BANGKOK — Now entering its 21st year, the U.S. President’s Emergency Plan for AIDS Relief, the largest commitment by a country to eliminate a disease, is considered a government success story, credited with major advancements in combating HIV/AIDS globally.

But this year, eight provisions of the law also known as PEPFAR are up for reauthorization, making it a key health measure up for congressional consideration.

It’s early in the process, but major overhauls to the law this year so far look unlikely. Instead, both the Biden administration and lawmakers on both sides of the aisle are eyeing a clean reauthorization and no changes to annual appropriations. Biden requested $4.8 billion for fiscal 2024 in direct global HIV funding, consistent with what it has received since fiscal 2019.

Quietly, though, advocates warn that factors like the COVID-19 pandemic, inflation and ambitious U.N. pledges to eliminate the HIV/AIDS epidemic by 2030 have raised the pressure to not lose progress. 

Advocates who’d like more money for the program are muting their concerns, worried about undermining bipartisan understanding of an agreement and jeopardizing the program. If one person opens the door, one global health advocate warned, then everyone will.

Still, the concerns come at a crucial time: Changes to other countries’ domestic public health policies could jeopardize the same groups PEPFAR aims to help, including sex workers, transgender individuals or men who have sex with men. 

All are at increased risk of infectious diseases like HIV. 

Thailand

One of the countries that has received PEPFAR aid, Thailand, is famous for its red light districts, which are home to an estimated 100,000 to 300,000 sex workers and a key driver of international tourism. Experts estimate sex tourism accounts for 10 to 12 percent of the country’s gross domestic product, though prostitution remains illegal in Thailand and sex workers face a number of barriers to accessing health services and other basic needs. 

Thailand relies on community-based organizations, funded both domestically and through PEPFAR, to reach out to populations like sex workers who are more likely to fall through the cracks of the health system. Thailand began receiving PEPFAR funds in fiscal 2007 but in recent years has transitioned from relying on the Global Fund and used additional bridge funds hoping to shift to a fully domestic HIV response.

Of the $4.8 billion in funding, some $223 million went toward preventative services for 3.9 million people in key populations globally in 2022. About $28 million or 12 percent of that was targeted at sex workers.

Two recent Thai policy changes could hinder efforts to reduce the spread of HIV.

The Thai government announced it would no longer reimburse community groups serving at-risk populations for services where a client could be covered by their own insurance, including for HIV testing and treatment. Thailand provides universal health coverage through its three-tier system for civil servants, private sector employees and for all other citizens.

The National Health Security Office, a Thai health agency, also began prohibiting community groups from prescribing pre-exposure prophylaxis, which reduces the odds of contracting HIV, shifting this burden fully to hospitals. 

Stephen Mills, an epidemiologist and regional director for the USAID-supported EpIC program at FHI 360, a global health nonprofit, said the changes “will prevent Thailand from remaining a model system in the fight for HIV epidemic control.”

Mills said Thailand’s health security office has submitted a petition to the country’s Office of the Council of State, to review the legislation that prompted the change. The result of that interpretation is expected later this year, he said, and his organization has worked with community organizations to help them survive in the interim.  

Mills said PEPFAR “has been indispensable” in helping countries such as Thailand  confront the HIV epidemic. 

Still, the changes have had an impact on groups such as the Thai-based Sex Workers In Group, or SWING, which connects mostly female and transgender sex workers to health services and other necessities. The group, founded in 2004 to address rising HIV rates among sex workers, has received funding from PEPFAR and the U.S. Agency for International Development.

Surang Janyam, SWING’s director, told CQ Roll Call in November that while the universal health insurance system is good for Thai people, the policy requires getting care in your hometown or where you register. 

But many of SWING’s patients have moved from other parts of Thailand and are reluctant to go home because of the stigma of working in the sex industry or the expense of traveling home.

One Friday night last November, at SWING’s offices in the heart of Patpong, a Bangkok red light district popular with foreign tourists and expatriates, Dara, whose name was changed to protect her privacy, spoke of working in her hometown as a hairdresser for 12 years before leaving her ex-husband to move to Pattaya and then Bangkok to pursue sex work. 

An animated, confident woman in her 30s, she said she plans to stop doing sex work in about 10 years when her kids are done with college. She initially paid for her pre-exposure prophylaxis at a local hospital but switched to SWING, where she could also get birth control. 

Thai policy changes mean she will have to seek services using her Thai private plan tier.

Nok, a 35-year-old transgender sex worker from central Thailand, whose name was also changed to protect her privacy, said she has been working for six years in the industry. Speaking through a translator, Nok said she grew up poor and had to quit school as a teenager, but sex work has been lucrative for her to help her sick mother.

Though Nok received her pre-exposure prophylaxis at another clinic, she and Dara lost access in January, when the Thai government stopped community clinics from providing the drug for free.

Congressional debate

Although early indications are that this year’s PEPFAR reauthorization will be straightforward, past debates have been fraught. PEPFAR’s first reauthorization in 2008 saw partisan tensions rise over liberal pushes to modify funding restrictions — such as an ill-fated attempt to remove a policy barring funding for groups that advocate the legalization of prostitution.

Much of the law is permanent, but reauthorization will allow Congress to revisit parts of it. Congressional committees have not established a timeline for legislative action, but on April 19, the Senate Foreign Relations Committee kicked off its first hearing on PEPFAR’s reauthorization.

“As it is known this next five years will determine whether we meet the goal of ending the global HIV AIDS epidemic by 2030, we must not take our foot off the accelerator if we hope to be successful,” said Chairman Bob Menendez, D-N.J., during the hearing.

Meanwhile, ranking member Jim Risch, R-Idaho, cautioned against dramatic changes to the program.

“We do not need to recreate the wheel,” he said. “Let’s not bog down the process by wordsmithing what already exists. This program is too important for that.” 

Sawitree Wongketjai, a Thai journalist, contributed to this report.