Seasoned Experts Weigh in on PEPFAR

A cast of seasoned AIDS experts gathered at the Center for Strategic and International Studies (CSIS) on Saturday evening, July 21, to weigh in on the President’s Emergency Plan for AIDS Relief (PEPFAR) on the eve of the XIX International AIDS Conference, dubbed “AIDS 2012”.

The conference is taking place in the USA for the first time in 20 years thanks to President Obama’s lifting of the travel ban on HIV-positive visitors.

“What has been PEPFAR’s strategic significance?”

An illustrious panel including Ambassador Eric Goosby (United States Global AIDS Coordinator), Ambassador Mark Dybul (former United States Global AIDS Coordinator), and Dr Anthony Fauci (Director of National Institute of Allergy and Infectious Diseases, NIAID) discussed the first topic: “What has been PEPFAR’s strategic significance?”

Dr Fauci, who was one of the architects of PEPFAR, talked of the humanitarian and moral responsibility that George Bush felt. He mentioned an African male comment that “PEPFAR is the best thing that ever happened to Africa.”

Amb Dybul, another architect of PEPFAR, reiterated that the “driving force was moral responsibility” but also commented on a “moral visceral reaction” that Pres Bush felt whenever he heard people say that Africans were too poor to take AIDS medicines or that they were too promiscuous. He explained that Pres Bush believed that it “represents the conscience of the US people.” He told a story of how a patient described PEPFAR by saying “it means that Americans care about us.” Amb Goosby commented that Pres Bush created PEPFAR because of the moral imperative and the fact that we could respond. He noted “talk is cheap; actions speak louder than words.”

All three panelists voiced concern about fatigue with respect to humanitarianism and ethical issues, such as HIV and PEPFAR, and warned the audience that we cannot afford fatigue 18 months prior to the re-authorization of PEPFAR. This led to the conclusion that we must shift the message to “we can control AIDS,” “we can fix the problem,” and we can create an “AIDS-free generation.”

The second panel shared their answers to the question “What has PEPFAR taught us, for good and bad?”

Dr. Wafaa el Sadr of ICAP praised PEPFAR as providing as place for innovation, for learning on the ground, for fast translation of science into action followed by enormous scale up, and for problem solving by health care workers and policy makers. She thinks the early perception was that PEPFAR was run by Washington DC and not owned locally, but then argued that PEPFAR could not have achieved what it did without country ownership. Dr el Sadr also described as a tragedy the people who have the courage to have an HIV test, only to test positive, but have a CD4 count above the level eligible for treatment.

Dr Alex Muganzi of Uganda described PEPFAR as “the best things that has happened to Africa with respect to HIV.” He described the early days when medicines were very expensive and health care workers had to choose who would receive them; he equated it to ‘acting like God.” PEPFAR revolutionized HIV treatment, shattered misconceptions that Africans cannot adhere to an HIV medicine regimen, and increased the role of civil society.

Dr Jeff Springer, drawing on his experience in Zambia, noted the prevailing beliefs that patients would not come due to stigma, that labs could not handle HIV tests, that patients could not take medicines … all these preconceptions were blown away, leading to a “paradigm shift about what is possible.”

“What Should PEPFAR look like in five years?

The last panel brought together Dr Chris Beyrer, Dr Kevin De Cock, Dr Tom Quinn and Dr David Serwadda to debate: “What PEPFAR should look like in five years” and in particular, reaching an “AIDS-free generation.”

Dr Beyrer cautioned that HIV prevalence will increase as more people live longer thanks to HIV medicines. He expects declining incidence and lower levels of transmission. He cautioned, however, that HIV epidemiology keeps changing and we “can’t get to an AIDS-free generation without addressing these populations”: sex workers, men who have sex with men, and injection drug users.

Dr De Cock added that the term “AIDS-free generation” also means virtual elimination of mother to child transmission and that all persons with HIV access medicines early with the best available medicines. He questioned why none of the previous panelists mentioned medical male circumcision, to which Dr Quinn commented that it’s “the most cost-effective prevention intervention today.”

Dr Serwadda requested that we look longer than five years. He focused heavily on country ownership, challenged PEPFAR to engage countries more, and insisted that “governments must put their mark on it.” With respect to most at risk populations, Dr Serwadda suggested that countries should look at the epidemiology, identify the new infections and put the money there; he predicts that at some point, “countries will come around and put the money there.”

PEPFAR Featured in Journal of AIDS

The Saturday evening panel discussion coincided with the launch of a special issue of the Journal of AIDS: “PEPFAR: Its Vision, Achievements and New Directions,” highlighting a “decade of data and experience.” Read the special JAIDS issue on PEPFAR.

Sara A. Holtz, DrPH, MPH, is senior technical officer at Management Sciences for Health.

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