The massive U.S. AIDS initiative known as PEPFAR, or “The President’s Emergency Plan for AIDS Relief,” an $18-billion commitment launched in late 2003 by the Bush administration, has played a major role in changing the course of the global AIDS epidemic. On January 10, Harvard School of Public Health (HSPH) recognized that achievement, and its own role therein, by hosting a conference titled “PEPFAR in Africa: HSPH’s Role in the Largest Public Health Endeavor in History.” As one of the first and largest PEPFAR grant recipients, the school received $107 million in the course of five years to expand AIDS treatment and care in three of the most afflicted countries: Tanzania, Botswana, and Nigeria. The symposium provided an opportunity to take stock of the University’s contribution to the enormous gains made in the fight against AIDS in recent years and to recognize the significant hurdles that remain ahead.
Moderator Max Essex, Lasker professor of health sciences and chair of HSPH’s AIDS Initiative, opened by providing some historical context for the PEPFAR program. He recalled how, in the early 1980s, “few people thought we would ever be able to treat the disease, because drugs for viral diseases simply didn’t exist at that time.” The discovery and development of antiretroviral drugs in the 1990s transformed the HIV/AIDS diagnosis from a death sentence to a potentially manageable condition—but the drugs’ prohibitive cost kept millions in the developing world from benefiting from this advance. Not until the early 2000s did drugs begin to reach patients in Africa. And even though treatment quickly proved effective there, Essex explained, healthcare providers remained concerned about “donor fatigue and skepticism that the world would be able to scale up delivery of sufficient medication” globally. As HIV/AIDS continued to spread, PEPFAR emerged as a critical response to this global humanitarian and ethical crisis. (Essex in 2010 recounted the human toll in Botswana in the book Saturday Is for Funerals, as described in this magazine.)
David Hunter, the school’s dean of academic affairs, then described the school’s unique readiness to respond to President Bush’s “emergency” call. HSPH’s long-established partnerships with AIDS organizations on the ground in Tanzania, Botswana, and Nigeria provided a foundation on which to build comprehensive approaches to tackling the epidemic, and to ensure that local NGOs would be ready to take over the grants in 2009, in accordance with the PEPFAR plan. Hunter called PEPFAR “a shining example of HSPH’s translational mission,” declaring that “history will show that only a school of public health could have launched the kind of multidisciplinary, holistic response that was required.”
Much of the conference focused on presentations about the HSPH/PEPFAR supported programs, with two representatives—one from the African entity and one from HSPH—addressing developments in each of the three countries. Speakers outlined ways in which the partnerships had developed local capacity to address the myriad challenges of the disease: from the extensive training of hundreds of clinical and support staff, to the upgrading of lab facilities, the improvement of diagnosis and follow-up, and the introduction of electronic databases and the construction of clinics, hospitals, and pharmacies. In all, the programs in Botswana, Tanzania, and Nigeria have treated more than 160,000 patients with life-saving antiretroviral drugs.
Richard Marlink, Beal professor of the practice of public health at HSPH and executive director of the HSPH AIDS Initiative, noted that his team’s work in Botswana was guided by the principle “We are not in charge”—meaning the team “would not be dictating, but supporting.” In practice that meant listening closely to what Botswana’s Ministry of Health identified as priorities. Unlike Tanzania, Botswana (one of sub-Saharan Africa’s most stable and prosperous countries) did not need new clinics; it needed “integrated training for clinical and lab support and an effective system for monitoring and evaluation.” Marlink describes the current focus of the Botswana-Harvard AIDS Institute Partnership as “healthcare delivery science,” which involves “digging deep in the lessons we have learned from 100,000 patients followed over nine years” in order “to improve outcomes” and ensure that all of the country’s districts are providing treatment and care to those in need.
The presentations highlighted the different scale of the challenges found in each country. Botswana, with a population of only 2 million, has achieved antiretroviral therapy (ART) coverage for more than 80 percent of the estimated 320,000 people in the country living with HIV; Tanzania, a country of 44 million, has reached only 33 percent ART coverage of its 1.4 million HIV-infected people (according to the UNAIDS Report on the Global AIDS Epidemic for 2010). Nigeria, an ethnically heterogeneous state with a total population of 170 million, faces the steepest climb. Less than 25 percent of its estimated 3.3 million infected inhabitants were receiving ART coverage in 2010.
Professor of immunology and infectious diseases Phyllis Kanki, principal investigator on the Harvard PEPFAR grant (for a description of her role in securing the grant, see “The Politics of Paying for HIV Care”), noted that “Botswana could fit into a single suburb of Lagos.” She spoke about the many achievements of the AIDS Prevention Initiative in Nigeria (APIN) since its inception in 2000, describing one of its earliest projects in a Lagos shantytown that served hundreds of homeless people, sex workers, and local bar employees living in the shadow of the city’s five-star hotels. Today, APIN has expanded its activities to nine of Nigeria’s 36 states, where it operates a total of 32 sites. Kanki acknowledged, however, that Nigeria was still falling short in prevention of mother-to-child transmission, and in reaching children of two years or younger who are infected with the virus.
The panel discussion was cautiously optimistic. New evidence, published in 2011, has shown that oral antiretroviral drugs can prevent heterosexual HIV transmission in 97 percent of cases—a game-changing discovery that Max Essex said “gives hope that we may be able to treat our way out of the epidemic.” Yet Kanki noted that even though there are now some six million people receiving antiretroviral therapy worldwide, “There’s still a long way to go, and we need to focus on how we are going to sustain the effort, to maintain the quality of treatment and ensure better access for those in need.” Added Marlink: “The final push in the effort to turn the tide on the epidemic may prove the most difficult.” How each country deals with “ownership [of the PEPFAR grants],” he said, “will depend on differences in resources and government effectiveness.”
In his closing remarks, HSPH dean Julio Frenk, the Angelopoulos professor of public health and international development, noted that “AIDS has clearly changed the way we see public health” and that “PEPFAR has changed the way we think about what public health can accomplish.” The epidemic, he said, “has galvanized our social energy around a solution to a challenge” and has exemplified a model of “enlightened technical assistance” based on partnerships dedicated “to building local capacity for the long term.”
Last to speak was University provost Alan M. Garber, himself a physician and health-policy specialist, who described PEPFAR as “a remarkable experiment” that “has shown that governments can have an enormous effect.” Even though PEPFAR “was not created to promote research per se,” he noted, “it has yielded an enormous amount of data that has spawned important research initiatives.” The Harvard/PEPFAR program, he concluded, while saving tens of thousands of lives in Africa, has “brought tremendous educational benefits to our students,” and in the process “has changed this University.”