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Special Briefing On the U.S. Commitment to Fight AIDS and the Launch of PEPFAR's New Five-Year Strategy


Special Briefing
Eric Goosby, M.D.
U.S. Ambassador, Global AIDS Coordinator
Washington, DC
December 1, 2009

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MR. DUGUID: Good afternoon, ladies and gentlemen. Welcome to the State Department this afternoon. We are with Ambassador Eric Goosby, who is the U.S. Global AIDS Coordinator. His duties include running the entire U.S. Government’s international HIV/AIDS efforts. In this role, Ambassador Goosby oversees the implementation of the U.S. President’s Emergency Plan for AIDS Relief that is, PEPFAR – as well as the U.S. Government engagement with the Global Fund to Fight AIDS, Tuberculosis and Malaria.

With that, I give you Ambassador Goosby.

AMBASSADOR GOOSBY: Well, thank you. It’s a pleasure to have an opportunity to talk to you today. I’d like to begin to – with acknowledging the efforts of many people on PEPFAR from the State Department, USAID, CDC, Department of Defense, Peace Corps, and other agencies that all contribute their expertise at field headquarters to make this program work. It’s a combination of people all over the world who support people in-country to put the programs in place, really quite an orchestration.

I’d also like to acknowledge the efforts of President Bush and members of Congress from both sides of the aisle for creating and supporting this program. I’ve been working in HIV/AIDS for 25 years, both domestically and internationally. And I can remember the days before PEPFAR was in place – they weren’t that long ago – when patients were two, three in a bed, put under the bed, on the floors, in the hallway of most of the Sub-Saharan African countries that we’re engaged in now, waiting for treatments that basically weren’t available.

Today, the situation is markedly different. PEPFAR has brought hope to millions of people across the world with its treatment and care programs. In 2009 alone, PEPFAR has supported life-saving antiretroviral therapy for more than 2.4 million people, essential care to nearly 11 million people, and counseling and testing for nearly 29 million people. And through efforts to prevent mother-to-child transmission, PEPFAR prevention of transmission from mother to child for 100,000 babies born to HIV-positive mothers in the past year alone, building upon the nearly 240,000 babies born HIV-free over the past five years.

But unmet needs are still the dominant feature of this program. We have gotten through approximately a third of the population that is in need of care and the millions who are participating in high-risk behaviors who need prevention interventions. There are an estimated 33 million people living with HIV, 2.7 million new infections occurring annually, approximately 2 million deaths annually, and for every two people we’ve put on treatment, five more have become infected. If we are to sustain the gains we’ve had and have made against this epidemic, PEPFAR must work in closer collaboration with country governments to support and mount a truly global response to the shared global burden of disease.

Today, I’m announcing the release of our five-year strategy, which will be followed later in the week by the release of several annexes with more information about specific areas within the document. Let me give you a quick overview of PEPFAR’s next phase.

First, we’re going to begin transitioning from an emergency response to a sustainable one through greater engagement with and capacity building of governments. PEPFAR has already started this with its Partnership Framework activity, which is a five-year strategic plan developed in collaboration with our partner governments. But we need to do more, especially around supporting the creation of mid-level government capacity to oversee, manage and eventually finance these programs. It is a good start.

Secondly, we’re going to focus on prevention. We’re going to scale up highly effective prevention interventions like male circumcision, prevention of mother-to-child transmission. We’re going to work with countries to determine not just how many people are infected in their communities, in their countries, but where the new infections are occurring. Geomapping and understanding that demographic relationship to geography allows you to make decisions around prevention program positioning, so you can put your programs in front of that expanding movement of the virus through the population.

With treatment, we will continue a strategic scale-up of services to more than four million people. The focus will be on certain populations – the sickest, pregnant women, pregnant women in general who are HIV-positive, and HIV/TB co-infected individuals – while we work with both our country partners in the international community to continue to lower the price of commodities and distribute the costs of treatment among multiple funders.

As we carry out these prevention, care and treatment activities, we will do so with an eye toward how these activities strengthen the broader health system. We will work not only to continue our quality delivery of services and expansion of both care, treatment and prevention services, but we will also look to create a durable response that can benefit the entire healthcare system and continue the expansion and capability of services for what are often HIV-positive populations.

I look forward to working closely with partner countries, other donors, and PEPFAR staff in the field to implement the concepts of this strategy. I’d like to thank you, and I’m open to any questions that you might have.

