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The Honorable Christopher Coons Chair Committee for Appropriations Subcommittee for State, Foreign Operations, and Related Programs U.S. Senate Washington, DC 20510 The Honorable Mario Diaz-Balart Chair Committee for Appropriations Subcommittee for State, Foreign Operations, and Related Programs U.S. House of Representatives Washington, DC 20515 May 22, 2024 The Honorable Lindsey Graham Ranking Member Committee for Appropriations Subcommittee for State, Foreign Operations, and Related Programs U.S. Senate Washington, DC 20510 The Honorable Barbara Lee Ranking Member Committee for Appropriations Subcommittee for State, Foreign Operations, and Related Programs U.S. House of Representatives Washington, DC 20515 Dear Chairman Coons, Chairman Diaz-Balart, Ranking Member Graham, and Ranking Member Lee: On behalf of the organizations listed below, we ask that you fund global HIV/AIDS programs in the Fiscal Year (FY) 2025 no less than $6.79 billion for Global Health Programs at the Department of State, including $5.14 billion for the President’s Emergency Plan for AIDS Relief (PEPFAR), $1.65 billion for the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as ensure that the programs are governed by policies that expand access to health care, uphold human rights, and help to put the world on track to end AIDS by 2030. We also request $350 million to fund USAID HIV/AIDS programs and $60 million for the Joint United Nations Programme on HIV/AIDS (UNAIDS). We recognize that the impact of international conflicts puts pressure on U.S. foreign aid budgets, but we would like to take this opportunity to reiterate the importance of continuing to build upon the lifesaving progress realized through U.S. investments in global HIV/AIDS programs. Failure to do so will result in the loss of hard-won progress and the numbers of HIV infections and AIDS-related deaths rising, and will risk two decades of U.S. strategic investments in this critical area of global health security, human rights, and America’s global leadership. In his 2003 State of the Union address, George W. Bush announced the President’s Emergency Plan for AIDS Relief. Now, over 20 years later, PEPFAR has proven to be one of the most remarkable global health successes of our time. It has long been a uniting cause in Congress, enjoying bipartisan support across four presidential administrations, and is a shining example of U.S. global health leadership. Through innovative, targeted, and science-based HIV prevention and treatment programming, PEPFAR has saved over 25 million lives, helped stabilize nations through health infrastructure investments, and fundamentally changed the course of the HIV pandemic. Its impact extends well beyond the fight against HIV and AIDS. Decades of expertise, diplomacy, and infrastructure were deployed throughout the COVID-19 pandemic, enabling the delivery of diagnostics, care, and vaccines to populations that may not otherwise have been reached. It proved what can be done with a strong framework and a whole-of-government approach. It demonstrated its capacity to be a critical asset in building systems to prepare for health threats we may face down the line. We recognize that this request represents a significant increase over enacted budgets for the PEPFAR program in previous years. The reality is that PEPFAR has continued to operate with essentially flat funding for fifteen years, while expanding successful programs, greatly reducing the number of new HIV infections, continuously increasing the number of people on life-saving HIV treatment, and rapidly scaling up new and innovative prevention, testing and treatment methods. Without increased funding, PEPFAR simply will not be able to operate at the level of effectiveness and efficiency that millions of people around the world depend on, and the failure to end HIV/AIDS as a public health threat by 2030 will be written in stone. With the additional funding requested, PEPFAR could improve and expand upon programs that work and repair and rebuild programs that have been set back by global health crises. Critical Gaps in the Global HIV/AIDS Response UNAIDS estimates that if HIV service coverage is held constant at current level, the world will see an estimated 7.7 million additional AIDS-related deaths between 2021 and 2030. Success in the fight against HIV remains deeply unequal across populations due to discrimination, stigma, violence, and inequity. The majority of new infections are in sub-Saharan Africa, where women and girls account for 63% of all new infections. In 2022, 4000 adolescent girls and young women acquired HIV each week. Overall, key populations and their partners accounted for 71 percent of new HIV infections worldwide in 2021 and 49 percent of new infections outside of sub-Saharan Africa. HIV treatment access for mothers and children continues to lag, with 1 in 5 pregnant or breastfeeding women living with HIV are not receiving antiviral treatment and just half of HIV positive children receiving the treatment they need to survive and thrive. Despite the success of many of PEPFAR’s prevention interventions, they are still not at a scale to make the necessary impact on the global rate of new HIV infections and get the world on track to end AIDS by 2030. The UNAIDS Global AIDS Strategy, reinforced by the 2021 UN High Level Meeting Political Declaration on HIV/AIDS (adopted by the majority of member states, including