Science & Diplomacy: PEPFAR Is a 'Triumph of Medical Diplomacy'

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AIDS Ribbon hanging on north portico of the White House in honor of World AIDS Day, 2007. | dbking, Wikimedia Commons

The U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which has for ten years developed bilateral partnerships with countries to prevent and treat HIV/AIDS, represents an extraordinary success, in large part because it required measurable objectives and engaged key medical experts, according to a new article in the AAAS journal Science & Diplomacy, written by Harold Varmus, director of the National Cancer Institute.

Through interviews with people who were pivotal to the planning and implementation of PEPFAR, Varmus has drawn lessons that could be useful for other programs that aim to confront some of the problems of the developing world. The article and a related slideshow were published on 1 December, overlapping with the commemoration of World AIDS Day.

Many Americans are unfamiliar with PEPFAR and would be surprised to learn that it has been highly effective, supplying an estimated 5 million patients with antiretroviral drugs by 2012 — up from 1.7 million in 2008 — as well as protecting nearly 1 million infants from maternally transmitted HIV and testing nearly 50 million people for infection, Varmus writes. And, many would be further "astounded to learn that it was invented, in a remarkably direct way, by President George W. Bush, whose reputation in international affairs is dominated by his war on terrorism, military interventions in Iraq and Afghanistan, and the antagonism he displayed to the United Nations and to several of our traditional partners."

In fact, President Bush was deeply involved strategically at every stage of the project.

Although he objected to existing foreign aid policies, viewing them as paternalistic and judged largely by spending levels instead of results, the president did contribute U.S. funds to the Global Fund to Fight AIDS, Tuberculosis, and Malaria, at the urging of Secretary of State Colin Powell and Secretary of Health and Human Services Tommy Thompson. In June 2002, Bush also announced his International Mother and Child HIV Prevention Initiative. At the same time, according to his memoir, he told his deputy chief of staff, Joshua Bolton, "Go back to the drawing board and think even bigger."

Bolton assembled a small group including Gary Edson, who became a central figure in the planning of PEPFAR, and Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases (NIAID). Under instructions to use dollars to achieve concrete goals, select target countries that could make good use of the money, include measurements of the outcomes, and restrict the funds to combating HIV/AIDS only, Fauci and his team got to work. They drew up lists of countries that the program might assist and estimated costs for prevention measures, provision of antiretroviral drugs, and other aspects of care such as antibiotics or orphanage support. They estimated that the program might cost as much as $15 billion over five years.

The entire operation was planned "under a blanket of strict secrecy, intending to avoid the interagency strife that Bush and others feared would result from a more open process," according to Varmus. The announcement, planned for the State of the Union address in January 2003, was bound to create some hard feelings among those who had been kept in the dark, including leaders in Congress, officials at the United States Agency for International Development, and many cabinet members. Another concern, shared by some members of the White House senior executive staff, was that such a large, ambitious plan might be difficult to finance and impossible to achieve, thereby exposing Bush to failure and criticism.

The president's staff thus asked Fauci to invite a small group of physicians to speak directly with skeptics and critics from the Office of Management and Budget and other parts of the White House. The physicians sensed the importance of the request and assembled rapidly from far-flung countries. They were: Eric Goosby, a professor at the University of California, San Francisco, School of Medicine, who had been treating a few AIDS patients with antiretroviral drugs in Rwanda; Peter Mugyenyi, head of the Ugandan JCRC, who had been providing AIDS patients, mainly wealthy ones, with antiretroviral drugs; and Paul Farmer (from Harvard Medical School and founder of the global health organization Partners in Health) and Bill Pape (a Haitian-born physician from Weill Cornell Medical College and founder of a community health foundation called GHESKIO) who had both treated AIDS patients in Haiti.

The testimony presented at this crucial meeting helped convince the president's representatives that the program should go forward. The experts who had worked in the field provided evidence that antiretroviral drugs and preventive measures could be deployed effectively and at reasonable cost, even in very poor settings. And, they showed how the new drug regimens could restore health. "Even the most skeptical people in the room realized that such dramatic transformations would encourage others at risk in the target countries to determine their HIV status and that treatment would return desperately ill people to productive lives as breadwinners and parents," according to Varmus.

The final decision occurred just in time to be included in the president's budget for fiscal year 2004 and in the State of the Union speech. The announcement was, as predicted, a surprise to many, and met with responses ranging from skepticism, to enthusiasm, to resentment. However, White House staff managed to secure the necessary funds, with help from Senate Majority Leader Bill Frist, a surgeon who spent time working in Africa each year, Senator Richard Lugar, a member and later chairman of the Foreign Relations Committee, and Representatives Tom Lantos and Henry Hyde.

With actual spending relatively close to the initial plan, and demonstrable results, the program was renewed with little change or opposition five years later.

One of the most dramatic aspects of PEPFAR's success is the effect on life expectancy in African countries, which had been plunging since the arrival of the HIV/AIDS epidemic in the 1980s but rose substantially after the start of PEPFAR, according to Varmus.

Several of the factors that contributed to PEPFAR's success could be applicable to other programs, including careful planning, bilateral rather than multilateral relationships, objectives that are measurable and highly likely to be achieved if the investment is made, mandated evaluations, and advice from appropriate experts. Certain conditions are required to conceive, launch and implement such plans, however, and it is difficult to generalize, Varmus notes. "Despite these considerations, the triumphs of PEPFAR should inspire further efforts to confront carefully selected problems of the developing world with similar determination and success."