HIV/Aids initiative that was ‘an astonishing act of vision’ is all grown up, but still faces compelling challenges

HIV/Aids initiative that was ‘an astonishing act of vision’ is all grown up, but still faces compelling challenges
Actor Danny Glover attends a rally calling for congressional action to stop the growing global Aids epidemic, 10 April 2002, on Capitol Hill in Washington, DC. (Photo: Alex Wong / Getty Images)

This year is the 20th anniversary of Pepfar — the US ‘President’s Emergency Plan for Aids Relief’. It is the most important public health/foreign assistance initiative ever undertaken, becoming a template for international efforts against other diseases.

Pepfar arose out of  a White House decision to bring together concerns about Africa, the president’s relationship to America’s evangelical community, and the advice of healthcare professionals to address the Aids crisis. It represents George W Bush’s positive contribution to the world. 

Back in the early 1980s, the public and medical circles across the globe were starting to come to grips with a terrifying new disease with a very confusing profile. From the beginning, it was being identified in diverse, seemingly unconnected communities of people. But what did it all mean? 

This disease was infecting gay men, Haitians, airline cabin crew members, blood transfusion recipients, intravenous drug users, members of artistic and cultural communities, and then African Americans and Africans more generally, but all of its victims were being infected by still-unknown vectors or causes.  

At least initially, treatment regimens largely consisted of symptomatic, palliative care, aimed at making those who were infected more comfortable — that is, until they died from the effects of opportunistic, and hard-to-contain conditions such as Karposi’s sarcoma. 

From the vantage point of current circumstances in which HIV/Aids is a controllable condition and not a death sentence – as long as patients follow a regimen of anti-retroviral medicines – it may be difficult to remember just how much this disease was provoking a growing terror. 

Worse, there was a growing revulsion against those infected — fuelled by the fact its aetiology remained a mystery, and by virtue of the virtual certainty of death, once a person was infected.

In those years, this infection was spreading rapidly worldwide. Initially at least, South Africa was spared from the worst spread of the disease due to its global isolation as a result of its apartheid policies. 

Following the collapse of the apartheid system, the new, incoming South African leaders tended to underplay Aids’ impact as an emerging national public health emergency. This was likely due to still-low levels of infection, as well as their belief in the need to focus more attention on other needs for government.

Given the challenging state of South Africa’s health sector, it should not have been surprising that HIV/Aids was making real inroads into the country’s most vulnerable communities. This was especially the case for those with already-low levels of nutrition and who suffered from serious gaps in public health support. 

A decade earlier, medical researchers in France and the US, along with those in a number of other nations, were already working to identify the cause of the disease. From there, it would be on to establishing treatments, preventative measures and, even, potential cures.

In May 1983, doctors at the Pasteur Institute in France, led by Françoise Barré-Sinoussi and Luc Montagnier, isolated a retrovirus they believed was the cause of Aids. (They received the Nobel Prize for Medicine in 2008 for this work.) 

Meanwhile, the following year, an American team led by Robert Gallo of the Institute of Human Virology confirmed the discovery of the virus, and, independently, Jay Levy’s group at the University of California, San Francisco, also isolated it. 

In South Africa, by the early 1990s, questions surrounding the increasing spread of HIV/Aids and its growing socioeconomic costs became entangled in a range of divisive, political, racial and rhetorical battles. 

On the one hand, as drugs such as Nevirapine and AZT to treat Aids began coming into use, in South Africa, popular criticisms (echoed or encouraged and abetted by some government officials) were that such drugs were dangerous (or, at minimum, ineffective). Further, their expense was a kind of extortion on the part of foreign drug companies, the so-labelled Big Pharma. 

Accordingly, the government opposed distributing them via government-supported healthcare, insisting it was acting on behalf of the public interest. 

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A further criticism was that HIV/Aids was not a specific disease at all. Because it had been originally described by physicians as a syndrome, this critique insisted HIV/Aids was essentially opportunistic medical outcomes from larger socioeconomic conditions and severe nutritional deprivation (themselves the result of years of segregation and apartheid), rather than from that recently identified and isolated virus. 

This particular critique was argued fiercely by then president Thabo Mbeki, as he was quoted as saying, “A virus cannot cause a syndrome,” thus taking a legalistic (as opposed to clinical) approach to medicine and medical research. 

Some part of Mbeki’s opposition seems to have stemmed from a desire to push back against a narrative he believed unfairly blamed the now-exploding infection in South Africa on the sexual mores of Africans. Thus, any focus on distributing anti-retrovirals was a deflection from addressing the more important root causes of poor health.

A third version of South African government policy on HIV/Aids came to the fore via pseudo-medical ideas that gained footholds in the Mbeki administration. 

