AIDS 2012: Key Lessons From a Decade of Action on Global AIDS, and the Way Forward

June 25, 2012

Amb. Eric Goosby, U.S. Global AIDS Coordinator

*** Remarks as Prepared ***

Well, thank you very much, Noam. I appreciate the kind introduction. It’s really an honor to be with you. I think the Brookings Institution has really gone out of its way to make me feel welcome, but also to kind of scramble this to make it a meaningful and rich contribution from both people in the audience and those on video.

The AIDS 2012 conference is now just one month away, as we heard. Thanks to the Obama Administration, for the first time in more than 20 years, this meeting is taking place in the United States.

As Americans, this should make us proud. What should also inspire pride is that the conference comes to the nation’s capital at a pivotal moment in our fight against AIDS.

Seven months ago, many of you in this room heard Secretary Clinton declare the historic goal of creating an AIDS-free generation. Less than a month later the President stated that we not only can win this fight, but we will win this fight. These words from the President and the Secretary were based on a series of scientific discoveries, primarily funded by the United States, which have become game-changers over the course of the past year.

And because of the science, the world will come together at AIDS 2012 to say that we’re turning the tide. A tide that once overwhelmed the world is now a tide that is uniting the world. Hope is truly taking the place of despair.

But we are not going to be wholly successful in our fight against AIDS, or improving global health overall, if we don’t take on three specific areas of improvement.

First, let me offer a bit of history. I have been involved in this fight against AIDS for a very long time. In the 1980s—in 1981—I was working as a clinician in San Francisco and experienced the grief and loss that came with seeing so many people succumb to the disease because we had nothing to stop the progression of the disease in them. That all changed in the mid-1990s when antiretroviral treatment literally brought people back from the brink of death with highly active retroviral therapy in the form of the protease inhibitors. In the United States having access to this treatment has transformed HIV/AIDS into a long-term chronic condition, cared for largely in an outpatient setting. It has saved many, many lives.

But this access to treatment was not universal. About thirteen years ago, I turned my attention to the global pandemic, and I will never forget what those early years showed us. AIDS was wiping out a generation and reversing health gains in Africa. Hospitals were completely overwhelmed by the massive volume of dying people. These were routinely multiple people in a bed, people on the floor. They weren’t getting the antiretroviral treatment that was available here in the United States and Europe, so HIV infection was truly a death sentence.

AIDS threatened the very foundations of societies. It wiped out people in the prime of their lives when they should have been caring for their families. It created millions of orphans unable to attend school without the support provided by their parents.

And the disease stalled economic development, leaving countries stuck in the cycle of poverty. That in turn created societal instability, leading the UN Security Council to identify AIDS as a security issue in 2001.

It’s because of this emergency that resources were mobilized to address AIDS. We weren’t looking around for a global health issue to spend money on. In truth, this crisis found us. Today, AIDS is no longer a certain death sentence in sub-Saharan Africa. A decade ago almost no one in Africa was receiving treatment. Now over 6.6 million men, women and children are on antiretroviral treatment in developing countries, with the vast majority of them being in sub-Saharan Africa.

It’s almost impossible to overstate America’s contribution. Through PEPFAR as of last year the United States supports nearly 4 million people on treatment. That’s up from 1.7 million in 2008, showing continued rapid expansion even during these tight budget times. PEPFAR’s programs supported drugs to prevent mother-to-child transmission in 2011 alone for 660,000 HIV-positive women. Thanks to this effort, an estimated 202,000 infants were born HIV-negative. We also supported HIV testing and counseling for more than 40 million people, again in 2011 alone - truly an incredible achievement.

These results aren’t just numbers; they are lives saved, each of them. Each individual is part of a larger family and community. That has been and will continue to be our best test of success. For PEPFAR, it’s all about results. By adopting a targeted approach to address one of the most complex global health issues in modern history, and then taking it to scale with urgency and commitment in resource-challenged settings, the United States has challenged the conventional wisdom on really what is possible.

