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Tue December 17, 2013
How The U.S. Helped Fight The Global AIDS Epidemic
Originally published on Wed December 18, 2013 7:50 am
A decade ago, President George W. Bush announced an unprecedented global health initiative: $15 billion over five years to fight HIV in developing countries.
"There are whole countries in Africa where more than one-third of the adult population carries the infection," Bush said in his 2003 State of the Union address. "Yet across that continent, only 50,000 AIDS victims — only 50,000 — are receiving the medicine they need."
Congress quickly passed the bill. By the end of May 2003, the President's Emergency Plan for AIDS Relief, or PEPFAR, was law.
Over the past decade, the U.S. has spent more than $50 billion on PEPFAR, largely to test and treat people for HIV in sub-Saharan Africa.
Some health officials have questioned whether PEPFAR has drained money from addressing other problems. But in general, the initiative has been considered a success.
Nearly 10 million people around the world now have access to antiviral drugs, and treatment for two-thirds of these people is directly supported by PEPFAR, the U.S. government reported earlier this month. Treatment for HIV-positive mothers funded by PEPFAR prevented 740,000 infants from getting infected with the virus at birth.
Back in 2003, South Africa was the epicenter for the global AIDS epidemic. Infection rates were soaring. More than a quarter of pregnant women were HIV positive. And yet the government was still denying that there was a connection between HIV and AIDS.
NPR's Melissa Block talked Tuesday with Dr. Francois Venter, a South African HIV specialist, about PEPFAR's impact in South Africa, which has received more money from the initiative than any other country.
Venter, who is at the Wits Reproductive Health and HIV Institute, was part of a secret task force within South Africa that was trying to come up with a response to the epidemic.
On the situation in South Africa
At the time, we were having running battles with what was then the "denialist" government. They were trying to stop us from giving antiretroviral drugs to stop mother-to-child transmission.
It was a really tragic time. The minister of health, the president, the whole cabinet was just running interference. And at the time, the PEPFAR money started to roll in ... I can't tell you how bizarre the situation was, where you have the minister of health and the president saying they don't believe HIV exists on the one hand. And then these drugs were flowing freely, almost, in certain places and in certain clinics.
On the magnitude of funding for PEPFAR and its initial goals
When Bush said $15 billion — it's such a large amount of money. Firstly, I don't really know the concept of what that means ... I don't think we anticipated how direct that support was going to be. It came with lots of constraints, but they kind of turned around to us and said, "Put as many people on antiretroviral therapies as you possibly can. Test as many people for HIV as you possibly can."
It was a very different world suddenly.
And you have to understand that nobody had done anything on this scale before. So there were a lot of mistakes to be made. I have criticisms of the approach. I think there wasn't nearly enough focus on how to disburse the funding.
On what he could initially accomplish with PEPFAR money
We were able to hire staff, and we were able to buy drugs. We could fix little aspects of the government. I remember my own clinic: We first were able to renovate the place ... We were able to put in additional pharmacy staff, additional doctors, additional nurses.
I think PEPFAR, really, has saved a huge number of people's lives. This has been one of the most effective public health inventions outside of clean running water, decent nutrition and vaccine programs. This has made an unbelievable difference.
MELISSA BLOCK, HOST:
Imagine a large scale government program, one that involves a lot of federal spending to help people not here in the U.S., but in foreign countries and it's a program that has enjoyed deep bipartisan support for more than a decade. Let's go back to January 28, 2003.
PRESIDENT GEORGE W. BUSH: Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many.
BLOCK: In his State of the Union Address that year, President George W. Bush announced a public health initiative of unprecedented scale, the President's Emergency Plan for AIDS Relief, or PEPFAR.
BUSH: There are whole countries in Africa where more than one-third of the adult population carries the infection. Yet across that continent, only 50,000 AIDS victims, only 50,000, are receiving the medicine they need because the AIDS diagnosis is considered a death sentence, many do not seek treatment. Almost all who do are turned away.
BLOCK: President Bush told the nation what he was proposing was a work of mercy beyond all other efforts at that time.
BUSH: And I ask the Congress to commit $15 billion over the next five years to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.
BLOCK: His request was met with a standing ovation. Congress quickly passed the bill with broad bipartisan support. By the end of May, PEPFAR was law. Fast forward 10 years, nearly 10 million people have access to antiretroviral drugs, or ARVs, two-thirds of them directly supported by PEPFAR. The U.S. government has, to date, spent more than $50 billion fighting HIV/AIDS around the world.
Tomorrow, on the program, we'll address some of the challenges ahead. Today, a look back at what the PEPFAR initiative has accomplished. Think about what was happening with HIV/AIDS in the early 2000s. We asked leaders in the field to talk about what was going on in Sub Saharan Africa.
ANTHONY FAUCI: My name is Dr. Anthony Fauci and I'm the director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health.
LAURA GUAY: My name is Laura Guay. I'm the vice president for research at the Elizabeth Glaser Pediatric AIDS Foundation.
DAVID WILSON: My name is David Wilson. I'm the World Bank's Global AIDS Program director.
FAUCI: Well, my concern was that we were having a pandemic that was completely out of control, particularly in the developing world.
WILSON: At the peak of HIV and before treatment, people's entire social lives were visiting hospital beds, attending funerals over weekends. You saw people in the hospital who were wasting to death. You'd see people in the streets who were emaciated and thin. When you drove on the highways to cemeteries there was mile after mile of coffin (unintelligible).