the United States) calls for a substantial increase of investments in HIV prevention efforts and structural interventions to eliminate barriers to service utilization and contribute to reducing inequities in HIV incidence. The urgency of investing in HIV prevention is made greater by the introduction of new prevention technologies, including the dapivirine vaginal ring (DVR) and long-acting injectable pre-exposure prophylaxis (PrEP), which reduces the risk of getting HIV through sexual transmission by 99 percent. Rapid scale up of these tools is needed to maximize their impact and cost-effectiveness. Additionally, investment in the research and development of an HIV/AIDS vaccine is essential – and has already contributed to the swift development of highly effective mRNA vaccines for covid-19. Vaccines are the most powerful and cost-effective tools for controlling the spread of any virus, and without a vaccine and a cure, an end to this devastating epidemic will remain out of reach. State of Our Investments Global resources to fight HIV and AIDS have decreased since 2017, leaving a 30 percent shortfall for what is needed to fully address the epidemic. UNAIDS now estimates that annual investments will need to rise to $29.3 billion (in 2019 dollars) by 2025 to get the AIDS response back on track in low- and middle-income countries. While domestic contributions make up 57 percent of all resources available, global financial support is still a critical element of success, and the contributions of the United States play a leading role in leveraging the commitments of other donors. Increasing PEPFAR funding by $750 million dollars in FY25 would show the U.S.’s commitment to ending AIDS as a public health threat, and support closing the funding gap. This investment would make a significant down payment in the fight to end AIDS and will motivate other funders to step up as well. An investment of $1.65 billion in FY2025 would support the extraordinary work of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has saved helped save 59 million lives since 2002. We are grateful to Congress for consistently providing robust funding to the Global Fund and to the administration for its bold pledge for the Global Fund’s three-year replenishment. The Administration’s $1.2 billion FY25 request, if funded by Congress, would fulfill the three-year U.S. pledge, assuming the 2:1 match requirement is based on non-U.S. donations toward a Global Fund replenishment, as is the standard practice. Congress has the option to provide additional support, beyond the $1.2 billion request, if it chooses. A robust contribution would avert 41.8 million new cases and infections from the three diseases—providing HIV screening and testing to 70.8 million people, providing malaria treatment and care to 26.8 million people, and screening 30.1 million people for TB. That translates into an estimated 510,000 additional lives saved over the estimated level that could be achieved based on the budget request. U.S. investments in global health, including the Global Fund, advance the health security of all Americans by helping to build health infrastructure in countries around the world, enabling them to quickly identify new disease threats, bring them under control, and prevent them from spreading to other countries. Global health investments also help nurture trade relationships with other countries. A $1.65 billion contribution from the U.S. would produce an estimated $47.8 billion in economic returns created by health gains. The success of PEPFAR is due in part to its unique structure that allows it to utilize the strengths and vast knowledge and experience of USAID and the Department of State to effectively address the global AIDS pandemic. The $350 million in funding allocated to USAID for HIV/AIDS programs supports multi-country, cross-cutting initiatives critical to the success of the PEPFAR. Funding from this account directly supports technical leadership and program assistance to field programs efforts that will be even more critical as the PEPFAR continues to build country-level capacity and transition programs to country-led counterparts. Without strong funding for this account, USAID’s investment in the new prevention tools such as long-acting injectable PrEP, and development of multipurpose prevention technologies and an effective HIV vaccine, could be in jeopardy. Finally, we ask specifically that you protect the critical role the Joint United Nations Programme on HIV/AIDS (UNAIDS) plays in the global HIV response by including $60 million in funding for UNAIDS. Support for UNAIDS is an important and abiding commitment the United States has made to the global fight against HIV/AIDS for more than two decades. With offices in over 70 countries, and 70 percent of its staff based in the field, UNAIDS has a unique on-the-ground presence, providing critical support for PEPFAR and the Global Fund investments and programs at the country level which cannot be duplicated or substituted. UNAIDS leads the coordination of global efforts to end AIDS by 2030, provides technical support for effective implementation of national programs and coordination of international efforts, and generates the only global set of HIV/AIDS data which is mandated by PEPFAR legislation. UNAIDS data and annual global report are essential for effective strategic planning and allocation of resources and efforts, including by the United States, and mobilizes political commitment