Dr. Fauci and Colleagues Await AIDS Relief Reauthorization by Congress

Dr. Dave Campbell

The United States Congress is considering the reauthorization of PEPFAR. The death sentence of AIDS has been significantly decreased across the world in the last 20 years, since The U.S. President’s Emergency Plan for AIDS Relief was spear-headed by President Geroge W. Bush, Dr. Anthony Fauci, and others. In that time, 25 million deaths have been avoided, while 5.5 million babies born to HIV-positive mothers lived their childhood HIV-free. PEPFAR, designed by Bush to avoid paternalism, offers 55 low-and middle-income countries struggling with the HIV/AIDS crisis a partnership with tools for sustainability. PEPFAR also offers hope.

Continuing PEPFAR will ensure millions of people access to prevention, care, and treatment for HIV/AIDS. Concerns of anti-abortion advocates have stymied the reauthorization process by Congress. PEPFAR has long held that they do not subsidize abortion. Members of Congress are being asked to decide between the moral imperative of saving lives through successful foreign-aid healthcare programs supported by PEPFAR, and the convictions of those who advocate against abortion. Members of Congress are working with the specter of a government shutdown looming. Wrangling the reauthorization of PEPFAR is a test of courage and humanity.

The experience of scientists and clinicians engaged in the early battle against the life-threatening HIV/AIDS crisis provides crucial perspective. Leslie Diaz, M.D., is a respected infectious disease specialist in Florida. She trained at the University of Florida in infectious diseases in the mid-nineties, in the decade after HIV was shown to be the cause of deadly acquired immunodeficiency syndrome. Dr. Diaz has committed her career to preventing and treating HIV/AIDS. I caught up with her recently and asked about game changers for HIV/AIDS prevention and treatment.

“I finished my fellowship in 1996,” Dr. Diaz told me. “By that time, we had already developed our first protease inhibitor, which came out in December 1995.” She will never forget it. The following year a second protease inhibitor to treat HIV became available. Those two medications turned around the numbers of not only new HIV cases and dramatically lowered the death rates. But the new medications were not available to most people across the world. Besides the cost, some experts did not believe the logistics of getting medication to prevent and treat HIV/AIDS would allow effective management of the crisis in the most desperate and impoverished countries, especially in parts of Africa.

According to Dr. Diaz, the death rates were cut in the United States by the new medications by over 50 percent. “But people living with HIV in Africa did not have access to these medications, like those in the U.S.,” Dr. Diaz told me. “Death rates were skyrocketing through the 90s and into the next century, especially in sub-Saharan countries.” PEPFAR stepped in and changed that crisis. $100 billion in funding has been directed internationally to countries that together are home to 78% of all people living with HIV.

Dr. Diaz was part of a growing wave of infectious disease specialists in the United States able to effectively treat HIV and AIDS. “We were able to make a difference with these individuals.” Dr. Diaz told me. “Instead of just keeping our fingers crossed and hoping that they wouldn’t die or progress.” She was thrilled when PEPFAR was put in place for the international community.

“Throughout the year 2002, we put together the architecture for a program that was designed initially to prevent 7 million infections and to treat 2 million,” Dr. Fauci told me this summer. “The program would take care of 10 million people including a lot of orphans.” The program was initially budgeted at $15 billion over five years and was slated to involve a relatively small 14 countries, 12 in sub-Saharan Africa, and a couple in the Caribbean.

The program proved to be very successful. “We have new data now that says that if you’re undetectable, you don’t transmit,” Dr. Diaz told me. She now sees HIV infection as a comorbidity like having diabetes or some other chronic illnesses. “If you take your medicine, you do the labs, follow with the doctors, stay healthy and do the tests that you need to do to screen for different things, you live a very long life, and you don’t die of HIV. It’s as simple as that. But that’s the luxury that we have here in the states.” That luxury has been translated through PEPFAR to the international community. Another expert in HIV/AIDS, a virologist by training, puts the history of HIV, AIDS and PEPFAR in perspective.

Ambassador Dr. John Nkengasong, the newly appointed head of the Bureau of Global Health Security and Diplomacy and the U.S. Global AIDS Coordinator told me that early in the 1980s, he and his peers in public health started hearing about the occurrence of pneumonia in the United States. It was reported by the U.S. Centers for Disease Control and Prevention. At that time, he was a student at the University of Yangon, Cameroon. “Really out of curiosity,” he told me, “I wanted to understand what that was. Because there were no cases documented in Cameroon doesn’t mean it did not exist. We just did not have good systems in place to document that.”

