Articles published yesterday in the July 2012 issue of July 2012 issue of Health Affairs focus on the President’s Emergency Plan for AIDS Relief (PEPFAR), the US program to address global HIV and AIDS, and the largest investment to date of any country to fight a single disease.  The thematic issue examines the origins of the program; the lessons learned from implementation; the successes achieved in terms of human health and well-being; and the opportunities that now exist to lay the groundwork for an “AIDS-free generation.”

The new Health Affairs issue will be discussed this morning at a Washington DC briefing. The issue and its dissemination are supported in part by the US Department of State and Office of the US Global AIDS Coordinator; Merck & Co, Inc.; BD (Becton, Dickinson and Company); and the US Department of Health and Human Services (HHS).

An End To HIV/AIDS Is In Sight, But A Global Effort Will Be Required

Ambassador Eric Goosby, US Global AIDS Coordinator in the Department of State, notes that PEPFAR–supported programs provided antiretroviral treatment for nearly 4 million people in 2011 and prevented  200,000 infant HIV infections. “Few people thought it would be possible to establish effective interventions and expand them around the world, but PEPFAR showed it can be done,” says Goosby. “An end to HIV/AIDS is in sight, but it will take a truly global effort in science, public health and political commitment to make this a reality.”

Along with the significant effects of antiretroviral treatment for key populations, Goosby highlights strong results from voluntary male circumcision and the importance of rapidly expanding these and other proven methods. Goosby notes the development of a “combination prevention” strategy under PEPFAR, and the creation of an associated discipline of implementation science that allows for the rapid diffusion of best practices and all-important evaluation.

Continued global investment, including through bilateral programs such as PEPFAR and through multilateral mechanisms such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, will be crucial even in a time of global economic challenge. Goosby argues that it will also be necessary for partner countries to assume a growing management and financing role in light of the still “great unmet need” for HIV treatment, prevention and care.

The Influence Of PEPFAR On HHS’ Global Health Strategy

Nils Daulaire, director of the Office of Global Affairs in the U.S. Department of Health and Human Services outlines HHS’ first-ever Global Health Strategy and its 10 objectives for improved global health, and describes how HHS’ role has been redefined to include health outside U.S. borders. Daulaire explains that lessons from PEPFAR informed the Strategy, and that learnings from the multitude of U.S. agencies involved in PEPFAR’s “whole-of-government” approach helped shape its framework and approach.

“The global HIV/AIDS crisis presented the galvanizing force behind a marked change in how the U.S. government approaches the health of the nation,” says Daulaire. “Americans’ health is inextricably tied to the rest of the world, and the Global Health Strategy is the roadmap at HHS to apply our unique strengths to make sure the next phase of PEPFAR is successful.”

Chronicling Progress Made And The Challenges Ahead

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases of the U.S. National Institutes of Health, and Gregory K. Folkers, Fauci’s chief of staff, examine the significant progress made in developing prevention and treatment options for HIV/AIDS and outline what is needed to overcome systemic funding and delivery challenges for a “clear path toward an ‘AIDS-free generation.’” They emphasize the dramatic impact of antiretroviral drugs and the positive economic return of investing in the delivery of these drugs to HIV-infected people. They also highlight the importance of increased testing and counseling for HIV infection, innovative approaches to reducing the associated stigma, and new strategies to help patients stay in treatment and adhere to their medication regimens.

Prevention strategies are also critical in the absence of a cure, according to the authors, as the number of new HIV infections continues to far outweigh the number of people receiving treatment, and the trajectory of the disease remains daunting. Implementing proven prevention approaches such as voluntary medical male circumcision and antiretroviral drug therapy for HIV-infected pregnant women and their babies, and continuing efforts to find a vaccine and cure should remain priorities to turn that tide.

“Among a number of HIV interventions that we know work, perhaps the most exciting strategy is treatment as prevention,” says Fauci. “If we can get an HIV-infected person on combination antiretroviral therapy before the immune system is severely damaged, we have a chance to not only improve his or her health, but also to significantly reduce the risk of HIV transmission to others.”

Michael Merson, founding director of the Duke Global Health Institute, and colleagues detail the various phases of PEPFAR, from its initial focus on emergency treatment and prevention services in fifteen low- and middle-income countries to its reauthorization in 2008 and current emphasis on service expansion and sustainability under the Obama administration’s US Global Health Initiative. As a result of PEPFAR, and with additional contributions from the Global Fund to Fight AIDS, Tuberculosis and Malaria and other governments, agencies, and private foundations, HIV/AIDS deaths and new infections have declined about 20 percent, and 6.6 million people now receive antiretroviral therapy.

Along with these successes, the authors offer criticisms of the program and describe the remaining challenges that could limit its effectiveness in coming years. Most important, they warn of the difficulties of implementing new goals to treat 6 million people by 2013 and 15 million people by 2015.

“Continued US leadership, strong political and financial commitment from the international community, and a continued emphasis on HIV prevention are paramount, or the global response could face major setbacks,” says Merson.

A Behind-The-Scenes Look At The Development Of PEPFAR

John Donnelly, global health journalist and author, provides a history of the development of the PEPFAR program under President George W. Bush, with key insights from major decision makers in the Bush administration and global AIDS relief communities. He offers a behind-the-scenes look at how experts on AIDS prevention, treatment, and care from the United States took lessons from Africa to answer the president’s call to “think big” and devise the most comprehensive approach ever to reducing the burden of HIV and AIDS. He explains in this compelling narrative how the president and his chief advisers managed to keep mostly secret this unprecedented announcement of $15 billion in funding until a landmark State of the Union address announcement.

“Few people then believed a conservative Republican president would do such a thing, but George Bush did, and his signature humanitarian effort in Africa has had more impact than any US foreign assistance program since the Marshall Plan,” says Donnelly.

Other articles in the issue find major economic and educational benefits from PEPFAR as well as lessons for HIV/AIDS prevention and treatment for the United States:

  • HIV patients head back to work. Jacob Bor, Harvard School of Public Health, found that people living with HIV in rural South Africa and treated with antiretroviral drugs delivered through a PEPFAR program recovered to 90 percent of baseline employment levels after four years of treatment.
  • Bottom-line benefits of antiretroviral therapy. Harsha Thirumurthy, University of North Carolina at Chapel Hill Gillings School of Global Public Health, highlights the positive employment effects of antiretroviral therapy for infected adults, the positive effects on school attendance of children in households of adults receiving treatment, and the possibility of employers helping to cover the cost of therapy.
  • Lessons from abroad. Joe Fu, Office of the US Global AIDS Coordinator, encourages US policy makers to consider successful strategies from the PEPFAR experience overseas, especially in the areas of testing, early diagnosis, targeted prevention for key populations, and social services.