Analysis | How a landmark program’s fate could upend girls’ futures (2024)

Good morning! I’m Fenit Nirappil, a public health reporter for The Washington Post. Even as the presidential primaries dominate the headlines, I always appreciate tips about overlooked issues in public health, like the burden of HIV in adolescent girls, which we discuss below. Please send your story ideas and tips to Not a subscriber? Sign up here.

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Today’s edition: A dispatch from New Hampshire on the health issues important to Granite Staters, who just gave former president Donald Trump a resounding win in the first-in-the-nation Republican primary. Why House Republicans are subpoenaing the Biden administration’s health secretary. But first …

How uncertainty about PEPFAR weighs on adolescent girls’ health

The future of the President’s Emergency Relief Plan for AIDS Relief, or PEPFAR, remains up in the air after Congress missed a deadline to reauthorize it, and Republicans, as The Washington Post first reported in October, have delayed more than $1 billion in funding over concerns about inadvertently funding abortion services.


I spoke to Janet Saul, who recently retired after serving as PEPFAR’s director of gender and rights and coordinating DREAMS, an initiative launched in 2014 to prevent HIV cases in adolescent girls and young women in sub-Saharan Africa and Haiti. DREAMS stands for determined, resilient, empowered, AIDS-free, mentored and safe. This conversation has been edited for length and clarity.

H202: How does DREAMS fit into PEPFAR?

Saul: Our previous ambassador at large, Deborah Birx, saw a disparity in the data, that adolescent girls and young women were exponentially more likely to acquire HIV than their male peers. We clearly weren’t meeting their needs. We knew we needed a game changer, something very different because it was obvious business as usual wasn’t working for this population.

H202: Why are adolescent girls far more likely than adolescent boys to acquire HIV?


Saul: Limited educational opportunities, limited economic opportunities, as well as high rates of intimate partner violence, adolescent pregnancy and child marriage. When you look at who adolescent girls and young women have sex with, they tend to be young men approximately eight years older. They are more likely to have HIV than younger men and boys.

H202: So what does it take to prevent HIV cases in young girls?

Saul: In addition to condoms and PrEP [shorthand for pre-exposure prophylaxis], which are really important in HIV prevention education, we have programs to keep girls in school. We have programs to teach them skills for employment or for starting a small business and saving money. We have programs to prevent and respond to gender-based violence. Those become very critical for adolescent girls and young women because of the structural factors that place them at risk.

H202: What’s at stake for this program if PEPFAR isn’t funded?

Saul: Girls that DREAMS would be supporting to stay in school would have to drop out. Girls who are receiving PrEP to avoid HIV may no longer have access to those medications until someone else picks up providing that. DREAMS programming going away will have ripple effects far beyond just the girls engaged in the programs. It provides programs for adolescent boys and young men to understand different ways of thinking about and treating young women.

If you talk to adolescent girls and young women who have become employed and started their own business through DREAMS, they will very proudly tell you how they use their money not just for themselves, but to help their families put food on their table and to send their siblings to school. All of that would be gone.


Globally, 71 percent of new infections among 10-to-19-year-olds are in girls. DREAMS ending would put a big dent in our progress in ending HIV as a public health threat by 2030.

H202: What else do you want people to know?

Saul: As we all saw with covid and Ebola, infectious diseases don’t know any borders, so they can affect health worldwide as well as the world economy. Preventing HIV among adolescent girls and young women and other highly vulnerable populations is important and not just for those individuals, for their communities, their countries, but also the entire world. We can’t underestimate the global connections and ripple effects of good public health programming and the lack of good health programming.

From our notebook

KFF Health News’s Phil Galewitz sends us this dispatch from New Hampshire:


Yesterday’s events largely turned on voters’ feelings about former president Donald Trump, but health-care issues — access, costs, the Affordable Care Act and, especially for Democrats, abortion — weren’t far from mind, I found in interviews with more than 50 Granite Staters. Here’s a snapshot:

Democrats were more likely to cite health care as a top concern than Republicans. “Health care is my No. 1 issue,” said Ben Gilson, 90, a retired orthopedic surgeon. While he said he has excellent coverage and pays little in out-of-pocket costs, he worries many younger people struggle and wants to make sure the Affordable Care Act is retained.

Trump supporters frequently pegged illegal immigration as their most important issue. “The border is a disgrace,” said Art Sullivan, 75, a registered independent. Asked if health care is something he thinks about when comparing candidates, he said he has a Medicare Advantage plan that covers his bills and provides access to care.


And fans of Nikki Haley were focused primarily on defeating Trump. Elaine Kozma, 73, said health-care issues are vitally important to her as a cancer survivor. Haley won Kozma’s vote because she thinks she can trust her more than the former president.

In the end, Trump beat Haley decisively in the GOP primary, while President Biden won the Democratic contest as a write-in candidate. You can read Phil’s full report here.

On the Hill

House Republicans subpoena HHS secretary

Republicans on the House Judiciary Committee subpoenaed Health and Human Services Secretary Xavier Becerra yesterday for information on his agency’s Office of Refugee Resettlement.

The details: Chairman Jim Jordan (R-Ohio) ordered Becerra to release documents and communications related to the office’s vetting and placement of unaccompanied children with suspected gang or criminal ties found crossing the U.S.-Mexico border.


