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Lawmakers, former officials urge structured transition of PEPFAR to country ownership to protect gains and U.S. interests
Summary
Witnesses and members said PEPFAR should move toward country led programs with clear benchmarks and private‑sector involvement while guarding against chaotic withdrawals that could harm public health and U.S. diplomatic interests; China’s increasing presence in Africa was cited as a security risk if transitions fail.
Ambassador Mark Dybul, former U.S. officials and members of the subcommittee told the panel that PEPFAR’s long‑term sustainability requires carefully planned transitions to domestic financing, private‑sector engagement and stronger country ownership.
Dybul and other witnesses said domestic financing already accounts for a rising share of HIV financing—one figure cited during the hearing put domestic sources at about 59 percent of HIV‑related spending in 2023—and that many countries could begin structured transitions now. Dybul said roughly three dozen countries with substantial PEPFAR and Global Fund allocations could “successfully transition within a few years,” provided the U.S. and partner governments negotiate formal compacts with annual, transparent benchmarks and reductions rather than abrupt cuts.
Witnesses and members emphasized that faith‑ and community‑based organizations would be particularly vulnerable to an unstructured withdrawal because many governments do not have mechanisms to fund them. Multiple witnesses urged integrating U.S. development finance and trade instruments—cited examples included the U.S. International Development Finance Corporation and the Millennium Challenge Corporation—to bring private investment and create markets that sustain health gains.
Several lawmakers framed the transition question in national security and diplomatic terms. Amb. Dybul and others argued that PEPFAR had created “soft power” benefits—one witness quoted a clinic director in Axum, Ethiopia saying, “PEPFAR means the American people care about us”—and warned that rapid U.S. retrenchment would open diplomatic and economic space that China, Russia and other competitors could fill. Members asked witnesses whether a properly executed transition would deny competitors a foothold; witnesses replied that a well‑managed handover to local governments and private partners would reduce that risk, while chaotic withdrawal would create openings for outside actors.
Members also asked about new technologies that could help achieve sustainability, including long‑acting injectable pre‑exposure prophylaxis and potential vaccines. Witnesses said those products could reduce new infections and lower long‑term treatment burdens, but stressed that they are supplements, not substitutes, for steady program operations and careful transition planning.
Across the hearing witnesses agreed on two priorities: avoid abrupt cuts that would reverse health gains, and develop country‑by‑country transition plans with clear timelines, realistic benchmarks and private‑sector participation. Several members urged the administration and implementing agencies to provide such transition compacts to the committee as part of FY2026 appropriations oversight.
