The Most Successful Global Public Health Plan You Probably Never Heard Of : Consider This from NPR Today, when we hear the word pandemic, most people think of COVID-19. But by 2003, while rates of HIV infections and deaths from AIDS had stabilized and fallen in the US, in sub-Saharan Africa, the rates were at epidemic proportions.

In his State of the Union address that January, President George W. Bush announced a massive investment in the global fight against HIV –The President's Emergency Plan for AIDS Relief, or PEPFAR.

In the twenty years since, the program has dedicated billions of dollars to HIV prevention and treatment across Africa and other regions, saving tens of millions of lives.

NPR's Pien Huang speaks with Ambassador Dr. John Nkengasong, the U.S. Global AIDS Coordinator, and Dr. Helene Gayle, an epidemiologist and president of Spelman College, who spent 20 years at the CDC focused on HIV treatment and prevention and global healthcare.

The Most Successful Global Public Health Plan You Probably Never Heard Of

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OLUSEGUN OBASANJO: What we have is a pandemic out of control, which is gravely threatening our nations, our children and our future. We are an endangered continent.


When we hear the word pandemic now, most people think of COVID. But back in September 1999, Olusegun Obasanjo, who was then president of Nigeria, gathered with leaders of other African nations as a continent under siege to sound the alarm about HIV/AIDS.


IRA FLATOW: In some African countries, as many as 1 of every 4 adults - 1 of every 4 - is infected with HIV.

HUANG: That same year, Ira Flatow, host of Science Friday, echoed the grim reality of the AIDS epidemic in Africa.


FLATOW: Since the epidemic began 15 years ago, the disease has killed 11 million Africans, more than 80% of the world's AIDS deaths.

HUANG: By 2003, rates of HIV infections and deaths from AIDS were stabilized and falling in the U.S. But in sub-Saharan Africa, HIV infections reached a deadly peak. The previous year, almost 3 million people died from AIDS, making it one of the worst years of Africa's HIV epidemic. But 2003 would also bring an enormous change in the fight against HIV, rewriting the playbook for global public health.


GEORGE W BUSH: Seldom has history offered a greater opportunity to do so much for so many.

HUANG: In his State of the Union address that January, President George W. Bush announced a massive investment in the global fight against HIV, the President's Emergency Plan for AIDS Relief, or PEPFAR.


BUSH: This comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs and provide humane care for millions of people suffering from AIDS and for children orphaned by AIDS.

HUANG: In the 20 years since, PEPFAR has dedicated billions of dollars to HIV prevention and treatment across Africa and other regions. But as progress on HIV cuts infections and lowers the risk of that virus, other health threats like COVID and new emerging diseases have come to the front. CONSIDER THIS - 20 years on, does the world still need PEPFAR?

JOHN NKENGASONG: It was really an existential threat.

HUANG: That's coming up. For NPR, I'm Pien Huang. It's Saturday, March 18.


NKENGASONG: In terms of life expectancy, it has decreased significantly in some countries by up to about 35 years lost, like in Zimbabwe, or 28 years lost in Botswana, South Africa about 12 years lost.

HUANG: Ambassador John Nkengasong is the U.S. global AIDS coordinator and special representative for global health diplomacy. Last summer, he took on the leadership and management of PEPFAR. He says the program has been a huge success, especially when you look back at how bad the HIV situation used to be in African countries.

NKENGASONG: Funeral homes were everywhere. Buriers and the coffin markets were thriving in most African countries.

HUANG: Twenty years later, Nkengasong says, deaths and infection rates have dramatically decreased, with tens of millions of men, women and kids getting life-changing treatment. And the treatment infrastructure that PEPFAR put in place has also helped with other health threats on the African continent.

NKENGASONG: PEPFAR's public health platforms that have been established over the last 20 years continue to play a pivotal role in supporting countries to respond to outbreaks like the COVID pandemic, Ebola outbreak in Uganda and monkeypox.

HUANG: He says that when it comes to PEPFAR's original purpose, there's still more to be done.

NKENGASONG: In some countries, the rate of new infections is about three to seven times higher in girls and young women than the corresponding rate in boys and key populations - I mean men who have sex with men, transgender female sex workers and others. We are also focusing on sustainability. How do we sustain the gains that we've made over the last 20 years and making sure that the political leadership continues to recognize that HIV/AIDS is not over.

HUANG: Coming up, the next front in the global battle against HIV. That's when we return.


HELENE GAYLE: This was so important, not only because of the overall impact that it had on economies and people's lives and in the rest of the world, but also, I think, an important part of our legacy as Americans to be generous to the rest of the world.

