Warren W. Buckingham III – best known as Buck – is director of the Office of AIDS Relief at the Peace Corps. In his career he has played critical roles in fighting AIDS domestically and globally. Most recently he had a major impact as the Kenya country coordinator for the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program for six years, overseeing a budget that grew from $30 million in 2003 to nearly $600 million today. He began his work in AIDS some 26 years ago in writing a proposal that secured funding from the Robert Wood Johnson Foundation to establish the AIDS Arms Network in Dallas, Texas, one of the first domestic demonstration projects for enhanced care of people living with AIDS in the U.S. (These grants are largely viewed as having provided the foundation for the Ryan White CARE Act, and Buck worked for a period of time in the early 90s at the U.S. Health Resources and Services Administration in the Ryan White Program). Soon after Buck started on that project, he was diagnosed with HIV. For years, he has spoken publicly about living with the disease, helping to erase stigma and shame both in America and Africa. John Donnelly interviewed Buckingham for the final interview in a Science Speaks series on 30 years of AIDS.
When did you start thinking about the AIDS epidemic?
It was probably late 1983 or early 1984, and I was living in Dallas at the time. There was a group of gay mental health professionals that had organized a hotline for people to call in about issues around mental health and dealing with being gay. I had volunteered to answer the phones once every couple of months, and when I did it the fourth or fifth time, it was like a switch had been flipped. The people who called in didn’t want to talk about mental health issues. It was about, “I’m sick or a friend of mine is sick, and I need help.”
It really took over my life after the Robert Wood Johnson Foundation issued a call for proposals to “replicate” the San Francisco model on AIDS response. I volunteered to write it on behalf of a Dallas coalition. That was 26 years ago, and my life has been radically different ever since. I thought I was going to write a grant proposal and go back to what I was actually doing with my life, but the proposal was accepted and people only half-jokingly argued that because I was the only person who really understood it, I had to agree to be the project director.
What do you remember most on a personal level about the epidemic?
One thing was when we opened the doors for the project in Dallas, and we anticipated a slow, steady pace of growth. We opened Oct. 1, 1986, and it felt like it was only overnight before we had 1,000 clients enrolled. The community response was phenomenal.
In 1988, I was diagnosed myself (with HIV) and finally had all of my denial swept away. Sitting with my doctor and looking forward and looking back, and figuring out what had happened in terms of my health, recalling my own social and sexual history, I realized I was infected 10 years earlier in 1978. I was told by my doctor in 1988 that if he was good at his part of the deal, and if I was lucky and careful, I might live for two and a half years. It’s nice to outlive those kinds of projections and begin to celebrate how incredibly lucky I’ve been, but also how much research and medical care have really advanced in what, in retrospect, is a very short time.
What was it like to be in the Kenya Embassy at the beginning of PEPFAR?
At first, there was significant incredulity. A feeling of, “Is this real? Is Congress actually going to deliver on what President Bush asked for? And if they do fund it, what does it mean for Kenyans and what we can do for Kenya?” What was humbling and inspiring in Nairobi is that we were incredibly fortunate to have a group of people working from the U.S. Agency for International Development (USAID), the Centers for Disease Control and Prevention (CDC), the State Department and other agencies that not only wanted to figure out how to do as much as possible for the benefit of Kenyans but also were not primarily concerned about their own agencies. There was an amazing sense of camaraderie about being given an unprecedented opportunity to change what was otherwise going to be an irreversibly horrible situation to one that had a bit more hope.
When did you realize that the outcome would be more than just a “bit more hope?”
It was toward the end of the first full year of PEPFAR implementation. One of the first things we did was to act on a cable that came out from the State Department that said they wanted us to look at U.S. government resources on the ground and scale them up rapidly. In 12 months time, in that incredibly compressed period of time, we doubled if not tripled the number of outlets in Kenya where people could have access to antiretroviral drugs. Kenya also was one of the first PMTCT countries (prevention of mother-to-child transmission), and how that little bit of a head start helped us overnight to just about triple our resources from $30 million to almost $90 million. We had an explosion of access that helped save kids from being infected.
When you started as PEPFAR country coordinator in Kenya, how many people were on AIDS treatment?
Our best guess, and it was from the pharmaceutical representatives, was fewer than 10,000 Kenyans were on antiretrovirals (ARVs), and of those on ARVs, for many the cost of it was impoverishing their families. The U.S. government also was financing three very small, timid, and meticulously planned pilot projects for treatment. Those three sites had fewer than 250 people on treatment.
Total. I saw the full turn of the tide two and a half years into the full-scale implementation when I was able to say publicly that compared to those 230 people on antiretroviral drugs in the trials, we now had that many Kenyans starting ARVs every single working day.
Today, how many Kenyans are on antiretroviral medicine?
More than 400,000.
Do you have one story out of the 400,000?
One that has stuck with me out of very, very many over the years was from fairly early in the implementation when I went out to Kericho, to the Walter Reed project, and went to the district hospital and saw hundreds of people queued up under a tin roof shed waiting to see a doctor to get prescriptions filled. Someone took me to see the adherence counselor. They took me to a corner of the shed, where this energetic woman was doing counseling. Her name was Rose. She had been a nurse at the hospital. Her husband died, she became ill, and she lost her job because she was too frail to work. About four months after she started treatment, she experienced the Lazarus effect that so many of us had observed here in the U.S., and she was back on her feet, ready to work. It was so amazing to see one person where we were not just bringing them back from the dead, but also bringing them back to useful employment.
What’s your vision for expanding the Peace Corps’ HIV work?
The future for Peace Corps is linked to the high-level priorities for the second phase of PEPFAR, shifting away from an emergency response and moving more toward sustainability and local ownership of the response. Other PEPFAR agencies are doing a lot of that work but it tends to be in the national capitals. The complementary skill that Peace Corps brings is a bottom-up approach. For years the U.S. government and others have tried and tried and tried to get real, lasting change to occur in the supply chain so that essential commodities reach people who need them. It seems like nothing seems to work to bring about sustained change. So we are looking at opportunities to recruit volunteers who could do inventory and forecasting of need. You would have USAID and CDC in the capital, and you would have 10 or 15 Peace Corps volunteers working in districts or sub-district depots. Instead of once-a-month supportive supervision from the capital, these folks would be sitting side-by-side with country counterparts for two full years working to get the systems changed and actually functioning as they should.