A Blueprint for Ending AIDS
Ambassador Deborah L. Birx, M.D.The TREAT Asia Report Interview: U.S. Global AIDS Coordinator, Ambassador Deborah L. Birx, M.D.
Dr. Deborah L. Birx was sworn in as Ambassador at Large and U.S. Global AIDS Coordinator in April of this year. As Global AIDS Coordinator, Ambassador Birx oversees the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. government’s engagement with the Global Fund to Fight AIDS, Tuberculosis and Malaria. From 2005 until taking her new post, she served as Director of the Division of Global HIV/AIDS at the U.S. Centers for Disease Control and Prevention (CDC). Ambassador Birx is also a proud U.S. Army veteran and served as the Director of the U.S. Military HIV Research Program (USMHRP) at the Walter Reed Army Institute of Research from 1996 to 2005.
TREAT Asia Report: What are your top priorities as U.S. Global AIDS Coordinator?
Ambassador Deborah Birx: PEPFAR’s first priority is controlling the epidemic in each country to achieve a sustainable response. This requires ensuring that all PEPFAR-supported programs are optimally focused programmatically on core interventions and geographically to control the epidemic and achieve an AIDS-free generation. We can’t achieve this alone, of course. Epidemic control is dependent upon shared responsibility that involves the leadership of host countries working in collaboration with donor nations, civil society, people living with HIV, faith-based organizations, the private sector, foundations, and multilateral institutions.
For PEPFAR specifically, we are focusing on three pillars. The first is accountability, or cost-effective programming that maximizes the impact of every dollar invested. Second is transparency and publicly sharing all levels of program data that are available. Third is impact and demonstrating sustained control of the epidemic, meaning lives are saved and new infections are averted.
Each of these pillars is supported by five priority agendas: The impact agenda focuses on controlling the epidemic. The efficiency agenda, where our efforts are concentrated on saving lives through smart investments. The sustainability agenda is about sharing responsibility and ensuring maximum coordination with host countries. The partnership agenda focuses on working with partners, like the Global Fund, to achieve an AIDS-free generation. And finally the human rights agenda, where we’re working to secure, protect, and promote human rights.
TA Report: PEPFAR’s annual funding has decreased $600 million since its peak in 2010. How will this impact the U.S.’s support of global AIDS efforts to ensure that countries can achieve an AIDS-free generation?
Ambassador Birx: We have the PEPFAR Blueprint to serve as our roadmap and the science that gives us a way forward to control HIV/AIDS. With this new budget environment, we have to ensure that every dollar is invested in the most impactful way.
It’s also important to remember that achieving an AIDS-free generation isn’t based on PEPFAR’s contribution alone. The PEPFAR Blueprint explains that shared responsibility and collaboration is critical to controlling the HIV/AIDS epidemic. We will continue to partner with a host of stakeholders working to control the epidemic to ensure that our efforts are complementary and effective. PEPFAR’s commitment has not changed, and it’s still the world’s largest contributor to the HIV/AIDS response.
While Director of the CDC’s Division of Global HIV/AIDS, Ambassador Birx visited the National Tuberculosis Reference Laboratory in Nairobi, Kenya.
TA Report: How is PEPFAR working with low- and middle-income countries to increase ownership of their domestic AIDS response without compromising the responses to key and marginalized populations?
Ambassador Birx: We know that if one of us is unsafe, we all feel unsafe, and if you impact the rights of one, you impact the rights of all. If people feel like they can’t access services, the epidemic will expand. And if we don’t start creating environments where all people are served, when the generalized epidemic starts declining in a country but HIV remains concentrated in specific risk groups, we will not have built the trust in those communities to ensure that the epidemic is also controlled there.
A number of countries have assumed greater responsibility for managing, overseeing, and financing their HIV/AIDS responses, which we welcome enthusiastically. PEPFAR will continue to work hand-in-hand with all our partner countries to support the gradual move to assuming greater responsibility for their national responses. In many contexts, this will not happen overnight, and the pace with which each of these partnerships evolves will appropriately vary from country to country.
As we work in partnership with governments, civil society, and the private sector to achieve an AIDS-free generation, we must remain guided by sound science, a focus on impact, targeting efforts where the virus is most prevalent, and grounding our work in approaches that protect the human rights of all people, including key and marginalized populations. Our programs need to be comprehensive across all risk groups, and our success demands that all individuals have equal access to appropriate and non-discriminatory HIV services. PEPFAR has always been, and will continue to be, clear in discussions with all of our partners that this is absolutely fundamental to controlling the HIV/AIDS epidemic.
TA Report: In many Asian countries, HIV rates among key populations are much higher than among the general population— reaching over 30% among people who inject drugs and men who have sex with men (MSM) in some countries. What is PEPFAR doing to facilitate better access to evidence-based prevention and treatment services for these groups across the region?
Ambassador Birx: PEPFAR works with host governments, civil society, and other partners to address the imbalance between the high levels of risk and disease burden borne by key populations (including men who have sex with men, sex workers, and people who inject drugs) and the low level of coverage of core HIV prevention, treatment, and care services for them. The PEPFAR Blueprint addresses the priority of expanding HIV services for key populations in areas with both concentrated and generalized epidemics. Focusing on high-burden populations is vital to a robust, comprehensive, and effective global AIDS response.
