celebrated 20 years of existence. Congratulations on this milestone. 

Thank you, John. 

Of the 25 countries benefiting from PEPFAR, how do you rate Uganda? What are some of the biggest wins? 

It’s been a fantastic result of this programme; we are celebrating 20 years since its beginning around the world. The programme is operating in over 55 countries and it has saved 25 million lives. 

In Uganda, 1.4 million Ugandans are receiving support through PEPFAR as prevention and treatment services through antiretrovirals (ARVs) and we estimate over 600,000 lives have been saved. 

We have accomplished a lot; we have been able to reach many people to receive treatment and prevention services. We have reduced mother-to-child transmission to below 2% (half a million babies born without HIV).

Any challenges to PEPFAR Uganda programme? 

There are challenges. There are still vulnerable populations, particularly young women, girls, and children who we need to continue to do more, first by making sure they know their status and then receiving treatment. 

But we can all be safer when everyone, from whatever community, can go test, receive treatment and suppress viral load, which means not spreading the virus to others. Our focus is on reaching epidemic control by having HIV under control by 2030. 

We intend to achieve this by reaching as many people as we can and working locally with everyone. Our goal is for 95% of the citizens to know their status, 95% to receive treatment and 95% or more suppressing their viral load.

What do the next five to 20 years of PEPFAR look like, especially for developing countries like Uganda?

We have accomplished a lot; we are talking about 25 million lives saved worldwide and 1.4 million Ugandans receiving treatment. 

So, recognising what we have accomplished first is important, but over the next five to seven years, which will be 2030, there’s more work to be done, including getting services out as far as we can for everyone to access them, working with partners to reach those particular communities, ensuring that almost everyone in Uganda knows their status and bringing anti-HIV services closer to everyone anywhere. Attention and focus have been put on the HIV vaccine development. 

Does PEPFAR have any plan to help Ugandan scientists to achieve this?

The great thing and key elements of PEPFAR are research, developing rapid testing kits and developing ARVs. It has been an alliance with scientists, academia, health institutions, government, even the private sector and pharmaceutical companies. 

That same treatment will eventually lead to the vaccine and additional treatment capability. We are supporting various efforts to research and develop those tools, including the vaccine, but there is still more work to be done; we hope we will have good news in the future.

You still ship in ARVS from outside even when Uganda has pharmaceutical companies (Cipla) that develop these drugs, don’t you think PEPFAR needs to empower local manufacturers? 

Yes, we surely want to make sure that there’s as much access to these drugs as possible, but there is, of course, a quality requirement. We need to make sure that the medicine does what they are supposed to do. 

We pay half a billion dollars under PEPFAR just here in Uganda and a large portion of these funds go to ARVs, but we will also continue supporting local manufacturers while maintaining access to quality medicine. 

Recently, there has been some reported uncertainty about PEPFAR’s funding to Uganda. What assurance do you give to people living with HIV and those at risk of HIV infection? 

When the anti-homosexuality bill was passed in May this year, President Joe Biden was very clear that the United States (USA) would be looking at all the co-operations with Uganda, looking at all programmes that we have in Uganda. Under US law, we have to make sure that our assistance is provided without discriminating against anyone and we are required to do that. 

And, obviously, we have concerns about this law because it discriminates against individuals, it prevents individuals from accessing this life support. 

We have reviewed the Continuity of Operations (COP) and there is a pause in our country's operating plan, but, eventually, we have concluded, that we will go forward with the COP for the coming year, which allows us to continue spending funds under PEPFAR. 

There will be some redirection of the funding to local organisations, but we have no desire whatsoever to limit access to these life-saving medicines and prevention options, so, the programme is continuing.

Are there conditions attached to this decision? 

No, we do not have any conditions, PEPFAR is aiming at supporting everyone. This is because we do not want anyone to be left behind in the fight against HIV, regardless of what they believe in, so that we can attain the 2030 target.

You say you are redirecting funds to local organisations, why? Don’t you think the health ministry will be the best to work with? 

The programme has been very successful worldwide and, in Uganda, by working with a range of partners. The model, not only here in Uganda, has been most efficiently and effectively implemented with local non-governmental partners and international institutions. 

But we do have a history of working with the health ministry and other entities of the Ugandan government by building capacities so that the programme can be successful. We have achieved a lot, but there is a lot to do and we are going to address that with local partners.

How then will the health ministry monitor these programmes? 

Our programme is transparent. We co-ordinate the country’s operating plan and it’s presented to the ministry, so there’s full knowledge of what is done.

How is the US government helping to ensure the sustainability of HIV/AIDS programmes in Uganda, considering the evolving landscape of global health funding? 

We are very committed to supporting the Ugandan people, we have been here for 20 years in this particular programme, but also, we have more than 60 years of the Uganda-US relationship for the prosperity and benefit of the Ugandan people. 

That commitment is going to remain both in funding, capacity building and in exchange. We do need to be more efficient, transparent and work with local partners because they know more of what is on the ground.

After a few months in Uganda, how do you find Uganda’s health sector?

 It’s been a model around the continent. The capacity that has been built has strengthened, especially with PEPFAR. Twenty years ago, the infection rate was above 20%, now they are below or a little more above 5%. We saw that capacity during COVID and the recent Ebola. There’s a strong ability to contain epidemics, which has saved lives. 

Where do you think Uganda’s health sector needs to improve? 

There are still vulnerable communities, particularly young women, girls and children. 

There’s a need to make sure these communities are on these programmes to the maximum as possible so that everyone is safe. Continuing to work with local communities will also help in achieving the target, but also making sure no one is left out, regardless of their background.

There are so many HIV preventive options that have been brought up, for example, the dapivirine vaginal ring and the recent injectable anti-HIV drug, but the government lacks funds to fully roll out these options, can’t PEPFAR help kick start these?

We are going to help as much as we can, but we have our limits as well. These preventive options have their own cost, but we are always looking at what we do most efficiently and effectively. 

Ultimately, part of PEPFAR’s programme is for countries to take on the responsibility and invest in these programmes, but we will continue to do as much as we can. However, in the long-term, success will be measured by how much countries like Uganda can invest in their health system.

December 1 will be the 35th commemoration of World AIDs Day, under the theme, Remember and Commit. What is your message? 

We have accomplished a lot, but there is still work to be done. That’s the key message for me. We should work together to save millions of people, not only in Uganda, but also around the world, ensuring that everyone can have access to anti-HIV programmes like drugs and prevention options, as well as continued dedication to science. We can reach epidemic control; we can cease to have HIV by 2030.