GHESKIO and the Beginning of PEPFAR Programs

Summary of an article by John Donnelly

The Center for Global Health’s partner in Haiti, GHESKIO, has widely expanded HIV/AIDS care in Port-au-Prince with the support of the U.S. government’s PEPFAR programs.  A recent article in Health Affairs recounts the birth of the PEPFAR program.  GHESKIO’s director and Professor of Medicine at Weill Cornell, Dr. Jean Pape, was instrumental in supporting the program’s development. A summary of the article is below. For the full article, click here.

In June 2002, President George W. Bush unveiled a $500 million initiative to fight HIV/AIDS abroad, focusing largely on preventing mother-to-child transmission of HIV in sub-Saharan Africa.  The president said, “The global devastation of HIV/AIDS staggers the imagination and shocks the conscience.” He noted that AIDS had already killed over 20 million Africans and was threatening 40 million more.  

After this surprising announcement, Anthony Fauci, the directors of the US National Institute of Allergy and Infectious Diseases met with Joshua Bolten, the president’s chief of staff.  Bolten told Fauci this was just a start to the president’s plans, and Fauci should begin to think about how to further address the problem of AIDS in Africa.  Bolten told Fauci that the president’s exact words were “Think big.”

Upon returning to the NIH in Bethesda, Maryland, Fauci met with one of his deputies, Mark Dybul, and they began planning.  Fauci and Dybul soon realized that some of the poorest countries in Africa had already shown them the way.  For example, Dybul saw that in Kampala, Uganda’s capital, not only was treatment possible, but that it could work as well as it did in the US. What he observed was in direct contrast to the view in many circles in the West, including among some senior officials in the US government, that AIDS treatment in Africa wouldn’t work because of cost, lack of health infrastructure, and cultural considerations that meant that Africans wouldn’t comply with rigorous treatment regimens.

In Tororo, a Ugandan town of 35,000, Dybul also saw that AIDS treatment could be effective in areas far from cities, where there often were no doctors and only weak health systems. Uganda’s innovative The AIDS Support Organization (TASO) had started in Tororo, and the CDC had established a research base as well.  Each day in this pilot project, health workers used motor scooters to visit their roster of patients in their homes to make sure patients were taking the drugs, eating well, and tolerating the medicines.  Dybul recalls, “It showed me that it was possible to treat AIDS both in clinic and through rural outreach.”

Fauci and Dybul decided that the plan they would produce for Bush would not rely solely on evidence from the Uganda experience, but would also be based on other models of scaling up treatment and prevention, such as Botswana’s early efforts. The plan would focus on places with the highest HIV burdens and limited funding, and on those where the US government already had strong capabilities in place. It would place high emphasis on building up systems and infrastructure quickly, so that governments could eventually enroll large numbers of patients on antiretroviral therapy (ART) and expand programs.

Fauci and Dybul put together a concept paper outlining their plan.  The plan forecast a slow start, reaching just 5 percent of the treatment goals in the first year. That estimate was based on experience in many countries with other diseases, where the lesson had clearly been demonstrated that capacity needs to be built before interventions can be scaled up. But by the end of year 4, work was to proceed at full throttle: On the supposition that 50 percent of each target would have been achieved by then, the plan called for moving swiftly to achieve 100 percent of each target by the end of year 5. In sum, the five-year targets, by 2008, called for supporting two million people on ART and providing other types of medical care to a total of ten million people infected with HIV.  The concept paper by Dybul and Fauci became the basic foundation for PEPFAR.

Fauci presented the plan to government officials; they liked the idea but wanted more information.  Furthermore, the White House was looking for other opinions on the HIV/AIDS crisis and solutions, so Fauci was asked to summon individuals who had experience delivering AIDS care to people in the developing world.  Fauci and Dybul invited  Peter Mugyenyi, head of the Joint Clinical Research

Center in Uganda, Paul Farmer, the cofounder of Partners in Health, Jean Pape, who also was treating patients in Haiti, and Eric Goosby, head of Pangaea Global AIDS Foundation in San Francisco.  Mugyenyi, Farmer, Pape, and Goosby came to D.C. and went to the White House.  They met with the president and his advisors to discuss the reality of HIV/AIDS treatment in resource poor settings.   Mugyenyi says he made two major points. “The first was that the carnage of AIDS in Africa constituted a moral imperative to act; that it was a catastrophe of astronomical proportions of people dying when they could have been saved, and the US was in a position to stop it. The second was that AIDS could be treated in Africa and treated with as good an outcome as was achievable in the US.” Farmer says, looking back, “we had faith in this, almost unwavering faith, about the slender amount of data on which to base a major health initiative. There was no reason to believe that the treatment of Africans would be any different than the treatment of Americans.”

Despite hesitation and criticism from many of his advisors, by late January, Bush had made up his mind. The global AIDS program would be announced in the State of the Union Address.

On January 28th, 2003, in the sixty-ninth paragraph of his speech, Bush said, “Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many… To meet a severe and urgent crisis abroad, tonight I propose the Emergency Plan for AIDS Relief (PEPFAR), a work of mercy beyond all current international efforts to help the people of Africa. Bush unveiled PEPFAR - a proposal to spend $15 billion over five years to combat AIDS primarily in fourteen countries, twelve of them in Africa. The comprehensive plan was designed to prevent seven million new HIV infections, treat at least two million people with life-extending ARTs, and provide humane care for 10 million people suffering from AIDS and for children who had lost one or both parents to AIDS. The chamber erupted in cheers.  In Cange, Haiti, Farmer was in bed, a computer on his lap, and he followed accounts of the speech over the Internet. When he saw the report, he thought, “The world has changed.”  Mugyenyi said he is not an overly emotional man, but that night tears rolled down his cheeks. He remembered the hundreds and hundreds of patients who had died in his hands—people whom he could have saved if he had the medicine. He remembered their faces and their names. Now, he thought, that was going to change. We will save the others. Help is coming.