Hope and History: Is the Response to HIV/AIDS Transformational?

Ambassador Mark Dybul, United States Global AIDS Coordinator
George Washington University
April 3, 2007

Thanks to all of you for joining me this morning for a discussion of this very important topic. It's an honor to be speaking here under the auspices of three great universities: Howard, George Washington, and my alma mater, Georgetown. Each is making very important contributions to global public health.

When the history of global public health is written, the launch of the President's Emergency Plan for AIDS Relief (PEPFAR)--both its size as the largest international health initiative in history dedicated to a single disease and its focus on results with ambitious goals for prevention, treatment and care--will be remembered as one of the boldest and most important actions--ever.

But PEPFAR is part of a broad and bold development agenda. Not since the Marshall Plan has the world seen such a massive commitment to international development. President Bush, with strong bipartisan support, has doubled resources for development overall and with his 2008 budget request, will have quadrupled them for Africa. And that does not include massive debt relief and a doubling of trade with Africa--fueling economic development, the ultimate engine for people to lift themselves out of poverty and despair.

In many ways, this new era is more ambitious than the Marshall Plan. Unlike the rebuilding of Europe, the American people are building life, liberty and opportunity where they have never existed in modern times. PEPFAR joins other Presidential Initiatives--the Millennium Challenge Corporation, the President's Malaria Initiative, the African Education Initiative, the Women's Justice and Empowerment Initiative and others--in a renaissance in development. It is a renaissance not only because of the unprecedented new commitment of resources, but because of a radical new philosophy based in the four guiding principles outlined in the Monterrey Consensus on development.

• First and foremost, country ownership;
• Second, good governance--because there is no country ownership without good governance;
• Third, performance-based development--it's not just about money but making the money work;
• And fourth, engagement of all sectors. Governments don't have a corner on compassion, generosity and expertise--everyone must contribute for a society to be transformed.

Fundamentally, this new philosophy rejects the failed "donor-recipient" approach developed during the Cold War and returns to the vision of the Marshall Plan. It is a philosophy rooted in a hand-shake rather than a hand-out. It is rooted in the power of partnership between people. It is rooted in faith and hope:

Hope for, and faith in, the people of the countries in which we are so privileged to work. Hope for, and faith in, the compassion and generosity of the American people. Just a few years ago, the success that PEPFAR has achieved would have been unthinkable. It is now clear that this hope and faith was justified - that the power of partnership is "transformational," as Secretary Rice would say.

Individuals, communities and nations are taking control of their lives and are beginning to turn the tide against the HIV/AIDS pandemic. This new model of partnership is already producing encouraging results and is, as the Institute of Medicine (IOM) recently noted in its review of the first 2 years of PEPFAR, "off to a very good start" and has "demonstrated what many doubted could be done." Through September 30 of last year, you, the American people, have supported life-saving antiretroviral treatment for 822,000 in 15 focus countries, and you have supported care for 4.5 million people--including 2 million orphans and vulnerable children. You have supported scale-up of the most comprehensive and evidence-based prevention program in the world: evidence-based behavior change messages for 135 million people of all ages and social strata, the development of safe blood systems, and services to prevent transmission of HIV from pregnant women to their children during more than 6 million pregnancies, averting an estimated 101,000 infant infections.

All this has been accomplished through the power of partnerships. The U.S. Government has been privileged to partner with the many local governmental and non-governmental organizations, including faith- and community-based organizations and the private sector, to achieve these impressive results. Eighty-three percent of our partners are local organizations, and the successes are primarily theirs, not ours.

The Marshall Plan was born of profound compassion and generosity - and so have been PEPFAR and the renaissance in development President Bush has pursued with bipartisan Congressional support. As President Bush has often said in this context, "To whom much is given, much is required." But in addition to this humanitarian concern, the Marshall Plan recognized that a Europe floundering in destruction and despair was a risk to global peace, freedom and prosperity and was, therefore, a risk to the interests of the United States. So too, the continent of Africa, and other regions, floundering in destruction and despair because of HIV/AIDS and poverty are a global risk to peace, freedom and prosperity and so, are a risk to the interests of the United States.