Our response to the global AIDS crisis has also transformed the health sector. We are seeing more and more, after the initial infrastructure, while focusing on HIV, PEPFAR’s investments have strengthened national health systems so they can more effectively deliver essential services for all the needs of their people, including the non-HIV needs of HIV-positive people.

Clinics and hospitals that were overwhelmed dealing with AIDS now have the capacity to address other health issues that our people face. Beyond that, we have rebuilt hospitals and clinics, increased quality and numbers of trained health care workers, put in patient information systems, put in quality laboratories, and strengthened our commodity procurement and distribution systems.

Our focused investments have enabled access to basic health care, often where little or none existed before. In countries with substantial PEPFAR investments, we’ve seen reductions in maternal, child and TB-related mortalities, increased use of antenatal care, wider availability of safe blood, just to name a few.

All of this helps explain why PEPFAR remains a true example of bipartisanship. People sometimes say that AIDS exceptionalism has distracted us from other problems, but that’s simply not true. Our response to the HIV/AIDS crisis has increased the size of the pie for global health and bolstered systems that can now respond to a variety of health issues that confront the population.

In reality, PEPFAR has proved that we can take a situation with little hope and turn it around. It challenges all of us to raise the bar for what our global programs are expected to achieve, because they must.

And that brings me to the first issue that I want and need to bring you to consider, and that is to stop treating PEPFAR as a one-off health program and start looking at it as the foundation of what we can do with our global health challenge. We need to stop claiming that AIDS has taken away attention from other diseases, and look at what we can be when we build upon our substantial AIDS investment and response.

We need a global health vision that is additive to our global AIDS response and allows us to capitalize on the investments already made. When you think about this, if PEPFAR has built a clinic; trained a doctor, a nurse, a lab tech; put a laboratory in place that wasn’t there that is reliable and can give the provider of care diagnostic information to make diagnoses, change diagnoses, or monitor care—to add a maternal health capacity or a child health clinic, immunization capability, nutrition, etc.—over time, we should be able to add treatments for the chronic diseases that are also increasing again in our HIV-positive population, as well as our HIV-negative population, such as hypertension, diabetes, and coronary-artery disease.

This doesn’t mean—and I emphasize this—that we stop our work on AIDS. What it means is that we need to make sure that health systems are not only prepared to deal with HIV, but with the other health challenges faced in the same person and communities affected by AIDS. We are at a point where we can turn to expand the service portfolio at the already-established AIDS sites.

Our path to creating an AIDS-free generation requires us all to work smarter and better together, which brings me to the second thing I need to put before you to really successfully achieve an AIDS-free generation. And that is country ownership. This is the starting point for everything we do. This challenge was stated clearly in Oslo earlier this month by Secretary Clinton, and I am pleased to announce today that we are going to hear more from the Secretary on her dedication to creating an AIDS-free generation at the AIDS 2012 meeting.

In Oslo, the Secretary said, and I quote, “Country ownership in health is the end state where a nation’s efforts are led, implemented, and eventually paid for by its government, communities, civil society, and the private sector. To get there, a country’s political leaders must set priorities and develop national plans to accomplish them in concert with their citizens, which means including women as well as men in the planning process. And these plans must be effectively carried out primarily by the country’s own institutions.”

Unfortunately, ‘country ownership’ is sometimes misunderstood to signal a complete absence of external support for a country’s response. Let me be very clear that this is not what we mean. What we do mean is that the overall leadership role belongs to the country, not to external partners. The United States cannot be the ministry of health for the countries in which we work.

In terms of health, this leadership means planning and overseeing its national health sector. And it means that we need to address head-on the difficult barriers to country ownership: donors failing to coordinate or allow coordination and making unreasonable demands of partners; governments that are devoting too little money to health and not investing in their people, not being held accountable for their, and I underline this one, not being held accountable for their results.

There’s no time to play the blame game for these obstacles. There’s no yield on that. We’ve all been part of them. It’s time to pivot and explicitly insert lines of accountability so our management and oversight can grown and learn lessons that allow us to improve and change the output of these programs to match the changing needs of the populations we serve.