MR. DUGUID: Jill.

QUESTION: Mr. Goosby – Ambassador Goosby, this shift from the emergency response to this sustainable one is very controversial, as you know, in the AIDS community, because some people say it takes attention away from the people who really need it, the people with AIDS, and kind of spreads it out to people – you know, mothers, children, people with other diseases, et cetera. How do you answer that?

AMBASSADOR GOOSBY: Well, I think that 60-plus percent of the people HIV-infected are women, that the person who normally shows up in the clinic visit are women, that our ability to access children comes through our ability to access women, our ability to access their partners, their husbands, 90 percent of the time is coming from an interface initially with the woman.

Men come into care very late, usually with an opportunistic infection, when they are well into symptoms, very late stage disease. And our best chance at changing that dynamic is to target women at the earliest stages of – in prenatal context, but also as they bring their children in for well-baby visits or immunizations. We believe that it is justified on a public health basis to go through a woman conduit to the whole family.

We are not talking about decelerating our activities in care, treatment, or in prevention. Indeed, our emphasis will continue a care focus, a treatment focus. Where we have to and need to turn the volume up is in our ability to aggressively get in front of the movement of that virus through each population, the prevention activities. So it’s not an abandonment. It is an expansion of those services. So the concern around an inattentiveness to what is a burden of disease that is about one-third addressed is not part of our strategy. We are actually trying to aggress on all fronts.

QUESTION: But the money that’s spent would be apportioned differently, then?

AMBASSADOR GOOSBY: Well, to say how much your treatment prevention and care dollars go from a 30,000-foot level loses a whole lot in translating down to the actual region, city, neighborhood within the city, for how and where your opportunities present themselves. It is always a prevention treatment continuum. Some opportunities in prevention are always there, some treatment needs are always there. And it’s up to those who are in front of the epidemic to decide how they divide their resources at that level to address the needs in front of them.

We are not saying that we’re going to put X amount into prevention, treatment, and care. We are going to expand services in all areas, but we are going to become more efficient in our ability to prevent vertical transmission from mother to child. We are going to start targeting high-risk populations as opposed to general public service announcements that have dominated PEPFAR 1 as one of the central strategies – the abstinence, be faithful type of activity. We’re linking family planning, reproductive health services to our prevention efforts because they are more effective. Those needs are going largely unaddressed, and where interfaced with populations that need both, we should overlap them.

The movement into other services are also logical, easy, where the medical infrastructure that’s in place to deliver the antiretrovirals should be the platform on which we expand into immunizations for the children that are coming into the clinic with their mother when they’re coming into the clinic for their antiretroviral care. We should not be afraid of immunizing the children in that setting. Looking for that kind of synergy is how we hope to expand some service constellations without dismantling the core functional component that’s already in place.

This will identify efficiencies that are considerable in our ability to move from a general population-based information system to high targeting of high-risk groups, targeting of high-risk groups as the key kind of shift in the strategy. It’s evidence-based. It’s more effective. It’s also cheaper.

MR. DUGUID: Thank you. I think Reuters is next.

QUESTION: Yeah, Andy Quinn from Reuters. Still along these lines, some critics are voicing fears that this – because of what they interpret as a funding shift may mean treatment interruptions in some cases, and particularly in some African countries – Uganda has been cited. Is the U.S. committed to preventing treatment interruptions in countries where PEPFAR is already involved? And what is the current U.S. understanding of this idea of universal access? Are we no longer thinking about ARVs as something that can be universally accessible with U.S. help?

AMBASSADOR GOOSBY: We have worked tirelessly to prevent stock-outs, which are largely not happening in PEPFAR. We are also looking to get those who are most ill lower T-cell counts coming out of opportunistic infections, those who are co-infected with tuberculosis, those who are pregnant, on antiretrovirals as early as we can meet them, stage them, remove the confounder of opportunistic infections and engage in antiretroviral therapy.

Fully committed to that, and to expand that capability, we know that we’re about a third of the way there. Uganda is no different than any of the other countries that we’re in. Uganda has about a third of the people already known who are positive and in need of antiretrovirals on antiretrovirals.

Our commitment to universal coverage, we’ve never stopped. We are a central component of that effort to get everyone who needs these drugs on these drugs. We remain committed to that. What we also realize is that the resources that are going to be needed for that need to converge at the country level to support the full realization of universal coverage. A bilateral program alone will not do that. But we are committed to work with our country partners to engage in that dialogue, to identify those resources to expand into universal coverage, completely a core commitment of our effort.