The first was the locally designed concoction, Virodene. It was developed via thoroughly compromised clinical trials in east Africa in which politically motivated financial interests had been involved. Further, its chemical composition was wholly unsuitable for dispensing to patients, and it was eventually shown to have no discernible positive impact on the infection. (A cautionary note: American readers probably should not snicker too much about this, given the Trump administration’s embrace of ultraviolet light, bleach, treatments for malaria, and anti-parasite medications intended for farm animals as tools to combat Covid.) 

A second approach of quack science was worse. Then health minister, Dr Manto Tshabalala-Msimang, insisted patients’ ingestion of dietary supplements comprising olive oil, beetroot and the “African potato” (Hypoxis hemerocallidea) would control HIV infections — and even reverse them.

By the time such ideas had run their course and bizarre dietary supplements and dangerous chemicals had been pushed aside as treatments, best estimates are that at least a third of a million people (and perhaps many more) had died unnecessarily due to a lack of appropriate care. 

This failure created lost earnings for many others due to illness, and it also generated a massive social cost affecting hundreds of thousands now living in child-headed households. 

While those with private medical care could, by the late 1990s, obtain anti-retroviral medicines coming into common use globally, the Mbeki administration continued to resist distribution via the national health administration’s hospitals and clinics. (The author was still confronting resistance to anti-retrovirals by many at the beginning of the 21st century when he was organising public affairs programming on behalf of the American Embassy with South African publics.) 

Thousands of people who live with HIV/Aids launch the Campaign to End AIDS (C2EA) on 5 May 2005 in Washington, DC. (Photo: Chip Somodevilla / Getty Images)

The Treatment Action Campaign protest on 29 August 2007 in Cape Town, South Africa. (Photo: Gallo Images)

A critically important legal battle in South Africa, waged on behalf of making anti-retrovirals available, ultimately culminated in a 2002 Constitutional Court decision. The court found against the Health Department and supported the Treatment Action Campaign in its fight against policies withholding anti-retroviral medicines from patients dependent on public health facilities. However, the actual supply and distribution of such medicines remained seriously insufficient.

Meanwhile, beyond South Africa’s circumstances, an ambitious international response towards the disease was evolving in the US. This was partially a recognition of the growing spread of the disease, but it was also understood that epidemics like this could become an actual international security risk to the US. Unchecked, it could lead to the collapse or incapacitation of fragile governments, and even create a landscape conducive to dangerous new mutations. 

In the White House during the first two years of George W Bush’s presidency, despite its growing obsession with Iraq, several separate ideas were coming together that led to a major commitment internationally on HIV/Aids. 

One fortuitous (and coincidental) circumstance was that three separate concerns had become the messaging responsibility of speech writer/presidential aide Michael Gerson. Gerson had become the administration’s liaison to the evangelical Christian community, charged with keeping the leaders of those groups aligned to Bush’s Republican Party. 

But he was also the president’s messaging coordinator on Africa policy (beyond the usual officials in the National Security Advisor’s Office and the State Department). Finally, he had also become the senior advocate for HIV/Aids policy and programmes within the White House.  

His drawing together of these three strands, and naming the new initiative Pepfar — the President’s Emergency Plan for Aids Relief — became a key point in Bush’s 2003 State of the Union speech. 

Writing in Devex, the authoritative news site for international development assistance, Michael Igoe explained, “Gerson is probably best known for his key — and controversial — role in shaping the Bush administration’s messaging and response to the Sept. 11 attacks. But he is also regarded as one of the architects of groundbreaking US global health and development initiatives that dramatically expanded the ambitions of US foreign assistance and reshaped the political dynamics of American aid programmes. [Italics added]

“Mark Dybul, who would become the first head of the US President’s Emergency Plan for Aids Relief, told Devex that Gerson, along with then National Security Advisor Condoleezza Rice, were key voices in support of a global HIV/Aids initiative in the pivotal December 2002 White House meeting when Bush signed off on the plan.

“‘He came up with the name,’ Dybul said of Gerson. The speechwriter figured out how to convey the urgency of the crisis — ‘Emergency’ — and the high-level leadership it would take to confront it — ‘President’s’.

“Bush’s 2003 State of the Union address would become a defining moment in the history of US global health programmes, but it was only the day before the speech that Dybul and Dr Anthony Fauci, who both helped design Pepfar, learned that Bush planned to announce the $15-billion initiative to the world that night. Gerson, an evangelical Christian, crafted the speech, and Bush’s language reflected a faith-based worldview they held in common…

“In addition to helping establish these cornerstones of US global health assistance, Gerson also helped sell them to Republicans and Democrats, assembling a bipartisan coalition of supporters that is still mostly intact.”

Benjamin Ryan of NBC News described this evolution of the plan, writing, “President George W Bush’s reputation may have been forever complicated by 9/11 and war, but a proposal he made in his 2003 State of the Union address became a historic humanitarian success; one that resulted in 25 million lives saved from Aids, 20 million people with HIV provided antiretroviral treatment and 5.5 million babies born to HIV-positive mothers but free of the virus themselves.

