PEPFAR Is Still Without a Leader. H.I.V. Activists Want to Know Why.

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The Biden administration has not yet nominated a leader for the President’s Emergency Plan for AIDS Relief, a $7 billion program that sets priorities for AIDS care worldwide — leaving countries that receive funding from the program without guidance during a pandemic that is particularly dire for those with H.I.V.

PEPFAR is led by a global AIDS coordinator, a cabinet-level position that was last held by Dr. Deborah Birx. Dr. Birx served from April 2014 to February 2020, when she left to join the White House coronavirus task force. Dr. Angeli Achrekar, a deputy, has acted as PEPFAR’s interim leader since President Biden took office.

Global health experts sharply criticized the delay in nominating a permanent chief. “Can we not think and act on two pandemics at a time?” asked Gregg Gonsalves, a longtime H.I.V. activist and an epidemiologist at the Yale School of Public Health.

PEPFAR was started in 2003 by President George W. Bush and has had bipartisan support ever since. Funds distributed by PEPFAR are used to support prevention and treatment programs, including offering voluntary male circumcision, as well as testing for H.I.V. and providing antiretroviral therapy to people of all ages.

It is widely regarded as the most successful global health program. Since its inception, the U.S. government has invested more than $85 billion in more than 60 countries, saving an estimated 20 million lives.

“PEPFAR is an example of what can be done when you combine diplomacy and global health,” said Dr. Carlos del Rio, an infectious-disease expert at Emory University in Atlanta and chair of PEPFAR’s scientific advisory board. “Throughout Africa, they love and they respect the U.S. because of PEPFAR.”

Credit…U.S. Department of State

Last week, a group of more than 50 advocacy organizations sent a letter to Mr. Biden, urging him to “immediately appoint a bold, creative and qualified” leader for PEPFAR. “This is unacceptable, particularly during a time of the dueling pandemics of H.I.V. and Covid-19,” they wrote.

The White House did not respond to a request for comment.

The coronavirus pandemic has disrupted access to H.I.V. prevention, diagnosis and treatment, as well as supply chains for condoms, lubricants and antiretroviral drugs, according to a recent report from UNAIDS.

And the pandemic has reversed hard-gained progress on ending H.I.V., including a 23 percent annual decrease in new infections since 2010.

The inertia on naming a leader is particularly damaging “when more leadership, ambition and governance is sorely needed to guide global efforts to make up lost ground on the H.I.V. response,” said Suraj Madoori, a director of the Treatment Action Group, an advocacy organization based in New York.

A new study released last week showed that people living with H.I.V. have a heightened risk of serious illness and death from Covid-19. The coronavirus pandemic could also benefit from the health care infrastructure set up to provide services for H.I.V., experts noted.

“There’s a lot that can happen now, using the PEPFAR structure to confront Covid in those countries,” Dr. del Rio said.

“Not leveraging the PEPFAR infrastructure — I think it’s crazy, it’s a huge missed opportunity,” he added. “This administration has been around for six months. Why have we not appointed them?”

Dr. del Rio said PEPFAR’s chief had been noticeably absent from global conversations, including a recent U.N. resolution to end AIDS by 2030, and efforts to enable PEPFAR sites to respond to the coronavirus pandemic. It’s also important for PEPFAR’s chief to speak up for the program when budget dollars are allocated, Dr. del Rio added: “I almost feel like the program is basically at a standstill.”

The absence of a U.S. voice is also having ripple effects on many issues in African countries, said Richard Lusimbo, a program manager at Pan Africa ILGA in Uganda. Core programs for key populations like L.G.B.T.Q. people have been cut in several countries since the start of the Biden administration. In Ivory Coast, for example, the budget for key population services was cut by half.

In Kenya, a dispute between its government and the U.S. Agency for International Development has led to a shortage of antiretroviral drugs. A permanent PEPFAR leader with political power would have been able to resolve that dispute, Mr. Lusimbo said.

Mr. Biden named Samantha Power to lead USAID on Jan. 13, even before he took office. And last week, the White House announced nominees for seven other positions.

For weeks, the H.I.V. community has heard that the administration is considering five widely known global health experts to lead PEPFAR: Shannon Hader, Charles Holmes, Chris Beyrer, Vanessa Kerry and Paul Farmer. But no candidate has emerged as the front-runner.

“Unfortunately, we are watching as global support for the Covid-19 response in Africa is missing, the AIDS response is being weakened, and it is not clear who the U.S. government’s leader is on this,” Mr. Lusimbo said. “Does the administration not understand that, for our communities, the AIDS response and the Covid-19 response are critically interlinked?”