HUANG: Dr. Helene Gayle is president of Spelman College and has worked in international public health and humanitarian aid for decades, primarily around HIV treatment and prevention. She remembers meeting the first person who received HIV treatment through the PEPFAR program.

GAYLE: Just to hear from this person how this had just transformed their lives, and that was at a time when HIV was a death sentence if you lived in Africa. This was somebody who really miraculously, if you will, was able to go back to living a life, being a productive family member, a breadwinner, member of the community. And that happened millions of times throughout the history of PEPFAR. But we also, through PEPFAR, were able to develop a public health and treatment infrastructure that has been hugely important as we tackled other global challenges like what we just went through with COVID. And so PEPFAR has such long-lasting, long-reaching impact.

HUANG: What is the scope of the problem now, and, you know, what are sort of the major challenges that face PEPFAR and the fight against global HIV/AIDS today?

GAYLE: Well, you know, I think as in anything, unfortunately, we have a short attention span. And it is for many people - because HIV is not as visible here in America as it was 20 years ago, you know, I think people have forgotten how serious the pandemic was and how it's still impacting people globally at a much higher rate than what we have here. So I think the biggest challenge is keeping people focused on why this is so critical, why it is so important, and why it's in our best interest to continue to make sure that we are generous and share our technologies with the rest of the world. So, you know, I just think this is so critical to continue people having a commitment to this program that has been not only lifesaving for millions of people but has also had a huge economic benefit that in the long run, you know, makes us all safer, more secure when the whole globe, the rest of the world has good economic well-being.

HUANG: I wanted to ask you about one criticism of the program, which, you know, focuses on a period where the program focused on abstinence education. The money that was provided to other countries as aid was sort of bundled with a message of abstinence, which imposed a moral message on all the countries that were getting aid from the program. I'm wondering what your thoughts are as you sort of reflect back to that time.

GAYLE: Yeah. Well, at a time when we didn't yet have the lifesaving medications that we have today, you know, a lot of the focus on our support to the rest of the world, just as it was here in this country before treatment was widely available, you know, was really focused on prevention. And prevention is always going to be where we should put a lot of focus because it's obviously much better to prevent someone from getting HIV than to necessarily need to take treatments and, as you mentioned, treatments that are lifelong. That said, you know, we know that for a sexually transmitted disease, the way to absolutely prevent is for people to not have sexual interactions. But we know that that is a natural part of life and that having a message that is abstinence only without thinking about the other parts of how you can reduce your risk - like condom use, like treating other sexually transmitted diseases - you know, is really not using all your tools in the toolkit. So we understand that, you know, there are lots of conflicting feelings about people who may have multiple partners, have risky sexual interactions. But at the end of the day, you know, this was about saving lives, and I think we had to use all the tools in the toolkit and not be confined to simply one.

HUANG: Over the past 20 years, the U.S. has spent more than $100 billion on responding to HIV and AIDS globally. And I know that it's made a huge dent in the problem, but I'm also wondering, like, how much more - I don't know if we can quantify it, but, like, how much more money will it take to sort of end the AIDS epidemic? And, you know, why is that a good investment for the U.S.?

GAYLE: Well, you know, I'm not sure that I can talk about, you know, dollars and cents and how much more it would take. I guess the question is really, you know, what would happen if we didn't spend those resources? And I think returning to the days that - before PEPFAR, allowing a pandemic to ravage populations, to rob generations of their future and their potential is just not something that I think we as the United States can sit by and watch happen.

HUANG: And as you mentioned, you know, the infrastructure that was created to combat HIV/AIDS through PEPFAR has been useful through the global pandemic for COVID. I mean, as other health threats emerge, do you think that PEPFAR should pivot to reach beyond HIV and AIDS?

GAYLE: You know, PEPFAR was created for a particular purpose, and I think it has done a great job of extending that platform to make sure that as PEPFAR as a program is developed, that it is thinking about what's the capacity that it's leaving behind, how can it serve more broadly? But I do think PEPFAR's focus on HIV and AIDS is important because we need to finish the job. It is still a major cause of mortality and morbidity in countries around the world, and I think until we finish that job, you know, it is important to have that single-minded focus, all the while understanding that we're developing infrastructure that will ultimately serve beyond just HIV and AIDS.

HUANG: That was Dr. Helene Gayle. She spent 20 years at the CDC focused on HIV prevention and global health and served as director of the HIV, Tuberculosis and Reproductive Health program at the Bill and Melinda Gates Foundation. Dr. Gayle is now the president of Spelman College. It's CONSIDER THIS from NPR. I'm Pien Huang.


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