“After two decades, this is the legacy of the President’s Emergency Plan for Aids Relief, or Pepfar — the most ambitious and transformative US foreign aid programme since the Marshall Plan rebuilt Europe from the rubble of World War 2…

“Highly effective antiretroviral treatment for HIV had been available in wealthy nations since 1996. Bush sought to end the international-aid paralysis that had denied such life-saving pharmaceutical access to people living with the virus in poorer nations and allowed millions to die.

“By 2003, sub-Saharan Africa, HIV’s epicentre, was on the precipice of broad-based societal collapse due to Aids. Life expectancy had plunged by 20 years, infant mortality had doubled, child mortality had tripled and millions of children had been orphaned by the disease. 

“Aids also posed a grave economic threat, with national average GDP dropping 2 to 4 percentage points per year across Africa.”

In keeping with the sense that the spread, dislocations and death from Aids was heading towards a major international security issue, Ryan described other backstage developments, “Secretary of State Colin Powell told Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases that HIV posed a dire threat to global security, given the masses of Africans dying during the primes of their lives and the fact that much of the continent’s military was infected with HIV…” 

Powell believed, “‘Anything that we could do to ameliorate the problem would be a step toward enhancing our own security’.”

Protesters during a demonstration by the AIDS Healthcare Foundation on 7 June 2004 in Los Angeles, California. (Photo: David McNew / Getty Images)

In the two decades since, Pepfar has held bipartisan congressional support that has translated into real budgetary commitments. Total funding has now reached around $100-billion. This is more money spent by any one nation than on any other single disease. 

And this figure does not include funds from participating governments, civil society and private donors. Nevertheless, when first announced, the smart money thought its goals would be impossible to become reality. To get a sense of the scale for the crisis, by late 2002, antiretrovirals had reached just 50,000 of the 4 million-plus people with HIV in the region who qualified for treatment. 

Looking back at the plan’s results, Dr Fauci said of the plan and Bush’s zeal for it: “As a rich nation, he felt that we had a moral responsibility not to have people dying from a disease that’s treatable and preventable merely because of the lack of resources in the region in which they live.”

Dr Wafaa El-Sadr, an epidemiologist, is the founder director of Columbia University’s Icap global health centre, and he is responsible for implementing key parts of Pepfar’s role in Africa and elsewhere. 

About Pepfar, El-Sadr says, “Twenty years later, sometimes it’s hard for people to appreciate what the world was like in sub-Saharan Africa then. I remember before Pepfar, walking the hospital wards in southern African countries. It was despair.”

Locally, retired Constitutional Court Judge Edwin Cameron adds, “Pepfar played – and continues to play – an enormous and pivotal role in saving many hundreds of thousands of South African lives that have been touched by HIV. 

“The unleashing by the US Senate and President George W Bush of massive funding to enable large-scale access to anti-retroviral treatment across Africa was an astonishing act of vision – what President Bush justified, in his belief framework, as ‘the faith imperative of treatment’.  

“Though the South African government deserves credit for enabling access, and especially for doing so through large-scale assistance by non-governmental partners, if Pepfar funding had not been there, our country’s massive, and massively successful, ARV treatment programme – to which millions of South Africans owe their lives and wellness – would not have existed.”

Returning to Ben Ryan’s report: “Sandra Thurman, who was the director of the White House Office of Aids Policy during the Clinton administration, recalled listening to Bush’s State of the Union address that night in her car. ‘I damn near drove off the road,’ she said. ‘It was positively the most presidential thing I’d seen anyone do in a long time. It took my breath away and made me cry tears of joy and gratitude’.”

Still, despite the presidential commitment to such a programme, many experts believed Africa’s health infrastructure would make it virtually impossible to achieve. 

Sub-Saharan Africa’s lack of infrastructure, supply chains, trained healthcare workers, proper roads and even running water were all intractable obstacles that would doom Pepfar, even as antiretroviral costs had fallen from $12,000/patient to $300 by 2003.

Today’s cost is about $65. 

Dr Deborah Birx led Pepfar from 2014 until she stepped down in January 2021, after joining the Trump administration’s coronavirus task force (and unfortunately becoming a lightning rod for the miscues of that administration’s policies). About Pepfar, however, she has said, “Many believed we should only do prevention and accept the premise that we could lose a generation of Africans.” But that was not what the plan became.

Pepfar gained the support of America’s faith-based community and they joined forces with Aids activists — recall Michael Gerson’s backstage efforts to bring them on board — and a bipartisan grouping of congressional leaders pushed for it in Congress. 

As a result, by May 2003, Congress had appropriated the funds Bush had requested. The current Pepfar director, Amb John Nkengasong, says that if Pepfar and the Global Fund (the parallel UN effort) had not stepped up to tackle the crisis, “it would have been a moral crisis of unimaginable proportions”. 