Yes, please.

QUESTION: Yeah. You know, yesterday, Secretary Clinton made a pretty strong statement against efforts by some countries to criminalize homosexuality. As you know, there’s a bill pending in Uganda, and have you considered what you’ll do if that bill passes? And more generally, how will you be working with some African countries that harbor homophobic attitudes and target gays?

AMBASSADOR GOOSBY: Well, it’s a good question. We have a similar evolution in our country. We had the legislation that was put up every year, that during the early days of Ryan White, that would – anything that promoted, quote, “homosexual” behavior was considered unacceptable and anything that did fall into that very large category was – attempts were made to not have those funded within the Ryan White context, things that promoted homosexual behavior, quote. We’re familiar with that type of mindset.

And from a public health perspective, it has no place in trying to engage and curtail movement of the virus into the population. Our collective experience, globally, in every country, both in developing and in resource-poor settings, has shown that every time you target a population in a negative way and put restraints, constrictions on their ability to reveal themselves to the society, to the community, you push that behavior further underground. When you push it further underground, individuals always come in later to care, later stage of disease, and continue in that period off of antiretrovirals to participate in high-risk behaviors that further spreads the virus through that community.

Our hope would be to – in a collegial, respectful way – to work with our colleagues in-country who are in policymaking decision places to understand that relationship, to understand the science of how the virus moves through populations and that how you need, as the public health responsible entity, to position yourself in front of each of those expanding waves of seroconversions. And until you do that, that remains a conduit for the virus to reenter the general – not high-risk behaving – population.

So our hope is that the science will lead the way and that that dialogue can stay on that level and that the governments that are involved will realize that it is in their interest and the interest of their larger population for them to develop strategies that address these populations.

Yeah.

MR. DUGUID: Thank you. Mr. Goyal.

QUESTION: Sir, as far as this disease, HIV/AIDS, is concerned, it affects also travels from and to the U.S. Whenever the ministers or foreign ministers or – other countries – lots of dignitaries visit here at the State Department, do you talk to them about this disease, as far as HIV/AIDS is concerned, how you are working with them? And finally, what kind of programs you have in South Asia, especially in India? How serious is this problem?

AMBASSADOR GOOSBY: We talk about policy positions that discriminate against populations, that deter our ability to identify, enter and retain patients in care; all of those types of issues that differentiate and separate, that discriminate, work against your ability to identify and embrace and care these individuals in a very profound way. So we do talk about that.

India’s incidence is very low. But it, at the same time, has – it competes with South Africa, but is -- probably has more people infected than any other country. The kind of decentralization of healthcare in India, as well as the state configurations of government, have put the discussion in responding to the epidemic almost as a separate discussion for each state. But India has engaged in an effective strategy for prevention especially, and has moved well along the road to educating their physicians and especially their nurse populations and the private sector to create a cadre of healthcare worker relations with backup from physicians and nurses that is effectively identifying, testing, and entering people in services. So India is well along the road of engaging to prevent and block the spread of their epidemic.

QUESTION: Thank you.

MR. DUGUID: AFP, Lachlan.

QUESTION: Yeah. Lachlan Carmichael, AFP. You talk about sustainable country programs. Is there a list of countries that were in the first roll or, you know, first priority, or is it – I mean, there are about 30 countries all together, I understand?

AMBASSADOR GOOSBY: Yes, yes. We are committed to engaging all the countries in a dialogue that moves the country leadership – usually the ministries of health, the ministry of education, the finance minister – into a position with the programs where they take over management of the program, and eventually, we hope begin to increase their financial contributions to the program.

Our commitment will not waver. We don’t think that many of these countries will be in a position to put resources towards it for many years. But we do think that the ability for the country to start to manage the program, to have a national office that oversees both the epi [epidemiology] and the prevention and the treatment efforts will better enable the country to make, I think, rational decisions around where resources are most likely to have the largest impact at any given time.

