The U.S. President's Emergency Plan for AIDS Relief - November 2009 Newsletter

Ambassador Eric Goosby, U.S. Global AIDS Coordinator, discusses successes in combating global HIV/AIDS since the inception of the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), and outlines his vision for the future of the program.

What has the United States done to combat global HIV/AIDS since PEPFAR's launch in 2003?

As the largest commitment in history by any nation to combat a single disease, providing more than $25 billion to the fight against global AIDS, PEPFAR has had numerous achievements in the past six years. For instance, today, an estimated four million individuals in low- and middle-income countries have access to antiretroviral treatment - and more than half of these individuals are supported by the American people through PEPFAR.

PEPFAR has also provided compassionate care for more than 10 million people affected by HIV/AIDS, including more than four million orphans and vulnerable children, and we have supported prevention of mother-to-child transmission programs that have allowed nearly 240,000 babies to be born HIV-free.

But these successes would not have been possible without our strong partnerships with countries around the world. As we move into the second phase of the program, we look forward to building on our achievements and working together with our partner countries to ensure a sustainable response.

PEPFAR was reauthorized last year by the U.S. Congress, and as you mentioned, the program is entering its second phase. As the new PEPFAR Coordinator, what is your vision for the future of the program?

Looking forward, four major themes will guide the program's work - intensifying the focus on HIV prevention; pursuing strong country partnerships, country ownership and coordinated multilateral engagement; supporting health systems strengthening through programs and country-driven planning; and taking effective interventions to scale to achieve population-level health outcomes. Focusing on these four areas in the coming years will be crucial if we are to maximize our efforts and expand opportunity and prosperity to more people in more places around the world.

As we move forward, PEPFAR will continue to work with governments and our global partners to ensure the sustainability of the programs we support in order to create strong national HIV/AIDS responses in the countries in which PEPFAR works. President Barack Obama, Secretary of State Hillary Rodham Clinton and I are committed to addressing the HIV/AIDS crisis around the globe,and the U.S. will not step away from this commitment.

Secretary Clinton has said that she and President Obama are deeply committed to continuing and building on PEPFAR's success. But how exactly does PEPFAR fit into the Obama Administration's Global Health Initiative?

The fight against global AIDS is a central piece of the global health agenda outlined by President Obama and Secretary Clinton. And as the United States' global AIDS program, PEPFAR will play a pivotal role in furthering the Administration's Global Health Initiative. This initiative will continue our country's leadership on global health priorities like HIV, tuberculosis and malaria, while expanding the integration of current U.S.-supported programs with efforts that address maternal and child health, family planning and neglected tropical diseases. As part of this effort, the U.S. will use existing HIV prevention, treatment and care programs as a platform to strengthen and extend health systems in many areas, including human resources, infrastructure, informatics, commodities logistics and laboratory services.

As PEPFAR works to build on its existing efforts, how will the program work to also increase country ownership and sustainability of HIV programs?

The most effective response to HIV and other diseases is one tailored to the specific situation in each country. Ultimately, national governments carry the long-term responsibility of responding to their respective epidemics, so PEPFAR will work with countries to implement sustainable interventions that address their needs and are grounded in local capacity.

To ensure this happens, the United States will place a renewed emphasis on partnering with countries to build national HIV/AIDS responses over the next five years. We are already working to engage partner governments through Partnership Frameworks. Through these five-year joint strategic frameworks, PEPFAR is supporting and strengthening national HIV/AIDS strategies and better positioning countries to address their HIV epidemics over the long term.

Along with this effort, America will support country leadership as they engage international partners, civil society and non-governmental organizations to support their fight against HIV/AIDS. And we will support governments as they work to make universal access a reality in their countries.

Through these efforts, I believe that we will continue to make progress in the fight against HIV/AIDS. And the United States will continue to stand strong in our commitment to defeat this pandemic.

When Damte Lemi and Genet Teka first heard about HIV counseling and testing, they were uneasy about learning their status. But their hesitation was alleviated when they visited this year’s Erecha Festival – an annual cultural and religious event in Debre Ziet that celebrates the first harvest of the Ethiopian Spring.

At the festival, which draws 300,000 Ethiopians from different parts of the country, the couple saw signs announcing mobile HIV counseling and testing centers.

“When we saw the announcement, we immediately decided to take the advantage of the free service,” said Damte. “We are heading to marriage and we are now happy we took the test.”

The mobile center they visited was supported by the Organization for Social Services for AIDS (OSSA), a local organization that receives support from the U.S. Centers for Disease Control and Prevention (CDC) through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

Damte and Genet were two of more than 400 people that received voluntary HIV counseling and testing center during the two-day festival.

Shemeles Feye and Kelemuawa Lemu are another couple that visited one of the mobile testing sites set up at the festival. Married for two years, the couple traveled 70 kilometers to take part in the festivities, and while there decided to receive voluntary HIV counseling and testing.

