A week after Ambassador Deborah Birx took office as U.S. Global AIDS Coordinator, she issued her first official statement, ” . . .on the Principles of PEPFAR’s Public Health Approach.” A reiteration of commitment to human rights and to continued responsibility for delivering HIV prevention, treatment and care services, even in challenging security environments, and in a landscape of shifting responsibilities for components of the work begun by the President’s Emergency Plan For AIDS Relief, it addressed an expanse of concerns. One theme, however, common in current global health parlance, was missing, at least in its usual wording. While the statement expressed appreciation that “a number of host governments have assumed even greater responsibility,” the term “country ownership” was nowhere to be found.
The Ambassador who took the task of seeing PEPFAR through to its next phase, the one she summarizes as one of “impact, accountability and transparency,” likes data. She seldom talks without some numbers close at hand to underscore her points. But in a field in which acronyms and statistics can dominate the discourse, words are receiving new attention. And in appearances since, including her ceremonial swearing-in two weeks after that first statement, the term “country ownership” has yet to surface. It is an expression, she confirmed recently, when she sat down for an interview with Science Speaks, that she doesn’t use.
“I don’t because I was privileged to work in Africa before PEPFAR, before the Global Fund, and countries were doing everything they could within their power to combat HIV and AIDS before we arrived. They may have not had all the fiscal resources, but they had strategic plans that they were trying to implement, they were working closely with UNAIDS and the World Health Organization, and so I just don’t like the implication that they didn’t own the response to begin with. They owned the response before we brought additional funding,” she said. “I think people would like to say ‘greater country leadership, greater country financial investment, or greater country use of data to focus their response — but I believe they’ve owned their epidemic for a long time, and the response to it.”
Her April 11 statement, was above all else, a confirmation of partnership with those countries. But, at the same time, the statement was prompted in large part by concerns over Uganda’s passage, enactment, and then enforcement of its 2014 Anti-Homosexuality Act, which led to a suspension of work at the U.S.-supported Makere University Walter Reed Programme there, and to worries about the status of sustained, effective efforts to reach those most in need of services. The first crisis to confront PEPFAR efforts under her leadership, the law has both challenged donor-funded responses, and raised questions about Uganda’s commitment to fighting its own epidemic. That fallout was followed by the Ugandan Parliament’s passage of an HIV and AIDS Prevention and Control Bill that included provisions criminalizing HIV transmission, requiring involuntary testing, and compromising patient confidentiality, and that Amb. Birx and others have spoken out against.
“Uganda’s a great example of a country that had very strong leadership, that thought they had control of the problem, and took their eye off the ball. And they stopped focusing,” she said. “And that was before we had all these legislative issues. The team there had spent the last two years refocusing, carefully going through every piece of data — they had quite good data at province and district level. They were really back on track, and now we have this legislation.”
In public talks before her appointment, and since, Ambassador Birx evinces a belief in the power of well-targeted efforts that could be mistaken for optimism. “Do not underestimate the importance of focus and political will,” she said, during our talk. But, Birx, who headed efforts to bring antiretroviral treatment to Uganda through PEPFAR during her time as director of the U.S. Military HIV Research Program, emphasizes that she can envision the laws doing irreparable harm.
“They were already in trouble. For this on top of that, it’s very frightening to me,” she said. “Because when these epidemics get out of control and if things begin to unravel, there’s really not enough financing globally to treat an expanded epidemic. There just isn’t.”
The Ugandan police raid of the U.S. supported program in early April, Birx said, indicates a pervasive level of homophobia, in addition to a “political overlay,” that has surfaced across East Africa, and that, she fears could harm other countries as well.
“We know example after example that if you create barriers, even if you think in your mind you’re targeting this group over there, it bleeds into all groups, because if one of us is unsafe, all of us feel unsafe.”
The suspension of services at the Uganda program, which is reported to have moved services for men who have sex with men to another location, could have lasting impact, she noted.
“I think our concern is that if you lose focus or people feel like they can’t access services, all of these epidemics are going to expand,” she added. “Imagine if people thought they couldn’t go back and get their medication. Their viral load will go back up to 100,000.”
Uganda also has a strong civil society, Birx notes, but says, “frankly I worry about them every day.”
In a country where gay rights advocates have been murdered, beaten and arrested, reports of abuses have escalated since the Anti-Homosexuality Law’s enactment.
“It’s not safe for the groups that are advocating for the human rights of the LGBT community in Uganda,” Birx noted. “Yet they are there. And it has to be inspirational to all of us to work harder, and do more because they’re the ones facing this every single day. And they have made tremendous progress over the last five years.”
At the same time, she is concerned over reports that the law and its accompanying abuses has begun to fragment human rights and HIV advocacy movements.
“If that happens, we lose the power of the community voice, and that would be really very unfortunate,” she said. “But I can understand it in a very fearful time that this would become divisive, even among the civil society groups. So I think PEPFAR in general, is looking at options of how we can support civil society in the country, particularly in Uganda, but in the whole region where this is an expanding difficulty.”
She stressed that the responsibility is a shared one.
“Frankly we need the leadership in Africa to stand up. We need voices out of South Africa, we need voices out of the other countries to really take this to a debate of compassion and humanity, rather than a stigmatizing and alienating debate,” she said.”And, hopefully, the faith-based groups that have been silent to date will stand up and say that everybody that’s sick or potentially sick or could be sick, deserves access to life-saving treatment, life-saving services.”
She hopes those leaders, as well as diplomatic input and judicial responses, can get the country that once was an example to the rest of Africa back on track to defeat its epidemic.
“I think the U.S. group in-country, led by Ambassador DeLisi, is very much focused on this,” she said. “We’re all hoping that their Ministry of Justice looks at the legality of this, and the human rights of this and decides it violates the Uganda constitution, which is also very much rights-based. I think we’re all hopeful that this could all turn around. But every day that it doesn’t, every day that something else happens like [the new bill criminalizing transmission], makes us all the more concerned.
Tomorrow, Part 2: Ambassador Birx looks at efforts to reach young women and girls, the continued role of science, mechanisms of transition (and why she avoids saying “transition” ) and more . . .