The country needs to manage these programs. The population that these programs are serving are in and of the country. The public systems need to be identified and supported in expanding their capabilities as opposed to an NGO strategy where you’re putting and creating parallel delivery systems. We now need to move to more public-centered systems of care in conjunction with NGOs systems – kind of a hybrid, not just NGO parallel, but in and amongst the public system of care that is there to deliver and serve the populations in front of them. That management shift, and the creation and expansion of mid-level management capability, will save resources and will also better ensure that these programs are there for the 25 to 30 years that we need them to be, long after PEPFAR is a memory.

So our urgency to try to put these countries in a position of managing the programs is predicated on our desire to embed the programs in the medical delivery systems of the country so they’re there for the duration.

MR. KELLY: Reuters, please.

QUESTION: I was hoping you could talk just a little bit about funding. I know that some people are saying that PEPFAR has been flat funded for the next two years. Within your five – maybe you could – could you just talk us through how much has actually been given to PEPFAR to date, what you see as allocations coming from the U.S. Government in the next – say within, your next five-year outlook? How much more money is the U.S. going to put into PEPFAR?

And you talked and just said after PEPFAR is a memory – when do you think that the need for PEPFAR will dissipate? When are we going to be able to say it’s covered by everything else? And what are going to be the metrics that allow us to say that? When you – because you’re no longer are going to have targets about how many people are under care. You’re going to be saying we have built the health system in the next country, which is a much harder thing to measure. How are you going to figure out when you’re successful?

AMBASSADOR GOOSBY: Well, those are all good questions. It’s going to be an iterative process. We will not stop looking at numbers of people that we have tested, that we have staged, that we have started on antiretrovirals. We’ll continue to look at numbers of prenatal women, patients that we have identified, tested, and started on antiretrovirals for vertical transmission purposes. We’ll continue to measure and better understand the high-risk populations, the MSMs, the interjection drug users, the sex workers who frequently are the conduit through which the virus moves into low-risk populations, the general population. Those metrics will all continue to be in place, in movement or increasing in partner countries’ ownership and of management. That will be a central piece that we will not stop because of that.

Our strategy is to intensify the technical assistance that we give to countries to take over the role of both understanding through epidemiologic survey systems their epidemic and responding to it. And we believe that there is enough in-country experience now and other South-South expertise that can be tapped for technical assistance and mentoring relationships.

We believe that this is the correct way to go, because we believe it will build a stronger medical delivery system that is more durable. It is not a turning away from our conviction and commitment to the burden of disease that HIV/AIDS has presented to the planet. In that same context, it’s also important that we realize that there is a responsibility that is shared by all countries on the planet to respond to the burden of disease – not just HIV, but all disease. The more we work in this area, the more the issues around human rights have shown its head, that healthcare does impact a person’s ability to not only prevent a disease process in themselves, but also for preventing them from engaging in society, politics and contributing in the larger kind of societal sense.

And those efforts need to be – a dialogue needs to be created where we begin to acknowledge the burden of disease, the unmet component of that burden, and that we need to converge our resources to look for synergies, complementary cooperative coordination of those resources to meet that unmet need, so the universal aspects of care in HIV and other diseases can be realized.

MR. DUGUID: We have time for one question if it’s short.

QUESTION: Yeah.

MR. DUGUID: Jill, it’s short?

QUESTION: Yeah, it’s short.

MR. DUGUID: Okay.

QUESTION: Could you just tell us – you mentioned where – new infections, where are they happening?

AMBASSADOR GOOSBY: Well, they’re happening everywhere, including Washington, D.C. They’re – within any given epidemic, there are many epidemics that are occurring. And for people who think about responding to an epidemic, until you click into that, you will not be effective. It is not one shoe that fits all. Even in Washington, D.C., you have many populations that you need to have different strategies to engage on the movement of that virus through that population to arrest that.

In terms of – in a general sense, just to be – to answer your question, the epidemic is moving mostly in Eastern Europe and Southeast Asia. Eastern Europe has a huge prevention opportunity. You have a population that is largely concealed in MSMs and injection drug users, and are participating in behaviors that may be illegal in their country. And there are consequences for revealing yourself to the medical institutions that hampers the person’s willingness to be tested. That has allowed this epidemic in those countries to move unchecked. And the most rapid rises we’re seeing are in those regions of the world.

MR. DUGUID: Ladies and gentlemen, that’s all we have time for today. I’m sorry we didn’t get to all the questions, but we thank you very much who attended. And I thank you, Ambassador, for being with us today.

AMBASSADOR GOOSBY: Pleasure. Pleasure. Thank you.

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PRN: 2009/1199



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