in affected countries and among other donors globally, including to increase domestic financing for HIV programs in partner countries. Increased U.S. government funding will also help ensure UNAIDS has the necessary resources to strengthen its capacity and coordination role to fully implement the Global AIDS Strategy (2021-2026), which was adopted with the strong support of the United States. UNAIDS plays a critical role in advancing the U.S.’ goals of saving lives, advancing epidemic control, and increasing burden sharing in focus countries and by other donors. As noted in PEPFAR’s 2022 Annual Report to Congress: “UNAIDS is a critical leader in driving a comprehensive international response to fight HIV/AIDS. ... UNAIDS’ policy framework and the political commitment to eradicate HIV/AIDS complements and enables PEPFAR and programmatic efforts of the Global Fund.” Over twenty years into the program PEPFAR continues to show the world the United States’ compassion, but also effectiveness in addressing the challenges of global HIV and AIDS through prevention, care and treatment programs and policies that are grounded in science and respect for human rights. PEPFAR improves and saves the lives of people around the world and continues to advance our national security and development goals. It is imperative that we leverage PEPFAR’s success by scaling up successful programs to reach the most vulnerable and ensure that hard-won gains over the last twenty years are not lost. Funding global HIV/AIDS programs in Fiscal Year 2025 no less than $6.79 billion for Global Health Programs at the Department of State, including $5.14 billion for the President’s Emergency Plan for AIDS Relief (PEPFAR), $1.65 billion for the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as $350 million for USAID HIV/AIDS programs, and $60 million for the Joint United Nations Programme on HIV/AIDS (UNAIDS) and ensuring that the program is governed by policies that expand access to health care and uphold human rights is critical for this effort. We welcome the opportunity to work with you and your staff on these crucial and timely issues. Should any questions arise, if you need additional information, or if you would like to meet with members of the GAPP to discuss these issues, please contact Co-Chairs Katie Coester (kcoester@pedaids.org), Shannon Kellman (kellmans@unaids.org), or Suraj Madoori (suraj@avac.org). We appreciate your leadership and look forward to your assistance in the fight against the HIV/AIDS epidemic. Sincerely, American Academy of Pediatrics AVAC Children's AIDS Fund International Council for Global Equality Elizabeth Glazer Pediatric AIDS Foundation Evangelical Lutheran Church in America FHI 360 First Focus Campaign for Children Funders Concerned About AIDS Global Health Council Global Health Technologies Coalition Global Network of Black People working in HIV Health GAP (Global Access Project) HIV+Hepatitis Policy Institute Human Rights Campaign IAVI Management Sciences for Health MPact Global Action NASTAD PAI PATH RESULTS Together for Girls Treatment Action Group World Vision The GAPP is a coalition of more than 70 advocacy and implementing organizations committed to expanding and improving global HIV/AIDS programming in order to reach the goal of ending AIDS as a public health threat by 2030

Interested in more global health innovation news? Every week GHTC scours media reports worldwide to deliver essential global health R&D news and content to your inbox. Sign up now to receive our weekly R&D News Roundup email. On Friday, the World Health Organization (WHO) released its updated Bacterial Priority Pathogens List 2024, which aims to guide investments and R&D in new antibiotics and promote international coordination to address the rising global threat of antimicrobial resistance (AMR). The updated list, which incorporates new evidence and expert insights, includes 15 families of antibiotic-resistant bacteria grouped into critical, high, and medium categories for prioritization based on their burden and ability to resist treatment and spread resistance to other bacteria. Five pathogen-antibiotic combinations were removed from the new list and four new combinations were added, reflecting the dynamic nature of AMR.Last week, WHO authorized a second vaccine for dengue, which will hopefully offer millions more worldwide protection against the mosquito-borne disease, which is currently behind a major outbreak in the Americas and rising cases globally. The two-dose vaccine, made by Takeda, protects against the four types of dengue and is recommended for use in children between six and sixteen years old in regions with high dengue rates. The decision opens the door for donors and other United Nations agencies to purchase the vaccine for high-burden countries.Last week, the US Food and Drug Administration approved the use of self-collected samples with Roche and BD’s HPV tests, a decision that hopefully will expand access and reduce barriers to HPV screening, allowing more people to detect and treat cervical cancer. Screening for HPV is used to identify those who may be at risk of developing cervical cancer, most cases of which are caused by persistent HPV infection. Traditional screening involves a speculum-involved pelvic exam to screen for cervical cancer, which can be painful or uncomfortable for many patients. Self-collection allows patients to collect their own vaginal samples for screening in a health care setting.