“Initially we didn’t know there was free HIV testing, but we feel fortunate to get tested,” Kelemuawa said.

“We have been married for two years and we want to spend our future lives without fear,” Shemeles added.

On September 24, 2009, the Government of Kenya launched the 2007 Kenya AIDS Indicator Survey (KAIS) report. Speaking during the official KAIS report launch, Dr. Kevin De Cock, Director of the U.S. Centers for Disease Control and Prevention (CDC) in Kenya, recognized the 2007 KAIS for being the first in a new era of HIV surveillance.

The survey, supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through CDC and the U.S. Agency for International Development (USAID), is the most comprehensive national surveillance effort implemented by the Kenyan Government to date. Nearly 18,000 adults aged 15-64 completed an individual interview, and 88 percent of them consented to giving a blood sample. The consent process included education and risk reduction counseling on HIV, genital herpes and syphilis, the infections tested for in KAIS.

Speaking on behalf of the Director of the Kenya National AIDS Control Council (NACC), Regina Ombam stated that HIV remains a serious challenge in Kenya and emphasized the need for universal access to HIV testing. According to the KAIS, among the estimated 1.4 million Kenyan adults aged 15-64 years living with HIV/AIDS in 2007, only one in six knew their status. Ombam noted that this number is largely due to the fact that most of these adults have never been tested for HIV and recommended that, in addition to traditional voluntary testing counseling and testing, HIV testing be normalized and made more accessible through approaches such as provider- initiated counseling and testing at all health facilities and home-based counseling and testing.

Speakers at the launch also recommended universal access to HIV prevention within Kenya, and particularly highlighted access to male circumcision. The KAIS found 3.9 percent of circumcised males were infected with HIV compared to 13.2 percent of uncircumcised males.

But emphasizing that male circumcision cannot prevent HIV alone, the report also called for knowing one’s HIV status and that of their partners, contraceptive services for women who do not desire children, and primary prevention of sexually transmitted infections known to increase the risk of HIV. The importance of prevention among couples could not be overstated: 344,000 couples surveyed were HIV-discordant, meaning one partner is HIV-positive and the other is HIV-negative.

Comparing 2007 KAIS estimates to results from the 2003 Kenya Demographic and Health Survey, the overall prevalence of HIV among 15-49 year olds did not significantly change – 6. 7 percent in 2003 to 7.4 percent in 2007. A closer look at subpopulations, however, revealed important patterns. While urban HIV prevalence had stabilized or even declined, the burden of HIV in rural areas had increased. Since 2003, adults with no formal education and the poor faced increases in HIV prevalence compared to those with wealth or formal education, whose prevalence remained the same or had declined.

Dr. Ibrahim Mohamed, Head of the Kenya National AIDS/STI Control Programme, commented on the report emphasizing the need for comprehensive surveillance data to monitor the HIV epidemic and inform HIV policy and resource allocation.

An important activity for the people of Kenya, policymakers, and international stakeholders, the KAIS will play a crucial role in building an evidence base to guide the design and evaluation of the Kenya National HIV/AIDS Strategic Plan.

The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Millennium Challenge Corporation (MCC) are working in partnership with the Government of Lesotho to improve essential health services including prevention of mother-to-child transmission (PMTCT), increased access to medications, and scale up of HIV/AIDS prevention, care, and treatment for those infected by tuberculosis. Through this partnership, the MCC Compact Health Program in Lesotho will strengthen the nation’s health sector infrastructure and contribute to the scale-up of health care in the country.

Under this health project, MCC has committed up to $122 million to support infrastructure renovations and strengthen health systems in Lesotho. The project will support the rehabilitation of up to 150 existing health centers and 14 district hospital out-patient departments over a fiveyear period.

Currently, half of these facilities receive subsidies and in-kind drugs and pharmaceuticals by the Government of Lesotho in exchange for free or low-cost delivery of essential services to pregnant women, infants, and those at risk for HIV/AIDS.

By improving the conditions of these facilities and increasing access to essential services in health centers, MCC will contribute to safer birth deliveries and increased PMTCT efforts, among other health care benefits.

As of 2007, more than 90 percent of Basotho women attended antenatal clinics during their pregnancy. An estimated 40 percent of these women were HIV positive, and 83 percent received a prophylactic treatment which decreases the chances of transmission of HIV from mother to child. Despite these impressive statistics, it is estimated that only 50 percent of Basotho women deliver their children in health facilities, leaving half of the female population without access to HIV prophylaxis and other delivery essentials.

To address this, PEPFAR will scale up its PMTCT efforts in Lesotho to increase the likelihood of more children being born HIV-free, and at the same time to provide access to HIV treatment and care services.

“The PEPFAR/MCC synergy will result in fewer babies being born with HIV, and more children of HIVpositive mothers living long and healthy lives,” said Katie Crowley, the PEPFAR Coordinator in Lesotho.