Dr. Nkengasong joined a research group at the medical school where they were looking at HIV in the community. “We were looking at different populations,” he told me. “In 1988, I had an opportunity to go to Belgium at the Institute of Tropical Medicine, to study virology and specialize in HIV/AIDS. We had just known about this virus for less than six or seven years. My interest deepened because we were uncovering different strains of HIV. Today, we discuss COVID in the lens of different variants. But at that time, we were documenting what you call subtypes of HIV and the types of HIV.” According to Dr. Nkengasong, HIV was poorly understood at that time. He and his colleagues used to say there existed North American, European and then African strains. But scientific inquiry revealed that HIV was more diverse than they thought. “That is important,” he told me. “Because it is one of the reasons why we do not have an HIV vaccine still today.”

Dr. Nkengasong points out that the world has been researching HIV, or working on HIV, for the last 40 years. “All we had at that time were tests,” he told me. “We tested individuals who knew that they were infected, and we saw them die, especially in sub-Saharan Africa”. Fast forward to 2002 when President Bush launched the PEPFAR. “That truly began to change the face of HIV in Africa,” Dr. Nkengasong told me. “I used to sit in my office in Cote d’Ivoire, working for the U.S. CDC. I would look over at the infectious disease clinic and see how people would bring their loved ones to the infectious disease clinic. Shortly after, they were crying. It was very painful to see that. I went back there a few months ago, while in my current job, and sat in that office. I kind of imagined looking across the window, and imagining how ugly the face of HIV was at that time. But today, 20 years forward, with a program as impactful as PEPFAR, the ugly face of HIV/AIDS has been transformed dramatically.”

Dr. Uche Ralph-Opara started her career as a physician and clinician and is now the Deputy Chief Health Officer for Project Hope, a global non-profit that works in bringing resources for HIV/AIDS. I met up with her this summer in Washington, D.C. at Project Hope’s headquarters. She is originally Nigerian. Uche, as she prefers to be called, has been working in the global health space for over 18 years, starting as a clinician and then transitioning to core global health.

“My very first goal at public health programming was working on PEPFAR funded HIV care and treatment programs in Nigeria,” Uche told me. “I felt as a public health physician or public health expert I would be doing more impactful programs to strengthen those health systems and improve the health workforce.” She started working in the HIV space after obtaining a master’s degree, as a care and treatment expert in Nigeria. She started off as a volunteer enrolling HIV- positive patients into care and seeing them through the program.

“I really had a good impression of the PEPFAR program because that was the largest in Africa responding to the HIV pandemic,” Uche told me. “One of the things that really got me inspired was how the program helped vulnerable communities. If we did not have PEPFAR we would have had many more deaths, and lots of communities not achieving pandemic control that we want to achieve by 2030.”

When PEPFAR kicked in 2003, Dr. Diaz was in the thick of it in South Florida, treating a sizeable population of patients with HIV/AIDS. “I think for Florida, we’re kind of a little different than everywhere else in the states,” she told me. “We get a lot of immigrants from places, especially the Caribbean islands. When the program first came out, I remember commending President Bush for his efforts to do this because Africa at that time carried the biggest load of HIV and AIDS cases in the whole world.” Millions upon millions of people living in Africa back then were dying without treatment.

“With this program,” Dr. Diaz told me. “We were able to see with time a decrease in HIV cases and death rates.” Immigrants to Florida, especially from Haiti where PEPFAR was active, were not as progressed in the HIV/AIDS disease continuum as individuals without treatment. That treatment back home, often supported though PEPFAR programs, allowed Dr. Diaz and her colleagues throughout Florida to continue life-saving care for countless immigrants from Haiti and elsewhere in the islands. She feels lucky to work with FoundCare, a nonprofit organization that sees all comers.

Dr. Diaz believes in her heart that reduction in funding for PEPFAR will bring a devastating rewind of all the new cases, death rates, wellbeing, and stability in the management of HIV/AIDS. “We will go back 30 years,” she told me. “That’s the bottom line.” She knows there will be a huge impact on HIV and AIDS prevention and treatment if PEPFAR reauthorization falls short. She is gravely concerned about the lack of prenatal treatment of pregnant HIV-positive women. She believes more cases of other opportunistic infections, like tuberculosis, will spike, if funding for HIV/AIDS is restricted.

“There are billions of people in this world that live so differently than we do,” Dr. Diaz told me. “By helping those left fortunate we are helping ourselves over time.”

Dr. Fauci, Dr. Diaz, Dr. Nkengasong and Dr. Ralph-Opara each told me that the United States needs to think globally. Continuing the investment in PEPFAR will reap rewards for those without the same access to prevention and treatment as many in more prosperous parts of the world. They all know that PEPFAR, a global program, is an investment in the health of Americans, and of the entire world.