Dr. Rajiv Shah, the administrator of the United States Agency for International Development (USAID), is a central player in the US government’s AIDS fight. His agency, more than any other in the US government, guides aid programs in the developing world, working in 80 missions. But USAID also suffered a blow early this month when the administration announced that the Global Health Initiative (GHI) office was being closed. That ended the original vision of USAID being GHI’s home, which could have made Shah king of global health programs.
Q: Secretary of State Hillary Clinton announced this week that the administration would be put together a blueprint in five months for an “AIDS-free generation.” She first announced this vision eight months ago. Why does it take 13 months to put together a plan?
A: Let’s start with the goal. We were all very committed to create an AIDS-free generation. … We want to take a very honest and rigorous approach. We know it will require resources. We know it requires a great deal of local knowledge and development insights to say which communities are transmitting the most, how are we going to reach them, how do you reach people who are not as symptomatic? And what are the implementation strategies that are going to allow us to target and maximize outcomes against this goal?
We are trying to step through that in a very rigorous way. We are not holding anything up by doing that analysis. We’re embarking on an aggressive scale up of treatment, of prevention, of country ownership, of investing in country systems, even as we craft a blueprint that completely guides this country and our global partners for sometime in the immediate future.
Q: Is there a need for a blueprint, and is there wisdom in waiting for the results from the HIV combination prevention trials, which will test different approaches to reduce infections all at once?
A: The HIV combination prevention trial in Tanzania is particularly important because that’s probably the largest scale among them. It’s going to add a great deal of knowledge and data. But the reality is the pathway that defines success is going to look different based on the unique characteristics of the pandemic in countries and in communities. We need to do those trials and learn from them. We also are moving ahead with the aggressive presumption that combination prevention, including treatment as prevention, can be an effective strategy to get to an AIDS-free generation.
Q: Regarding male circumcision, you’ve had some problems in creating demand, such as what you’ve seen in Swaziland. What approach do you use now?
A: We need to apply more local insight, partnership with local institutions, better understanding of local behaviors and cultural preferences in how we scale up male circumcision programs. It is a medical intervention that has lots of data to substantiate its efficacy, but it is also a very personal and very significant cultural statement that we even in the United States in parts of our country debate and struggle with.
The big lesson learned is to take a little bit of time to be consultative with local partners who really know and are from the cultures in which we hope to scale up access to the intervention. I think we are working in the context of an aggressive scale up of male circumcision.
Q: The closing of the Global Health Initiative office ended the original dream of moving GHI to USAID. Are you disappointed that the dream didn’t materialize?
A: I kind of focus on what works and what doesn’t work, and what’s necessary to achieve our goals at a particular time. Our administration has set three critical health goals for our work: an AIDS-free generation; child survival call to action and eliminating preventable childhood death; and the virtual elimination or significant reduction of mothers who die in childbirth.
But what we learned in order to achieve them, we can’t have the current situation, where the US is keeping its funding constant in a tough global economy, but others are doing a little bit less. We know we need to have more focus and a more integrated approach. In the call to action we bring together malaria, preventing infections from mother to child, nutrition during the first 1000 days, GAVI and other immunization, and therapy for pneumonia and diarrhea. Let’s think of these as a combination approach to achieve the results of saving 5.5 million kids.
I know from my conversations with the president and the secretary that that’s their expectation — we are delivering on that. So, you know, the organizational structuring of it evolved in order to take on these goals and to address these challenges that were in our midst. Remember, GHI was launched before funding challenges existed both for US and abroad, and I think this is responsive to the reality of what’s needed.
Q: But GHI was perceived as the signature global health program of the Obama administration.
A: Just because we don’t have a Global Health Initiative coordinator at the State Department anymore doesn’t mean we don’t have a Global Health Initiative. We believe this structural approach will be more effective in delivering the kind of integration across services that we think is at the crux of getting health outcomes for the same resources, which is what GHI is about. It is true: We had a structure, we didn’t think it was the right structure to deal with the challenges going forward. We made changes to that, but we are absolutely committed to the GHI, to the goals we’ve established and to the concept of integrating service delivery to drive better results.
Q: At a panel at the Kaiser Family Foundation, Mike McCurry called on the Obama administration to articulate one clear global health goal – not three or five. But one. What do you think of that?
A: Mike was dead right. We got to this point by focusing on immunization, focusing on getting malaria bed nets to kids, focusing on HIV/AIDS. We still need to do that. But going forward, as Mike suggested, we need integrating concepts, concepts that people can be inspired by, that are operational and real, but that bring things together so that we are not competing with each other and instead grow enthusiasm for the overall effort.
That’s what the call to action for childhood survival was all about. You see 80 countries show up in the Washington meeting, co-hosted by India, Ethiopia and the United States. Fifty-six countries signed a pledge to eliminate preventable childhood deaths. Probably 20 some have already published scorecards to demonstrate how they are going to measure that. The US agencies and others have all agree to highlight the annual rate of reduction in childhood deaths as an operational metric to focus on across all of our grants. That’s the kind of coming together around something big, inspiring, and very genuinely country driven that I think will define success in the next decade for global health.
Q: Why did the call to action work then?
A: I don’t know the analysis, I just know the answer to the question. It’s somehow the energy is coming from the countries. We had a mid-level delegation from Yemen come to the Washington meeting, and they were so inspired that when they got back, when I got to Yemen the next week, the president of Yemen and deputy health minister both approached me and said, ‘We want to be part of this call to action. We looked to our statistics, we feel we can do better.’ When that happens, and that’s the demand signal we’re getting, that to me is what this should all be about, as opposed to our trying to construct something that then we ask others to respond.
Q: The phrase ‘turning point’ is used a lot when it comes to the AIDS epidemic. Do you use that phrase, and if so, why is it a turning point?
A: Well, the pandemic, the turning point, my understanding, the way I use it, is to refer to a specific moment when the number of global new infections is lower than the number of people added to treatment. Every year after that, you are reducing the number of people with the disease. We are not there. We are still in situation where the aggregate number of people with the disease is growing, so the turning point is a very important concept because once you hit that point you are on the decline and you can legitimately say we’re working statistically downhill toward zero. But the drivers of the turning point are what’s critical. That’s where you see that expanding prevention in a focused way that reaches the most transmitting populations is critical to achieving the turning point. And expanding efforts that effectively reduce risky behaviors so that you don’t have another turning point, and go back up again, are all critical to solve AIDS over the long term. So I think it’s a very viable concept.