GUAY: The wards were filled with people who were dying. There were very few programs to support people living with HIV. Early on, there was a lot of concern that we would never be able to do it. It's very difficult. There's a very limited health structure. It's a complex treatment and it just couldn't be done so it was not going to be a good investment.
FAUCI: When the president stepped forward, President Bush, that's when I started to feel that we could do something about turning this pandemic around.
WILSON: I think the scale of the initiative and its ambitiousness took us all aback.
GUAY: The money, when we heard about it, was a phenomenal amount and I think beyond all of our expectations.
WILSON: Now, a figure like that for global health or for HIV seems feasible, even normal, but at the time, it was breathtaking. It was very hard to believe.
FAUCI: There's no question. I felt it strongly then and now that he really had a genuine sincere feeling and conviction that we needed to do something about this and we needed to do it in a way that was responsible, a way that was transforming and that was accountable.
GUAY: But it was a big task, a huge undertaking to transform the AIDS epidemic in a continent and elsewhere in the world. It wasn't going to be done with a small amount of money.
BLOCK: We heard from Laura Guay, Anthony Fauci and David Wilson, three longtime players in the HIV/AIDS world. To understand the magnitude of PEPFAR's impact, take the case of South Africa, which has received more PEPFAR money than any other country.
In 2003, South Africa was the epicenter of the epidemic. Infection rates were soaring. More than a quarter of pregnant women were HIV positive and yet the South African government refused to act. Dr. Francois Venter, was part of a secret task force within South Africa's Department of Health that was trying to come up with a response.
FRANCOIS VENTER: You know, at the time, we were having running battles with what was then the denialist government who were trying to stop us from giving antiretroviral drugs to stop mother-to-child transmission, who were making life just very miserable in terms of accessing drugs.
BLOCK: This is the South African government at the time, which denied a connection between HIV and AIDS.
VENTER: That's correct. It was a really tragic time. The minister of health, the president, the whole Cabinet were just running interference. And at the time, the PEPFAR money started to roll in. So it was a very complicated, but very interesting and very productive dance almost between the Bush administration and this denialist government.
I can't tell you how bizarre the situation was where you have the Minister of Health and the president saying they don't believe HIV exists. (unintelligible) one hand and then these drugs are flowing freely almost at certain places encircling the experience.
BLOCK: President Bush, in that State of the Union Address, specifically said I'm asking Congress for $15 billion over five years. You didn't think that would happen.
VENTER: Yeah, and when he's at $15 billion, that such a large amount of money. Firstly, I don't really know the concept of what that meant. I also have no idea of what it was intended for. I don't think we anticipated how direct that support was going to be. You know, it came with lots of constraints. But they kind of turned around to us and said, Put as many people in ARVs as you possibly can. Test as many people for HIV as you possibly can.
It was a very different world suddenly. And you have to understand that nobody had done anything on this scale before, so there were a lot of mistakes to be made. I have criticisms of the approach. I think there was not nearly enough focus on how to disburse the funding. These were organizations that weren't used to receiving massive amounts of money. I don't think I've yet to hear of a large corruption scandal within PEPFAR. I think that's a testament to the kind of oversight that they insisted on.
But you had organizations who suddenly had their budgets increased tenfold almost within a year. I think that there was not enough support that came with this huge amounts of money, and we were learning on the run.
BLOCK: Well, as you started to see this PEPFAR money coming to South Africa, were you able to do that you couldn't before?
VENTER: We were able to hire staff and we were able to buy drugs. And we could fix little aspects of the government. I remember at my own clinic, we first were able to renovate the place and put in some TB infection control measures. We were able to put in additional pharmacy staff, additional doctors, additional nurses systems. Then we were able to start trying to take the healthy patients and move them out of the sick person's clinic into the periphery, and use staff to start tracking them.
We were able to fiddle with different mobile clinic HIV testing. We were able to treat communities that really had never had proper healthcare service. In particular, our group looked after a large sex worker program. And more recently, PEPFAR has (unintelligible) these innovation grants. And we've been able to address (unintelligible) high risk of mobile populations like truckers. And we expand the sex worker program to a whole range of other areas.
I think PEPFAR really has saved huge numbers of people's lives. This has been one of the most effective public health interventions. Outside of clean running water, decent nutrition and vaccine programs, this is made an unbelievable difference.
BLOCK: Well, the U.S. government is now saying that more responsibility for HIV AIDS work is going to be transferred to local governments, to countries. And they're using your country, South Africa, as an example. I believe they're going to.
What impact do you think that'll have on the work that you do?
VENTER: I have different feelings about it. It's very hard for me to justify a middle-income country like South Africa taking money from the American government and using it to buy drugs, when next door in a country like Uganda or Malawi or Zambia, the government doesn't have the money to pay for the drugs. We have the money to pay for the drugs. I think most of my colleagues would actually agree with that. And, in fact, the government agrees with that.
I think we're PEPFAR is at its strongest in South Africa is what is using technical support, how to write guidelines, how to look at one dream valuation system. We have a rich country in South Africa but we don't have the technical ability to actually often execute the programs. So I think it's appropriate that there's withdrawal and that there's a rationalization process, and that that money actually goes elsewhere.
I think it would be tragic though if PEPFAR - millions of people would die if PEPFAR withdrew from many of the other African countries - that's not the case in South Africa.
BLOCK: That's François Venter of the Wits Reproductive Health and HIV Institute in Johannesburg.
Tomorrow, more on the next leg of fighting HIV-AIDS. We'll hear from our correspondent in Kenya about that country's efforts to halt the spread of the disease.
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BLOCK: ALL THINGS CONSIDERED continues in a moment.
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