WASHINGTON, D.C. —The United States is terminating its funding to several of the Caribbean countries hardest hit by the HIV/AIDS epidemic. Directors of the US President’s Emergency Fund for AIDS Relief (PEPFAR), America’s global fund to fight AIDS around the world, said that they could no longer justify supporting the upper middle-income countries of the Caribbean, and have ordered fund terminations from as early as this year.
The Bahamas — which has the highest population prevalence of HIV in the English-speaking Caribbean, at just over 3% — will have its funding cut entirely in September 2017, followed by Barbados in 2018. Meanwhile, Guyana, Suriname and Trinidad & Tobago will have their funding slashed to historic lows for two years, before their allocations end in 2019.
Of the middle-income Caribbean countries, only Jamaica will be spared from cuts, but under strict conditions. Far fewer people living with HIV in Jamaica receive treatment than in the other upper-middle income Caribbean countries, and estimates are that more than 3 in 10 Jamaican men who have sex with men are HIV positive. To address this, PEPFAR will move 67-75% of its Caribbean regional budget to the island between 2017 and 2019. In exchange, Jamaica will have to meet ambitious targets to curb its epidemic, or PEPFAR will leave the English-speaking Caribbean region entirely, including the member countries of the Organisation of Eastern Caribbean States.
In the Caribbean, PEPFAR contributes to the cost of HIV prevention programmes, drug procurement, and the treatment, care and psychosocial support of people living with HIV and AIDS. The Fund also works with community organisations to target HIV prevention and care to LGBT people and commercial sex workers who are on the periphery of direct government programmes. PEPFAR’s interventions are further supported by health experts at US diplomatic missions, where some vacant posts have already been frozen as a result of the clawback.
PEPFAR’s moves now increase the burden on regional governments to bring their HIV/AIDS epidemics under control, even as public finances in several of the affected countries are already stretched. With the exception of Haiti, which will retain its PEPFAR funding entirely, a complete regional pullout would leave a US$9m gap¹ in financing for the Caribbean’s response to HIV and AIDS, based on PEPFAR’s 2014/15 expenditure levels.
Despite some progress, the picture of the Caribbean’s HIV/AIDS response is mixed. Prevention messages that focus on abstinence and condom use are mainstays of national health campaigns, and costly interventions such as drug prophylaxis to prevent HIV infection are off the radar for most. Moralistic views and discrimination against the LGBT community are effective barriers to healthcare, and the prevalence of HIV among these marginalised groups can often run times higher than in the general population.
Strong progress and adoption of international best practices, such as Barbados’ decision to treat all people living with HIV, regardless of the stage of their disease, have been largely supported by PEPFAR funds. Central governments will now have limited time to ensure sustainability of these gains and to finance gaps after the departure of US aid.
While PEPFAR’s Directors made no explicit link between their decisions and President Trump’s dictates to cut America’s levels of foreign aid, the repeal of PEPFAR’s reach in the Caribbean follows the administration’s decisions to cut funding to the United Nations Food and Population Fund, as well as its removal of federal dollars from Planned Parenthood and other international development programmes.
The US Congress recently passed the US-Caribbean Strategic Engagement Act, which an analysis featured in this publication deemed to be an important opportunity for advancing the Caribbean’s interests to the Trump administration. As at press time, sources tell Antillean that health and social development imperatives were not among the priorities advanced by CARICOM for the shaping of the future US engagement policy, despite CARICOM’s ambassadors in Washington and New York being briefed on PEPFAR’s decisions.
¹ Aggregate of PEPFAR’s expenditure on Member States of the Caribbean Community, with the exception of Haiti