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U.S. Department of State

Diplomacy in Action

The PEPFAR Blueprint: Creating an AIDS-Free Generation

Eric Goosby, M.D.
U.S. Ambassador

Washington, DC
November 30, 2012

8:30 A.M. EST


MODERATOR: Good morning, everyone. As our operator indicated, my name is Saul Hernandez, and on behalf of the Department of State and the Bureau of Public Affairs, we’d like to welcome you to this conference call.

Our speaker today is Ambassador Eric Goosby. He serves as the United States Global AIDS Coordinator, leading all U.S. Government international HIV/AIDS efforts. He is here today to speak about the PEPFAR Blueprint: Creating an AIDS-Free Generation, a document that was unveiled by Secretary Hillary Clinton in a ceremony yesterday at the Department of State. He will make some opening remarks, and then we’ll open it up to questions and answers. With that, I’ll turn it over to Ambassador Goosby.

AMBASSADOR GOOSBY: Thanks very much. Thank all of you for participating in this call today. I hope we can answer questions and clarify any issues that you bring to it.

We are at a remarkable moment in the response to HIV. After 30 years of this virus devastating populations all over the globe, we have gained enough knowledge to understand better both how the virus moves through an individual and damages immune function on an individual basis, but we also now understand the elements, constructs, of infectivity much more explicitly. So we really do now look at how that virus not only moves through individuals and their own immune [systems] but how that virus now moves through populations.

Our ability to understand risks, relative risks, some populations having higher risk than others, having behaviors that increase the likelihood of transmission, and then having knowledge around how to counter that transmission so the person with the same exposure does not end up getting infected, are all now part of the public health toolbox to contain and diminish [the] spread.

These tools are well known in isolation as individual interventions: the use of condoms; the ability to take an individual and have male circumcision, which drops yours risk of getting infected as an uncircumcised male by about 64 percent when you become circumcised – that protective ability again lasting for years after the actual circumcision; the ability to move with transmission from an HIV-positive pregnant mother to her fetus – [prevention of] vertical transmission is very effective when anti-retroviral drugs, especially three at a time, are used to prevent that transmission – down less than 2 percent; our ability to contain transmission in an HIV-positive person with the initiation of antiretroviral drugs – again, three antiretroviral drugs dropping the viral load in the person to the point where their infectivity drops by 96 percent. These interventions in combination also add to the ability to prevent infection. And we have found that condom distribution, male circumcision, prevention to mother-to-child transmission, with the addition of treatment, puts us in a position really for the first time where we can precipitously drop the number of new infections in a population.

Th[e] ability to do this is predicated on systems that identify, enter, and retain people in care. Social community-based responses that keep people in care over the duration of their illness, which is a lifetime, become critically important. Our ability to kind of put all of these modalities together to diminish transmission is what this blueprint has tried to focus on and map out a strategy for countries to, indeed, contain their epidemic and prevent new infections.

Secretary Clinton yesterday presented a discussion of the blueprint, as we call it, to look at how in combination we can, indeed, strengthen our response and contain spread in populations that are high risk and thereby contain spread into the general, low-risk population. The strategy itself is a document that outlines by example. It goes through four different models of countries that are at different stages in their epidemic and shows how the addition of these prevention interventions – the condom, male circumcision, [P]MTCT, and treatment – change the number of new infections in that population, if one starts at a CD4 count of 350, which is a later-stage disease and if you also start at a CD4 count of 550, at an earlier stage of disease.

This presentation shows how the United States Government, through the President’s Emergency Plan for AIDS Relief, will continue to support these efforts, and also speaks directly to the role that the country plays in mounting and orchestrating this response, being the primary convener of both planning and implementation decision making, taking funding from donor populations, donor groups, foundations, et cetera, to respond to their unmet need and makes allocation decisions accordingly.

It also speaks to the shared responsibility that this response will require needed from other donor communities as well as foundations. And I think we tried to really give that comprehensive total response needed for what really is now within our reach, an ability to decrease precipitously the number of people who become infected.

As Secretary Clinton said, an AIDS-free generation is really moving us to the point where those who are participating in high risk [behavior] get information that preempts their seroconversion or becoming HIV-positive, that those who are HIV-positive and pregnant have an opportunity to block transmission to their babies and no new children will be born HIV-positive, and those who were already infected get access to antiretroviral drugs that will give that individual – stop progression in that individual so there’s clear benefit for that person, but also to the larger public health benefit of dropping their infectivity, their ability to transmit, down by 96 percent.

So in combination, I think we have a real opportunity to aggressively move toward this AIDS-free generation within a three-to-five-year period. The document gives examples of different countries at different stages in their epidemic to show how the introduction of these interventions changes the incidence.

So I will stop there and let you take any questions to clarify or amplify on any of that. And again, thank you for participating.

MODERATOR: Okay. I guess we should have callers push *1. Participants, if you have a question you would like to enter into the Q&A mode, please push *1 on your phones.

OPERATOR: Thank you. I’m sorry I missed that, sir. Ladies and gentlemen, if you wish to ask a question, please press *1 on your touchtone phone. You will hear an acknowledgment tone. If you are using the speakerphone, please pick up the handset before pressing the numbers. Once again, if you have a question, please press *1 at this time. Hold for our first question.

