Despite a nearly flat budget, US Global AIDS Coordinator Eric Goosby today promised a “steep increase” in PEPFAR’s prevention activity, as the program pivots from an emergency US response to a broader long-term, country-driven endeavor. Indeed, Dr. Goosby signaled that PEPFAR will be as aggressive in scaling up prevention services in the next five years as it was in scaling up HIV treatment in the first five years.
Dr. Goosby spoke at a forum on US priorities in HIV prevention, hosted by the Center for Strategic and International Studies. In his opening remarks, Dr. Goosby described the huge challenge facing HIV prevention experts, noting for example, that for every 2 patients put on antiretroviral drugs, there are five who become newly infected. He also cited a National Intelligence Council estimate that by 2025, there could be as many 50 million HIV positive people living with HIV—25 to 30 million of whom would require treatment.
PEPFAR’s efforts going forward will center on “combination prevention” models that deploy biomedical, behavioral and structural elements. Dr. Goosby said PEPFAR’s new effort to more accurate map the HIV/AIDS epidemic in high-burden countries will help program officials develop more effectively targeted strategies that move “from the demographics backward.” And he said PEPFAR would also try to better evaluate programs so they know what works and what doesn’t.
“We want to be nimble enough in our understanding of what we’re doing to identify efficacy and move the machine … when we see something that indeed does impact,” he said. (Click here for more on PEPFAR’s five-year strategy.)
During a panel discussion afterwards, Dr. Goosby was asked how PEPFAR could achieve such ambitious prevention efforts with only minimal funding increases. He said the modest funding increases allocated so far, along with cost savings, such as anticipated decreases in treatment costs and eliminating funding that’s now directed to multiple groups to serve the same populations, would be sufficient to beef up prevention at time of constrained budgets.
He also said the US is pushing other wealthy countries to step up their commitment to combating the epidemic, so multilateral organizations, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, would be better funded.
“The Global Fund is kind of the future,” he said. “We need to work hard to make it everything it needs to be.” He said discussions with other G8 leaders have already begun, but the effort will require leadership from President Obama and Secretary of State Hillary Clinton. Another panelist at the CSIS forum, Sonjia Kenya, of the University of Miami’s Miller School of Medicine, said PEPFAR’s No. 1 priority in prevention should be nixing its abstinence-only policies. “It’s never done anything but increase transmission,” Kenya said. “It really ignores our current science … and we see the dire consequences these ideological constraints have in very disturbing outcomes around the world.”
Dr. Goosby agreed, saying a “critical” component in PEPFAR’s new prevention focus will include offering condom and family planning services. He said PEPFAR is working on new guidelines that will not “have an ideological belief system intervene” between provider and patient. But it not a simple task, he suggested, noting that some faith-based NGOs may refuse to provide such services. That requires PEPFAR and its implementers to develop a referral system to connect patients to the health services they need.
In response to a question about PEPFAR’s Internet-age savvy, Dr. Goosby said OGAC would soon launch a new campaign, in one or two countries, that uses texting and other social media tools to increase outreach, adherence, and other services. He said Rwanda is a likely target country for the campaign because officials there are very eager to implement such a strategy.
Not all the talk at today’s forum was about prevention. At one point in the session, Goosby hinted at the delicate balance between scaling up prevention and keeping promises on treatment targets. If there’s no increased treatment for HIV and it’s still perceived as the “kiss of death,” he said, then any effort to de-stigmatize the disease will fail.