The U.N. General Assembly, in its only Special Session ever dedicated to a disease, the U.N. Security Council, the U.S. National Intelligence Council, Secretary of State Colin Powell and many others have stated that the HIV/AIDS pandemic is a threat to national and international security. General Wald, the former Deputy Commander of the U.S. European Command with responsibility for Africa, has called HIV/AIDS the greatest threat to peace and security in Africa behind only weapons of mass destruction and terrorism. How can an infectious disease be a threat to global and regional peace and security? The answer is complicated but can be captured in terms of short and medium/long term risks. One short-term risk is clear--the devastating impact of HIV/AIDS on peacekeeping forces. Thirty-seven percent of all UN peacekeepers are African, but HIV/AIDS is taking a high toll on African militaries. HIV-related deaths have reduced the size of Malawi's armed forces by 40%. Seventy percent of all military deaths in South Africa are due to HIV/AIDS. In Uganda, more soldiers have died from AIDS than from the nation's 20-year insurgency. In a recent effort to field peacekeepers, South Africa could not field a single HIV-negative battalion. HIV impacts nations' abilities to protect their own citizens and to provide peacekeepers for other conflicts, fueling national and regional instability.

In addition, the risk of becoming HIV-infected is increased significantly among peacekeeping troops. HIV prevalence among Nigerian forces keeping the peace in Sierra Leone grew from 10% in year one to 15% in year three. So there is a vicious cycle: HIV/AIDS puts the health and lives of peacekeepers at risk, limiting the ability to field an effective force; and when forces are fielded, the HIV risk to the troops increases significantly, further impeding the ability to field peacekeepers in the future.

In addition to this immediate impact, in the medium- and long-term, the pandemic is rending the socio-economic fabric of communities, nations and an entire continent, creating a potential hotbed for instability and a breeding ground for terrorism.

The HIV/AIDS pandemic is unique in human history--not just because it is so widespread and debilitating, but because it strikes at the very heart of the population. HIV does not mainly attack the oldest, or the youngest, or the weakest--it strikes people in the prime of life. Since the 1990s, the single largest increase in HIV/AIDS mortality has been among adults aged 20 to 49. This age group accounted for only 20% of all AIDS deaths from 1985 to 1990 worldwide, but today it accounts for nearly 60%.

Communities are being hobbled by the disability and loss of the very segment of the backbone of any society--consumers and workers at the peak of their productive, reproductive, and care giving years. In the most heavily affected areas, communities are losing a whole generation of parents, teachers, laborers, healthcare workers, peacekeepers, and police.

The ultimate way to achieve sustainable development is through economic opportunity, and that requires a robust business sector. HIV/AIDS is straining corporate budgets through rising health care costs, increased absenteeism, a shrinking workforce, lost expertise, high turnover, and reduced productivity. In 2005 alone, more than 3 million workers worldwide were partially or fully unable to work because of HIV-related illness.

The ramifications for national economies are alarming. Between 1992 and 2004, HIV/AIDS caused 43 of the most heavily affected countries to lose 0.3% per year in employment growth and 0.5% in their annual rate of economic growth. By 2020, UNAIDS projects that HIV/AIDS will have caused GDP to drop by more than 20% in the hardest-hit countries. The World Bank recently warned that, while the global economy is expected to more than double over the next 25 years, Africa is one of the few regions at risk of being "left behind."

In a cruel irony of the disease, a vicious cycle of economic development threatening peace and security in the medium- and long-term mirrors the vicious cycle of the immediate impact on peacekeeping forces. Data from Africa, Asia and Eastern Europe have demonstrated that it is not the poorest of the poor at greatest risk for HIV/AIDS, but those who have climbed the first few rungs of the economic ladder. So HIV/AIDS limits the growth of economies, but as economies do expand, those participating in the economic advantages could actually be at greater risk of infection, leading to further impact on economic growth.

Of course the main impact is personal, but with ramifications for the social structures that keep communities and nations secure. Parents are dying from HIV/AIDS. Around the world, 14 million children under age 15 have lost one or both parents to HIV/AIDS. By 2010, that number is expected to exceed 25 million. In sub-Saharan Africa alone, the disease has left more than 11 million orphans, and by 2020 there will be an estimated 16 million.

