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USA/Africa: AIDS - Yes, We Can?
Dec 6, 2009 (091206)
(Reposted from sources cited below)
"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. ... But unmet
needs are still the dominant feature of this program. ... we're
going to begin transitioning from an emergency
response to a sustainable one through greater engagement with and
capacity building of governments." - Dr. Eric Goosby, Ambassador,
Global AIDS Coordinator for U.S. government
This AfricaFocus Bulletin, available on the web only, contains a
transcript of a press conference by U.S. Global AIDS Coordinator
Dr. Eric Goosby, presenting a broad overview of U.S. government
plans on global AIDS, and to answer questions from journalist
seeking a response to critics of administration plan for funding
Another AfricaFocus Bulletin,distributed by e-mail as well as on
the web, contains a strong critique of the trend to pit AIDS
funding against other health needs, rather than seeking adequate
funding for both.
USA/Africa: AIDS - No We Can't? (e-mail and web)
A third AfricaFocus Bulletin posted today contains several updates,
a summary report on the new UNAIDS annaul report, a joint press
release by PEFPAR and the Global Fund, and the AIDS day speech by
South African President Jacob Zuma.
Africa: HIV/AIDS 2009 Update (web-only)
For previous AfricaFocus Bulletins on AIDS and other health issues,
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Special Briefing On the U.S. Commitment to Fight AIDS and the
Launch of PEPFAR's New Five-Year Strategy
Eric Goosby, M.D.
Ambassador, Global AIDS Coordinator
December 1, 2009
U.S. Department of State
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
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
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
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
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
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.
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
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.
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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a particular focus on U.S. and international policies. AfricaFocus
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