As HIV/AIDS was exploding across the world, especially in sub-Saharan Africa, near the turn of the century, it was a moral imperative when president George W. Bush launched the President’s Emergency Plan For AIDS Relief in 2003.
Two decades after PEPFAR started, the death toll from the human immunodeficiency virus and the fatal disease it caused, the acquired immunodeficiency syndrome, has decreased by 69 percent worldwide, from its peak of 2 million lives lost to AIDS in 2004. It established a profound mark on global health. The initiative owes its success to many dedicated individuals including Dr. Anthony Fauci, whose pivotal involvement as one of the architects of PEPFAR cannot be overstated. I met with Dr. Fauci in Washington D.C. in early August, in advance of a Morning Joe production and MSNBC Prime-time special on PEPFAR. We touched on the issues facing the foreign-aid legislation’s reauthorization this fall with a deeply polarized Congress.
It seems ironic to Dr. Fauci that PEPFAR is being politicized with cultural issues. President Bush was a conservative Republican. PEPFAR’s original authorization and appropriation was “the most bipartisan thing you could possibly imagine,” Dr. Fauci says. “This has saved 25 million lives over a period of 20 year.” I told Dr. Fauci that a moral dilemma exists between right-to-life beliefs and the rights of young children to live free of HIV/AIDS.
When Bush was developing PEPFAR, people living in the United States, but not in sub-Saharan Africa, were increasingly able to access medications to treat HIV. Ambassador Dr. John Nkengasong, who was the first African Centre for Disease Control and Prevention director, told me, in an interview this summer in Washington, D.C., that it was a grim landscape in Africa back then. As the 20th century ended, the pandemic tore into the social fabric of nations, hampering economic progress and shrouding the future in uncertainty. In some places, entire families faced potential obliteration.
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“The statistics were horrifying,” Bush wrote in his memoir, Decision Points. “Some ten million people in sub-Saharan Africa had died. In some countries, one out of every four adults carried HIV.”
Dr. Anthony Fauci took the helm of the National Institute of Allergy and Infectious Diseases in 1984 and incorporated the science of the virus into broader societal implications. Under his leadership, critical strides were made in developing antiretroviral therapies, transforming HIV/AIDS from a death sentence to a condition that could be controlled with a pill.
Dr. Nkengasong, currently head of the State Department’s newly formed Bureau of Global Health Security and Diplomacy, told me recently about new medications in the pipeline to prevent and treat HIV/AIDS. “We are looking at very soon PEPFAR will be launching long-acting injectable drugs for HIV negative people that consider themselves at risk that will last about two to three months,” he says.
“The drugs for HIV, the combination that people used to refer to as the ‘cocktail of drugs,’” Dr. Fauci says. “began really in 1986-87 with a single drug AZT. That was from 1987 to 1996.” Over a period of time, a number of drugs were tested, and they showed that when put into a combination, they “could actually do something that was well beyond what we even anticipated in a positive way. That you could bring down the level of virus to below detectable in a consistent, durable way that could transform HIV from virtually almost an inevitable death sentence to something that could get people to live normal lives, maybe a lifespan—a year or two less—if given drugs early.”
The seed for PEPFAR had been sown within the corridors of the Bush administration. It was early in the process when Dr. Fauci recommended $500 million in foreign aid to suppress mother-to-child transmission in several low to middle income countries. Not long afterwards, a staggering budget of $15 billion over five years was decided upon. The initiative aimed to counteract the AIDS crisis on a global scale. The vision required the political skills of President Bush. The commitment required the financial resources of taxpayers. The medical and scientific foundation of PEPFAR required expertise — and this is where Dr. Fauci and the assembled team brought a vast reservoir of knowledge and talent to the table.
The PEPFAR strategy was integrated and holistic. It combined the distribution of antiretrovirals with a series of preventive measures: comprehensive public education campaigns, widespread condom distribution, targeted initiatives to prevent mother-to-child transmission, and investment in enhancing local health infrastructures. The blueprint relied heavily on prevention, and on eventual development of local governmental resources, so countries would eventually assume the healthcare responsibilities for their citizens.
“We knew that if we could treat a mother who was infected,” Dr. Fauci says. “that you could essentially block completely the transmission to the baby. You knew that you can get people who were literally on death’s doorstep—we call that the Lazarus Effect—and essentially get them to get a productive life.” According to Dr. Fauci, from 1996, when the first of the triple combinations became available to about the year 2000, drug development was in high gear. Better and better drugs became available. The drug regimen improved from multiple pills multiple times per day to essentially one pill with three drugs in it. In the developed world, a person had access to a pill a day and could get the level of the virus to below detectable.
“That was totally transformative,” Dr. Fauci says. “There was the natural feeling among many of us, myself and many of my colleagues, that in the developing world, particularly in sub-Saharan Africa, and in parts of the Caribbean, that those individuals where the virus was most prevalent, in developing countries, in poor countries…to get this extraordinary advance scientifically to be practically implemented in the developing world.”
Dr. Fauci championed the use of data as a vital feedback mechanism to recalibrate strategies and ensure the program’s transformative goals, adaptability and sustained effectiveness. Tens of millions have benefited from antiretrovirals, and millions of potential HIV infections have been averted. Behind these figures lies a mosaic of stories: families that remained whole, communities that continued to thrive, and nations that could look forward to a brighter future.
“What is at stake are the lives of adults and the lives of children,” Dr. Fauci says, directing his comments to Congress. “Children who will become adults and children who are not yet born. It seems to me that this is an incredible phenomenon that we should be proud of—PEPFAR—that has already saved 25 million lives. It came to be in a bipartisan effort. It needs to be saved, preserved and celebrated in a bipartisan effort. The history of PEPFAR is bipartisanship.”
“We must continue the funding partnership with countries that we are already supporting,” Dr. Nkengasong says. “There is a lot of pride when I go out there and you sit down with the political leadership of a partner country. They take pride in saying that they are very determined to increase their own funding but do not have the entire funding envelope…I think it is always a new story when you go from one country to another.” Dr. Nkengasong feels the gratitude of these countries when he holds a surviving baby in his hands, looks into the child’s eyes, and the tiny, innocent eyes tell a story that is part magical.