Educators are dying from HIV/AIDS. Africa is seeing especially high HIV-related mortality rates among teachers and school administrators; in Zambia, for instance, the equivalent of two-thirds of each year's newly trained teachers are being lost to HIV/AIDS. The loss of so many young and middle-aged adults is having a severe impact upon household, local, national, and regional economies. In HIV-affected households, the family's earned income drops while health costs rise. Extended families and communities are faced with the financial burden of caring for an increasing number of children who have been orphaned by AIDS with fewer teachers to teach them, lower family food production to feed them, and limited economic opportunity to provide for these and other basic needs.

Many children who have lost parents to HIV/AIDS are left entirely on their own, leading to an epidemic of orphan-headed households. When they drop out of school to fend for themselves and their siblings, they lose the potential for economic empowerment that an education can provide. Alone and desperate, they often resort to transactional sex or prostitution to survive, and risk becoming infected with HIV themselves - another vicious cycle of this epidemic.

Unfortunately, in our post-9/11 world, it does not require a lot of imagination or extensive analysis by security experts to see the medium- and long-term risks of the socio-economic impacts of HIV/AIDS on peace and security. In fact, HIV/AIDS is not only a security risk in Africa alongside weapons of mass destruction and terrorism, HIV/AIDS is inextricably bound to them. I must also briefly note the threat to global health from HIV/AIDS. An ever-expanding pool of immuno-compromised people worldwide can both more readily contract and spread disease, including more infectious diseases we cannot yet predict.

Take for example the recent rise in Extensively Drug Resistant Tuberculosis (XDR-TB) among HIV-positive people. To date, there has been a significant spread of XDR-TB in sub-Saharan Africa, and in South Africa, at least 44 of the 53 cases reported have been among HIV-positive persons (the remaining nine people were not tested for HIV). This must be of great concern to all of us, because XDR-TB is literally untreatable and almost always fatal. In this era of globalization, infectious disease knows no boundaries. Today it is XDR-TB - tomorrow it may be avian influenza or something even worse.

The surest long-term strategy for addressing transnational threats is to promote the health, stability, and economic well-being of developing nations, and confronting HIV/AIDS is at the heart of our strategy. While the focus of PEPFAR is on prevention, treatment, and care of people living with HIV/AIDS, the impact of our program is not--and need not be--limited to HIV/AIDS. PEPFAR is central to U.S. efforts to "connect the dots" of development. Our programs are increasingly linked to important U.S. initiatives in other areas of health and development. I would like to briefly address some of these.

Young people account for half of all new HIV infections--and an estimated two-thirds of these new infections are among women. Girls and women in developing nations are contracting HIV at an alarming rate, for complex reasons frequently tied to pervasive, powerful, and often brutal gender inequities. Women and girls are often simply powerless to protect themselves. Because of this, PEPFAR places a high priority on addressing gender inequities. In fiscal year 2006, we allocated $442 million to support more than 830 HIV interventions that include a gender-related element.

Each of PEPFAR's 15 focus countries is required to include programs that include one or more of these strategies: 

• Increasing gender equity in HIV/AIDS activities and services; 
• Reducing violence and coercion - and in this where we are partnering with the President's Women's Justice and Empowerment Initiative; 
• Challenging negative male norms; 
• Expanding women's legal rights and protections; and 
• Increasing women's access to education, vocational training, and micro-financing.

One of the most important things we can do is to ensure that girls and women have access to prevention and health care services. PEPFAR is the only major international initiative to require reporting by gender--and we have been doing it from Day One because we need to know if women and girls are getting the services they need. We are pleased that approximately 61% of the treatment and 70% of the counseling and testing we support is for girls and women--those levels exceed the share of those who are infected who are female. In addition, as I mentioned, we have supported prevention of mother to child transmission (PMTCT) services for women during 6 million pregnancies. And approximately 51% of orphans and vulnerable children receiving care at PEPFAR-supported sites are girls.

