At the Senate confirmation hearing for the next Global AIDS Coordinator four years ago, there was little talk of funding, when the nominee, Dr. Eric Goosby vowed to continue the program’s mission and “dare to think big.”
But as it happened, the global economic crisis that had begun to spiral downward the year before, continued and funding shrank. Still, science moved forward, and in the four years since Dr. Goosby became Ambassador Goosby, as the numbers of people receiving treatment and surviving multiplied, and the program shifted from emergency to sustainable response, its reach, scope, and mission grew to one that now has embraced the goal of an “AIDS-free generation.”
You don’t get there with easy answers, or without living fairly continually with the questions of how to do it differently than it has been done before. So when Ambassador Goosby, whose last day as Global AIDS Coordinator is today, took a few minutes to talk to Science Speaks, he spoke more of the work that continues than the work that has been done.
All the same, it is what has been done that lets him feel ready to move on, he says. And when he talks about what has been done, he is talking not of those already reached but the systems that will continue to allow more to be reached.
“We’ve seen thousands of changes of delivery systems, the identification of new partners, the standing up of those partners, the development of information systems that allow us to understand the impacts,” he says.
“The scientific challenges from the disease itself are going to be front and center for the next few years,” he says. “the issue of resistance is going to be much more critical.”
Surveillance to track resistance closely will be critical, and is in place he says. But this need is “concomitant” he notes with the shift to countries managing and overseeing their own programs, and that will be delicate.
“There are a huge number of lessons,” he says, to be learned from the process in South Africa, the first country to start the transition to running its AIDS program with the shift to shouldering delivery of its direct services. While maintaining the shift was necessary and timely, and that the “anxiety” and even “panic” it has created have peaked, he notes the process has yielded knowledge that could ease future moves. “We’ve learned that we need to do this slower, not a little slower, but significantly slower, and precede the actual shift of partnerships with a period, a process of discussion, where we include the patients that use the services in it, and put for the first time, government talking to civil society in the community.”
Goosby, who instituted PEPFAR’s first guidances for reaching men who have sex with men, and people who use injecting drugs, also has had the chance to apply lessons, or at least an approach he already had practiced through his career — matching responses to demographics.
“It’s no longer acceptable,” he says, for communities at the highest risk not to receive resources.
His successor, he says — when asked — needs to be aware of all of that, and more as challenges call for continued scientific responses.
Does his successor need to be a physician, too?
“I think if the coordinator is not a physician it has to be somebody who understands HIV, and TB, and hepatitis, and the better they understand that, the better they will be able to make what are going to be some difficult decisions, compounded by our transition into country ownership.”
Goosby, who is returning to University of California in San Francisco where he will once again see patients while “teaching students of all levels” is looking forward to establishing an institute for implementation science — another hallmark approach to PEPFAR during his tenure — that will focus, he says, on the connection between investment and impact.