We have – I’m sorry. I have Ms. Charlene Porter (ph). She’s with the Bureau of International Information. Go ahead, please.

QUESTION: Hi, Ambassador Goosby. Thanks for much for doing this. And you mentioned in one of our final comments the three-to-five year time period. The Secretary did say specifically yesterday she didn’t know how much longer HIV would be with us. Can you elaborate a little bit more on that? Do you really have expectations that within five years, we might achieve this goal?

AMBASSADOR GOOSBY: The – HIV will always be with us is the truth. The behavior that allows for transmission is very difficult to stop in populations that are even well educated around transmission risks. Our experience over the last 30 years is that there’s recidivism in individuals who are even health professionals who have cared for HIV, for many years have fallen into high-risk behavior at vulnerable moments.

So HIV is not going to go away. What is going to go away is the ability to HIV – for HIV to progress in the individuals with a diagnosis of AIDS. As people remember, there’s HIV – that’s everybody who’s infected – and then as you progress to a CD4 count below 200 or develop an opportunistic infection, that qualifies as a diagnosis of HIV becoming a diagnosis of AIDS.

We’re talking about preempting the movement of HIV to a diagnosis of AIDS, stopping progression in individuals and preventing primary infection in those who are HIV-negative, so keeping them negative. I think that the aspiration is in – is – for the three to five years are in the countries that are – on page 7 in the blueprint, there’s a table that shows you countries in Sub-Sarahan Africa that are close to reaching the point where the number of people who are going on antiretroviral therapy is greater than the number of people who are newly becoming HIV-positive. We’re calling this a programmatic tipping point, and what we mean by that is we are positioning ourselves so we have effectively blocked movement of the virus in the population better than the virus is moving in the population. So our ability to diminish the number of individuals progressing, moving to late-stage disease, and getting newly infected is what we’re talking about.

For the three-to-five year period, we’re really talking about the countries on that table that we feel are the highest-hit countries on the planet for HIV, and we believe they are positioned to, indeed, move in that direction. On that table, there are four or five countries that already have reached a point where there are more people going on treatment with antiretroviral drugs than are becoming HIV-positive. Those who go on treatment drop their viral loads to undetectable and become non-infective. So that’s what we mean by that.

QUESTION: Thank you.

OPERATOR: Once again, if you’d like to ask a question, please press *1. Hold for the next question, please.

There are no more questions at this time. Please continue. I’m sorry, Ms. Porter (ph) has called back in. Just a moment. Ms. Charlene Porter (ph), go ahead, please.

QUESTION: Thank you. I don’t want to abuse my privileges here, but if no one else is asking, I certainly have a couple more. Ambassador --

AMBASSADOR GOOSBY: We’re glad you do.

QUESTION: Okay. Ambassador Goosby, there’s a lot to take in with all the specifics of this plan, but I think there’s one really significant point that has not emerged yet, and that is your personal viewpoint. You have been in this from the very beginning. What are your personal feelings about having reached this moment? Did you ever think you would? Was it too far off, too – please address that point, if you could.

AMBASSADOR GOOSBY: Oh. Well, you’re the first person to ask me that. I am humbled by the moment that we’re in front of here. I have looked at this virus for 30-plus years move through individuals and destroy their lives, destroy the lives of the people that they care for and depend on them. I’ve seen communities wobble and fall because of the number of individuals infected. I’ve seen villages disappear on the planet because people were so devastated with death from the virus that they just kind of wrapped up and moved on to other family members outside of that locality. Those days of waiting 30 [days]– the month to a month and a half to bury your loved one, running out of wood, having coffin making being the rate limiting factor for burial, are gone.

The inpatient dominated response, where people come into care at late stage disease as the only moment of interface with the medical delivery system, has now been transformed to a predominantly outpatient response. We’re no longer, as medical delivery systems in any of the countries we’re in, waiting for a person to be close to dead with an opportunistic infection to come in for care. We have moved it to earlier stage disease by aggressive targeting of high-risk behavior and testing to follow, bringing those individuals who are participating in high-risk behavior but are HIV negative, having a strategy to keep them negative. And I have seen all of that, as I say, transform the epidemic to an outpatient response, de-bulking inpatient services. The three to four people in beds are gone on the continent for the most part. There are still some areas where that’s not true.

That has been breathtaking. The institution of a change in the perception that HIV was equated with death is happening. Hope is coming back on the horizon. People are getting re-engaged in their own lives and in the lives of their community. People who are on – who are HIV-positive and go on these antiretrovirals, 90-plus percent of them, if cared for properly, should go back to work. We are talking about a transformation here that is now happening in Sub-Saharan Africa, the epicenter of the epidemic, where most of the people were – just eight years ago, less than 50,000 people on the continent were getting treated. We’re now up over 6 million.

So I have to say that I am very optimistic that if we orchestrate the convergence of these prevention interventions correctly, if we insist that high impact preventions are what we fund first, and less impactful interventions come after that, if we understand and use the tool of treatment as prevention in a strategic and smart manner, we will, indeed, see this disease turn into a chronic progressive illness.