Commitment to meeting the needs of children is central to PEPFAR. Partner nations are making great progress in reaching HIV-positive children with treatment with U.S. Government support. Although PEPFAR is focused on HIV/AIDS, it encompasses health care services that have built on earlier U.S. Government-supported initiatives for children. For example, PEPFAR's "core services" for orphans and vulnerable children include TB and malaria screening; provision of antibiotics; education; and provision of food, nutrition, shelter, protection, and psychosocial support.

In fiscal year 2006, PEPFAR alone provided approximately $213 million--up almost seven-fold from the 2003 level of all programs for children--to support focus country programs that provide care for 2 million orphans and vulnerable children. Even more important than care for children who have already been orphaned, though, is the work we are doing to prevent children's parents from dying in the first place. An orphaned child faces a three-fold risk increased of death, from all causes, even if the child is HIV-negative. We are working with international partners to quantify the impact on children of keeping their parents alive through HIV prevention and treatment programs.

Education is an especially crucial element of the human development equation for children, since it offers the hope of self-reliance and an escape from poverty. Although education per se is beyond the scope of PEPFAR's mission, our primary contribution is to keep teachers and parents alive through prevention and treatment so that education is possible. We also support attendance programs for orphans and vulnerable children which include school fees, books and uniforms, as well as HIV prevention and life skills programs. We also work with other programs that provide education to children who are infected with or affected by HIV/AIDS.

PEPFAR also partners with the President's Africa Education Initiative, which is training half-a-million teachers and providing scholarships for 300,000 young people throughout Africa, predominantly girls. Studies show that girls who stay in school are at significantly lower risk of HIV infection. Although addressing the broad issue of food insecurity generally is beyond the scope of PEPFAR, PEPFAR does support limited food assistance for specific, highly vulnerable populations. For instance, in a pilot program in Kenya, we are supporting a local food manufacturing company in distributing nutrient-dense foods to orphans and vulnerable children; clinically malnourished people living with HIV/AIDS; and HIV-positive pregnant and lactating women in PMTCT programs.

For the most part, however, PEPFAR maximizes leverage with other partners that provide food resources. In Ethiopia, for example, PEPFAR contributes to the United Nation's World Food Program (WFP), and USAID's Food for Peace supports some HIV/AIDS programs. In 2006, PEPFAR Ethiopia and the WFP collaborated to provide food resources to more than 20,000 beneficiaries, including orphans and vulnerable children, adult patients on treatment, and care givers.

Another area in which PEPFAR is working to ‘connect the dots' of development in an innovative way is clean water, which is important for people on treatment. In September 2006, First Lady Laura Bush announced a groundbreaking public-private partnership called the PlayPump Alliance with the Case Foundation and many others. The goal is to bring the benefits of clean drinking water to up to 10 million people in sub-Saharan Africa by 2010, and each U.S. Government dollar will be matched by five dollars from the private sector. In addition to installing PlayPumps in schools, health centers, and HIV-affected communities, HIV/AIDS messages on PlayPump billboards will spread the word about healthy behaviors. This is a great example of 'connecting the dots' of development.

PEPFAR's focus on TB has increased steadily since the program's inception in fiscal year 2004. In fiscal year 2007, we anticipate funding of at least $120 million for TB/HIV in the focus countries--combined with approximately $91 million for bilateral TB programs, that is nearly a tripling of funding from just four years ago. Tuberculosis will continue to be an area of increasingly high priority for PEPFAR, because TB is the number one killer of HIV-infected people. In addition, there is growing concern about the advent of drug-resistant strains of TB among people who are HIV-positive. We are working closely with international partners such as the Global Fund and the World Health Organization to strengthen laboratory systems, establish infection-control measures, and expand programs to prevent, diagnose, and manage drug-resistant TB in people living with HIV/AIDS.

PEPFAR also continues to partner with the President's Malaria Initiative (PMI) in countries that are targeted by both programs. In 2008, as PMI expands, 15 countries will be jointly sponsored by the two Presidential initiatives. Our collaboration has already enabled countries to provide comprehensive services for some of the most vulnerable groups for both diseases, including pregnant women, people living with HIV/AIDS, and orphans and vulnerable children under age five.