  • An HHS spokesperson told The Health 202 that the agency has been cooperating with the committee and will continue to do so, adding that the subpoena is “entirely without basis.”

Meanwhile, across the Capitol …

Senate Finance Committee Chairman Ron Wyden (D-Ore.) sent letters yesterday to five third-party marketing organizations seeking information on their practices during the Medicare Advantage open enrollment period.

The letters — sent to the leaders of eHealth, GoHealth, Agent Pipeline, SelectQuote and TRANZACT — request details on how the firms use insurance agents, lead generators and other data to steer seniors toward certain Medicare Advantage plans.

  • A spokesperson for eHealth confirmed that the company received Wyden’s request and will respond to the committee directly. The other recipients did not respond to a request for comment.

Reproductive wars

Haley’s messaging on abortion could threaten Democrats’ 2024 pitch

Republican presidential hopeful Nikki Haley’s calls for “consensus” on abortion have drawn mixed views and sometimes conflicting interpretations on the campaign trail. They’ve also helped her appeal to voters on both sides of the issue, The Post’s Dylan Wells reports.


In New Hampshire, some voters said they see her as supportive of abortion rights, others as antiabortion. Many agreed the former South Carolina governor appears more reasonable and less extreme than her rivals.

Reality check: Haley is in fact staunchly antiabortion. But in interviews, many Democratic and independent voters said they were willing to look past concerns they have about her record or the possibility of a GOP president passing a federal ban — in large part because she has spoken in more personal and cooperative terms than other Republicans.

That concerns Democratic strategists, who fear that if she does beat the odds and become the GOP nominee, it would be much more difficult to run on an issue they want to make central to their pitch for President Biden’s reelection. Among Republicans, some see Haley’s messaging as a blueprint for talking about abortion in the future, as the GOP has struggled to navigate the politics of the issue since Roe v. Wade was overturned in 2022.

In other health news

  • A North Dakota court denied a request to temporarily block a portion of the state’s abortion ban that doctors say puts them at risk of criminal prosecution if they terminate a pregnancy to save a patient’s life or health, Jack Dura reports for the Associated Press.
  • Democratic lawmakers in Oregon unveiled a bill yesterday that would roll back a key section of the state’s pioneering drug decriminalization law, responding to fierce backlash over an explosion of public drug use and a surge in overdose deaths, Oregon Public Broadcasting’s Dirk VanderHart reports.
  • A federal appeals court upheld Martin Shkreli’s lifetime ban from the pharmaceutical industry. Shkreli gained national notoriety for hiking the price of a lifesaving drug and later served almost seven years in prison for defrauding investors, Bob Van Voris reports for Bloomberg News.
  • Nearly a dozen cases of measles have been reported in Pennsylvania, Virginia and Georgia in recent weeks, according to local health departments. International travel, coupled with declining global vaccination rates, is probably behind this spate of cases, experts tell Amanda Musa and Carma Hassan of CNN.

Health reads

At Va. rally, Biden and Harris blast Trump for antiabortion push (By Toluse Olorunnipa | The Washington Post)

Sugar rush

Thanks for reading! See you tomorrow.

As a public health expert with a focus on HIV prevention and global health programming, I can provide detailed insights into the concepts and initiatives discussed in the article you provided. Let's break down the key points:

  1. PEPFAR (President's Emergency Plan for AIDS Relief):

    • PEPFAR is a U.S. governmental initiative to address the global HIV/AIDS epidemic, particularly in hard-hit regions like sub-Saharan Africa and Haiti.
    • It was established in 2003 and has been instrumental in providing HIV/AIDS treatment, care, and prevention services worldwide.
  2. DREAMS Initiative:

    • DREAMS stands for "Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe."
    • It is an initiative launched in 2014 under PEPFAR to prevent HIV infections among adolescent girls and young women in sub-Saharan Africa and Haiti.
    • The initiative focuses on addressing socio-economic factors like limited educational and economic opportunities, intimate partner violence, adolescent pregnancy, and child marriage that contribute to the high HIV prevalence among this demographic.
  3. Challenges Faced by Adolescent Girls:

    • Adolescent girls and young women are disproportionately affected by HIV compared to their male peers due to various factors such as limited access to education and economic opportunities, high rates of gender-based violence, and age-disparate relationships.
  4. HIV Prevention Strategies:

    • Prevention strategies for HIV among adolescent girls include comprehensive approaches such as education on condom use, PrEP (pre-exposure prophylaxis), keeping girls in school, providing economic opportunities, and addressing gender-based violence.
  5. Impact of Funding Uncertainty on PEPFAR and DREAMS:

    • The future of PEPFAR and the DREAMS initiative is uncertain due to funding delays and missed reauthorization deadlines in Congress.
    • Lack of funding would jeopardize essential services like HIV prevention education, access to PrEP, and programs aimed at keeping girls in school and addressing socio-economic factors contributing to HIV risk.
  6. Global Health Impact:

    • The continuation of effective public health programs like PEPFAR and DREAMS is crucial not only for the individuals and communities directly affected but also for global health security and economic stability.

By addressing these key points, we can understand the significance of ongoing efforts to combat HIV/AIDS among vulnerable populations, particularly adolescent girls and young women, and the broader implications of funding uncertainties on global health initiatives like PEPFAR.

Analysis | How a landmark program’s fate could upend girls’ futures (2024)
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