I guess I would also just add on a personal level that my pride for the United States willingness to engage in moving our taxpayer dollars to the care of people in other countries who are in desperate need – it is one of the most benevolent acts that I think our country does. It is done without an expectation of any return. It has been sustained through both Republican and Democratic administrations, and we’re now moving into our ninth year. I do think that this is something that makes me, as an American, feel very proud.

I also am very gratified in looking at the topography in front of us, because countries in which we work, our implementing partners, our implementing countries, the country leadership has engaged in a robust way, especially in the last two years, in understanding that to sustain these services, their role needs to be intensified and broadened to not just urban kind of secondary and tertiary hospital settings, but to move out into clinic settings in villages and community-level support.

The transformation that we’ve seen in the health care delivery system has been breathtaking. The nurses, doctors, laboratories, procurement distribution systems that are in place for HIV/AIDS, which is a very complicated disease, are also available for hypertension diabetes and coronary artery disease for the same patients who are HIV-positive. So I see this as the wedge that has put an infrastructure in place that will put a blanket of healthcare in Sub-Saharan Africa that was not there before, that will serve the people in these countries for years to come.

QUESTION: Wow. Thank you so much.

OPERATOR: Ladies and gentlemen, if you’d like to ask a question, please press * 1.

There are no more questions at this time. Please continue.

We have one question from Ms. Alyson Grunder at Foreign Press Center. Go ahead, please.

QUESTION: Okay. I’m Alyson Grunder, the Foreign Press Center Director in New York. I was just wondering if you could talk a bit about how PEPFAR has influenced and possibly changed the way that U.S. Government approaches international health care assistance generally.

AMBASSADOR GOOSBY: Well, that’s another question I’ve never been asked before, but that’s a great one. I think it’s been a profound change in a couple of respects.

One is in realizing that you can take a complicated, devastating problem, like a disease, and direct resources towards it and change outcome. I believe before the concerted global effort that AIDS has required occurred, the belief that one could deal with these overwhelming, devastating, ubiquitous problems was low. And the feeling, indeed, up until PEPFAR and the Global Fund, which is around 2003 – 2001-2003 was when this discussion occurred – there was a strong belief by people in especially the development community that this was a waste of resources, that to put resources toward very expensive interventions like treatment, which they are, was, indeed, something that was irresponsible and that one should really focus efforts on prevention interventions and kind of step over the already infected community and let that just go through its natural history.

It was really courageous for those in the community that voiced it and demanded that the North-South disparity in prevalence of disease versus availability of treatment be addressed. Peter Piot in the UNAIDS arena was the most vocal around it, coming off of Jonathan Mann’s frame around HIV, that this really highlighted all these human rights issues. And access to healthcare as a basic human right, I think, very much moved through the AIDS community as kind of the motor for that thinking.

I believe that people who are close to these programs are convinced that you throw resources at a problem, you can make a huge difference. PEPFAR is a wonderful example of that, and I think the best example of that, and the Global Fund. Both are instances where convergence of countries – and the Global Fund in particular, that would never have a bilateral program – have an opportunity to put their resources toward an effort for HIV/TB, and malaria in the case of the Global Fund, that contributes to the overall containment of these diseases.

I do believe that there is an ethical responsibility that countries that have more resources have toward those who don’t. And the reason is because they have the resources. It is not that there is some historical event that aligns that responsibility; it is because of that resource differential. Those who have really have an obligation to ask themselves how can I share these resources to allow those to benefit from diagnosis and treatment of diseases that we know how to diagnose and treat?

So I think that the understanding and belief that you can respond to an overwhelming, devastating disease has been answered, and now the world, I think, is rethinking the traditional development approach around the role of countries in orchestrating and managing and overseeing these programs because of their connection to being able to sustain the services.

It’s our belief that PEPFAR, especially in the last four years, has understood the difference between creating parallel systems and coming into a country and engaging in true capacity expansion of the systems that are already there in and of the country, well interfaced with populations, and it is the expansion of those services that I think are most sustainable. That’s not to say that parallel systems aren’t needed; they are needed almost everywhere, but not as the dominant response, more as filling in between the holes in that continuum of services. And I, again, think that PEPFAR has demonstrated that in a dramatic way.

So I guess I would just say that these large global motors of resources for health issues can be effective when combined with countries that are capacitated to play the oversight role of managing and overseeing. Donors need to look and position themselves to engage with partnership and country leadership – both in the government and in civil society – to capacitate them to run and manage these programs and not be dominated by parachuting in what is excellent capability, but not sustainable. So I think that all of those things have happened.

QUESTION: Thank you.

OPERATOR: There are no other questions at this time. Mr. Hernandez, I will turn the conference back over to you, sir.

MODERATOR: All right. Well, with that we will conclude this event on behalf of the U.S. Department of State, the Office of the Global AIDS Coordinator, and the Bureau of Public Affairs. We’d like to thank everyone for participating in this call, and we will make a transcript available as soon as possible afterward. Thank you all once again.


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