At least one quarter of PEPFAR's total resources are devoted to capacity-building in the public and private health sectors--supporting physical infrastructure, health care systems, and workforce development. Workforce is key: we have supported training or retaining for 1.7 million and are working with the World Health Organization on task-shifting in order to expand the available workforce through the use of community health workers and other health professionals. We also recognize the need to increase the pool of doctors, nurses and other professionals and in 2008 we will triple our allocation for such training programs.

In addition, PEPFAR is working with host countries to build capacity by establishing transparent and accountable delivery systems that ensure an uninterrupted supply of high-quality and low-cost drugs, lab equipment, testing kits, and other essential medical materials.

Earlier this year, we announced the $10-million, public-private partnership Phones for Health, to strengthen healthcare services and monitoring systems through mobile phone technology. The Phones for Health network will have applications for more than just HIV/AIDS: in the event of an outbreak of any suddenly arising epidemic, this system will prove to be invaluable.

PEPFAR's capacity-building initiatives have positive spillover effects: whenever a country upgrades its health systems and strengthens the health workforce, it improves overall healthcare delivery. When the chairman of the IOM evaluation was asked what impact PEPFAR was having on general health systems, he stated that PEPFAR was strengthening them.

In addition, PEPFAR works closely with indigenous faith- and community-based organizations--supporting their efforts to grow their capacity to lead their nations' responses to HIV/AIDS. When such organizations expand their capacity in order to meet U.S. Government fiduciary accountability requirements, they are in a better position to support themselves in the future.

The so-called "burden of reporting" is actually a foundational feature of transformational development. Improvements in reporting systems enable developing countries to cultivate good governance and build freer and more stable societies creating a culture of transparency and accountability that has impact beyond HIV. One young Namibian told me that PEPFAR is actually building democracy through its accountability systems focused on country ownership and good governance.

Our rigorous reporting requirements are fostering the establishment of national health information systems in partner countries, many of which had weak or nonexistent systems prior to PEPFAR. Working with UNAIDS, the World Health Organization, Health Metrics Network, the World Bank, the Global Fund, and others, PEPFAR is expanding each country's reporting infrastructures and increasing the number of personnel who are trained in the field of strategic information.

The reporting requirements are also building an ever-increasing body of empirical data from which to develop, evaluate, and improve evidence-based HIV/AIDS interventions--and to do it in real time. As IOM noted, PEPFAR has thus created an opportunity to improve the quality of HIV/AIDS programs worldwide.

There has been much progress and millions of lives are being saved. The renaissance in development has begun. President Bush and a bipartisan Congress have boldly committed the American people to create life, liberty and opportunity throughout the world. But there is much more to do.

So you--the next generation--must get involved and get others involved - and you must do something harder than that: stay involved for the long term, because this pandemic and global development needs will be with us for a long time. And you must challenge us where you think we're wrong, because we don't have all the answers.

As the Institute of Medicine said - PEPFAR has made a good start and done what many thought was not possible. But they also noted that the U.S. must continue this leadership. PEPFAR is the first quantum leap in America's global leadership in HIV/AIDS--one from which we will not walk away. With this historic crisis comes an historic opportunity--for the U.S. and for the world. In the speech that launched the Marshall Plan, General Marshall told the graduating class of Harvard University in 1947:

It is virtually impossible at this distance merely by reading, or listening, or even seeing photographs and motion pictures, to grasp at all the real significance of the situation. And yet the whole world of the future hangs on a proper judgment. It hangs, I think, to a large extent on the realization of the American people, of just what are the dominant factors. … What are the sufferings? What is needed? What can best be done? What must be done?

As we look at the world today and the devastation HIV/AIDS has wrought, as we ponder the fact that by 2020 some estimate that 70 million people could die--more than died in World War II--we know what must be done. As President Bush said when he launched the Emergency Plan for AIDS Relief, "Seldom has history offered a greater opportunity to do so much for so many." Thank you for listening-- and thank you for being involved.