This year’s World Health Assembly represents a pivotal moment for global leaders to put in place policies that will bolster our preparedness against emerging threats and reinvigorate the battle against longstanding health challenges. As member states consider agenda items before this year’s assembly, the Global Health Technologies Coalition (GHTC) urges policymakers to prioritize the following actions to accelerate global health innovation:Adopt a resolution on antimicrobial resistance (AMR) with bold new commitments to spur the development of new tools and improve global surveillance capacity. This should include a pledge by member states to increase investments and incentives for research and development (R&D) of new antimicrobials and other tools—ensuring these innovations are designed to reach underserved populations and those in low-resource settings—as well as to support the creation of a new global AMR laboratory network to strengthen diagnostic capacity. In advance of the United Nations High-Level Meeting on AMR this September, it is also imperative that United Nations agencies hold an open, inclusive consultative process to define global AMR priorities.Pass the proposed resolution on maternal and child health, setting into action its call for increased R&D to address the often-neglected health needs of women and children. Member states should support the ongoing work of the World Health Organization (WHO)-led Global Accelerator for Paediatric Formulations Network, which coordinates stakeholders to address treatment gaps for children and seeks to align their national HIV/AIDS R&D investments with priority needs identified in WHO’s Paediatric Antiretroviral Drug Optimization list. To address treatment and prevention gaps for pregnant and lactating individuals, countries must also prioritize the inclusion of pregnant and lactating people in research and clinical trials.Substantially increase investments in R&D to meet the goals set forth in the WHO strategies on tuberculosis and neglected tropical diseases. To achieve the Global Strategy for Tuberculosis Research and Innovation, member states should increase domestic investments in tuberculosis R&D in line with fair share targets and supercharge research efforts to develop novel vaccines, point-of-care diagnostics, and improved therapies—ensuring tools are fit for purpose for underserved populations. To support the neglected tropical diseases roadmap, WHO and member states should position impacted countries to lead in R&D priority-setting, promote South-South collaboration models, and consider the growing impact of climate change on disease burdens. Additionally, to accelerate access to new health products, countries must also support WHO’s divisions on Science and Access to Medicines and Health Products in advancing approaches to better align WHO’s prequalification procedure and national and regional regulatory approval processes.Advance a pandemic agreement and proposed amendments to the International Health Regulations over the finish line. Too many lives have been lost and too much is at risk to let these critical processes fail. On the accord, member states must soften entrenched positions and work with earnestness to forge a consensus path forward that spurs inclusive R&D while ensuring all countries benefit from the fruits of science and innovation. Any agreement should include clear enforcement and accountability provisions and pathways to finance and strengthen research capacity in low- and middle-income countries.It is GHTC’s hope that countries will meet the moment on this historic opportunity to supercharge R&D efforts to combat future pandemics and other ongoing global health challenges.

GHTC submitted testimony on fiscal year 2025 (FY25) appropriations to the House and Senate Appropriations Subcommittees on Labor, Health and Human Services, Education, and Related Agencies (LHHS), urging robust funding for the National Institutes of Health, the Centers for Disease Control and Prevention, and the Biomedical Advanced Research and Development Authority, as well as to the House and Senate Appropriations Subcommittees on State, Foreign Operations, and Related Programs (SFOPS), urging robust funding for the US Agency for International Development, including funding for a Supporting Innovative Global Health Technologies Fund.