PEPFAR has long been a global leader in reaching and serving key populations with HIV services. During the Obama Administration, PEPFAR has significantly expanded these efforts, including by launching a series of special initiatives to address priority needs. PEPFAR targeted $33 million to support increased HIV programming among key populations in 12 countries, including four in Asia. PEPFAR awarded a total of $15 million to nine countries, including two in Asia, to strengthen the evidence base around best practices for reaching key populations with HIV services. PEPFAR also provides $2 million in annual funding to the Robert Carr Civil Society Network Fund, a unique collaboration that strengthens the capacity of civil society to address the HIV needs of key populations.
UNAIDS Executive Director Michel Sidibé (left) and Ambassador Birx during amfAR’s “Making AIDS History: From Science to Solutions” conference on Capitol Hill.
TA Report: PEPFAR’s Road Map includes the goal of eliminating new HIV infections among children by 2015. However, in 2012, HIV-positive pregnant women in South Asia had the world’s lowest rate of access to the antiretroviral therapy needed to prevent mother-to-child transmission of HIV. What are the barriers that prevent women from accessing prevention and treatment services in the region and what can be done to overcome them?
Ambassador Birx: One of the greatest challenges in the region is that the majority of women living with HIV are sex workers and/or women who inject drugs, which presents several barriers to reaching them with HIV services. One example is the inappropriate ‘copy-paste’ of generalized epidemic service delivery models to concentrated epidemic settings. The lack of friendly sexual and reproductive health services and poor linkages between community- and facility-based services is also a concern. Finally, host countries’ reluctance to fund sexual and reproductive health services for female sex workers and women who inject drugs, despite epidemiologic evidence that supports this model, continues to be a barrier to ensuring HIV services are available to those who need them.
PEPFAR employs a variety of strategies to improve access to and utilization of HIV services for women in the region, such as improving geographical targeting to locations with higher HIV prevalence and greatest presence of female sex workers and women who inject drugs, as well as paying greater attention to these groups when designing services to improve access. It is also essential to increase attention to structural barriers that impede access to facility-based services, such as limited hours of operation, for female sex workers and women who inject drugs. Reducing stigma and discrimination, both at the community and health care provider levels, is also essential. When female sex workers and women who inject drugs experience stigma and discrimination—in some cases, multiple times—when they’re trying to access services, they are discouraged from returning. What’s also key here is strengthening programs focused on training peer educators/navigators, who serve as conduits between the facility and the community.
TA Report: The anti-homosexuality laws recently passed in Uganda and Nigeria criminalize “promoting homosexuality”—a category that includes providing HIV services that target LGBT. What can PEPFAR do to ensure that LGBT in these countries can safely and freely access HIV services, and what can donors and development agencies do to support advocates in those countries as they fight to repeal those discriminatory laws?
Ambassador Birx: PEPFAR is a public health program. The principles of good public health demand that we strive to reach all affected populations with core HIV services even—and I would argue especially—when facing difficult cultural contexts, severe stigma and discrimination, or challenging security environments. These principles have underpinned PEPFAR from the outset, and we will never waver from them.
In many cases, PEPFAR operates in country contexts where certain individuals or groups, such as LGBT, are subjected to violence or legal sanctions. From a public health and human rights perspective, all forms of discrimination, harassment, and abuse, including on the basis of sexual orientation or gender identity, are unacceptable and run counter to all that we know works in effectively addressing HIV/AIDS from our nearly 35 years of experience.
No matter how challenging the conditions, PEPFAR has never been deterred from continuing to do all we can to support comprehensive, non-discriminatory HIV services for all individuals, and we will not back down now. As public health practitioners, our core ethical responsibility is to the people we serve and this holds true even when host government policies are at odds with sound science or good public health. It’s in these critical moments that key and marginalized populations need us most. PEPFAR stands with them in solidarity by doing everything within our power to sustain and expand their access to HIV services.
PEPFAR has also never shied away from addressing concerns with host-country governments and other partners when such policies or laws are instituted. We will continue to champion sound science and respect for basic human rights at every opportunity. Adherence to these principles is part of why PEPFAR has been so successful, and we will stay committed to them—and to those we serve.
TA Report: You previously served as Director of the U.S. Military HIV Research Program at the Walter Reed Army Institute of Research and led the development of a groundbreaking Thai vaccine trial. Why is it important to perform cutting-edge HIV research in the low- and middle-income countries where the majority of people with HIV live?
Ambassador Birx: The HIV Vaccine Clinical Trial RV 144, or what is often called the “Thai Trial,” was the first vaccine trial to support proof of concept that a vaccine can protect against HIV transmission. The opportunity to conduct research in high-burden settings has many benefits. Chief among them is the opportunity to collaborate with ministries of health and indigenous organizations, where U.S. scientists can work hand in hand with local scientists to conduct important research, build capacity, and develop and maintain sustainable research environments that can be leveraged to respond to other disease areas—providing added value to host countries.