Evaluating the programme’s successes, global health experts say a key element was Pepfar’s impetus for the creation of health infrastructure throughout sub-Saharan Africa from the ground up, including over 3,000 testing labs, training 340,000 healthcare workers, and developing a system for monitoring the epidemic. This network, in turn, became important for dealing with a new major health pandemic – Covid-19.

About its specific record in South Africa, according to US Embassy spokesperson David Feldmann, “The US Pepfar South Africa programme has worked in close partnership with the government of South Africa, multilateral organisations, and civil society over the last two decades. This partnership has resulted in substantial improvements in health outcomes in South Africa. 

“Life expectancy increased from 53 years in 2003 to 64 years in 2020 and new HIV infections declined by half from 2010 to 2019.  Additionally, with an estimated 8 million people living with HIV in South Africa, more than 5.7 million South Africans are on life-saving antiretroviral therapy. 

“While incidence is declining each year, there are still approximately 177,000 new HIV infections annually. The HIV burden in South Africa continues to grow and has yet to reach HIV epidemic control. 

“US Pepfar looks forward to continued partnership with South Africa to work toward ending HIV as a global health threat and reducing inequalities and resulting HIV infections.”

In looking at the still larger picture, by 2021, about 38.4 million people were living with HIV worldwide, according to the Joint United Nations Programme on HIV/Aids (UNAIDS) and nearly 29 million were on treatment, nearly four times the total in 2010. 

Ryan adds, “Thanks in large part to the fact that successfully treating HIV eliminates sexual transmission of the virus, the estimated annual transmission rate has dropped 52%, to 1.5 million, since 2010, while the annual death rate has declined 68% since peaking in 2004, to 650,000.” 

This, of course, had a positive impact on GDP growth — at least until the ravages of Covid struck. Unfortunately, the combined effects of the war in Ukraine and Covid have destabilised efforts to provide prevention, testing and treatment services. 

Still, as Ryan notes, “New infections have risen in three regions: Eastern Europe and Central Asia, Latin America, and North Africa and the Middle East. But in the 13 sub-Saharan African nations where Pepfar has prioritised its resources, HIV epidemic metrics continue to dramatically improve.” 

Even now, only a little more than half of the children with HIV in sub-Saharan Africa are being treated with antiretrovirals, in comparison with three-fourths of adults, according to UNAIDS.

The official Pepfar report from its offices in South Africa notes that for South Africa, “US funding for Pepfar grew from $2.2-billion in FY 2004 to $7-billion in FY 2022; FY 2022 funding includes $5.4-billion provided for bilateral HIV efforts and $1.6-billion for multilateral efforts ($50-million for UNAIDS and $1.56-billion for the Global Fund).

“As the Covid-19 pandemic continues to have profound effects across the world, Pepfar has acted to respond to Covid in countries that receive support in order to minimise HIV service disruptions and leverage the programme’s capabilities to address Covid more broadly.

“Looking ahead, Pepfar faces several issues and challenges, including how best to address the short- and long-term impacts of Covid on Pepfar and the HIV response; accelerate progress toward epidemic control in the context of flat funding; support and strengthen community-led responses and the sustainability of HIV programmes; define its role in global health security and broader health systems strengthening efforts, and continue to coordinate with other key players in the HIV ecosystem, including the Global Fund.”

The challenges remain compelling, as Ryan notes, “Recent analyses have found that half of new cases in the region are now in what are known as ‘key populations’ and their sex partners. These populations, which comprise just 5% of the overall population, include men who have sex with men, transgender people, sex workers and people who inject drugs.” 

Reaching such marginalised people with HIV services remains challenging, given policies in much of sub-Saharan Africa that criminalise the behaviours that transmit the virus.

Ryan adds, “A survey study published in The Lancet on 6 January found that among 10 nations in the region, those that criminalised sex between men, prosecuted same-sex relations and/or erected barriers for organisations that serve gay and bisexual men, respectively, had dramatically higher HIV rates in such men than those nations without these respective factors.” 

Such policies are rooted in longstanding anti-gay attitudes on the part of some government leaders, and among populations as well. 

Combatting HIV/Aids remains a continuing struggle, however, and, as far as the new US Congress is concerned, holding on to bipartisan support with the numbers of right-wing Republicans among the members of the House of Representatives, and given budgetary stringencies in South Africa, funding for the programme may yet prove to be a challenge in future. 

The struggle against HIV/Aids is not over. DM


Comments - Please in order to comment.

  • Colin Johnston says:

    Thanks for all this bit of history. There is a lot to be thankful for sometimes but I never thought it would be for what something Bush had done! It’s a pity though that many of the initiatives like this are driven by self interest and economic effects. Nevertheless – well done the US.

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