As external partners, we must acknowledge that we have a long history of playing the leadership roles, often creating an unhealthy relationship of dependence. Over time this diminishes the capacity of the country to ensure that services persist and, most importantly, remain of high quality. So we need to commit ourselves to support a health system organized around the needs of the country’s population, rather than around our needs as donors. We must choose to step back and support country leadership rather than reserving that role for ourselves. We have a responsibility to build capacity through technical support as countries assume more and more managerial and financial oversight and responsibilities.

As for governments, they have a responsibility to their citizens to orchestrate this continuum of services. They must identify their country’s unmet needs, prioritize the needs, and make the allocation decisions against those unmet needs using diverse funding lines, such as the Global Fund, PEPFAR, and other bilateral funding, so they are additive and complementary. Governments must include the people in the decision-making process who use the services, including civil society representation, civil society organizations, the faith community, and of course, the people living with HIV.

Let me address the issue of financing by countries. It is only one dimension of country ownership, but it is an important one in this era of constrained global resources. At the Abuja summit in 2001, African nations agreed that they would devote at least 15 percent of their national budgets to health. To date, few have. As Secretary Clinton has said that needs to change.

But we’re also seeing progress as countries begin to step up and take over services from external partners. In South Africa, the government has more than doubled its commitment to HIV over the last two years to over $1.3 billion dollars per year. A special two-year commitment by PEPFAR to provide antiretroviral drugs in South Africa with aggressively negotiated generic drug pricing as part of the agreement, help the government launch its own increased purchases with the new low prices allowing a shift from a trigger to initiate antiretroviral therapy at 200 CD4 cells to the 350.

Other countries have also increased their investments, and are making this a point of emphasis in our diplomatic discussions. In addition to financing, discussions of country ownership must address the political and cultural barriers to an effective response. In the HIV/AIDS dimension, this often involves marginalized populations that are often at most risk for HIV, including men who have sex with men, people who inject drugs, and those who have experienced sexual violence. We all know that countries are at different points in terms of recognizing these realities, and the need for public health responses to incorporate human rights. PEPFAR’s job is to bring science to the table and pursue dialogue toward responses that are country-owned, science-based and human rights-sensitive.

Another barrier to progress at the country level is failure to fully include women and girls. Given its disproportionate impact on women and girls, HIV is not only a health issue, it remains and has been a women’s health issue. PEPFAR and all HIV programs must be part of the broader effort to support countries in meeting the needs—the needs of women and girls, including those living with HIV. As external partners, we are in a position to engage countries in dialogue around, and strongly support, country-owned plans that will improve the overall health of women and girls.

There’s no doubt that the move toward country ownership in PEPFAR is a work in progress, but it is under way. During PEPFAR’s reauthorization in 2008, Congress provided us with the authority to establish Partnership Frameworks to make this transition. The Frameworks are designed as joint strategic roadmaps on AIDS, agreed to and signed by the United States and partner governments, promoting mutual accountability and sustainability over a five-year time period. PEPFAR has signed 22 Partnership Frameworks since 2009, launching really a new era of collaborative planning with our partner governments. I leave tonight to sign a Partnership Framework in Haiti.

Most importantly, the discussions are creating a new level of trust and transparency among those involved, as partners reveal vulnerabilities and limitations in a shared effort to prevent gaps in services. I believe we need to reach that same point of partnership in all of our global health work. For example, African countries face health workforce issues, handicapping all their health efforts. Through the Medical and Nursing Education Partnership Initiatives, the MEPI/NEPI, PEPFAR is supporting countries in developing sustainable local capacity to produce skilled doctors, nurses, and midwives for generations to come.

Of particular note, we make grants directly to the African educational institutions, the medical school or the nursing school. They are the principal investigator in these grants. They are the senior partners in these relationships, identifying a United States counterpart in the process.

In sum, as partners, we must challenge ourselves to apply our human and financial resources in ways that strengthen national leadership to expand the country’s capacity to make the programs more sustainable with the sole purpose of saving more lives. But country ownership alone will not solve the AIDS crisis, let alone our broader global health challenges.

We must also challenge the world to accept that global health remains a shared responsibility. It is not the purview of governments alone, but also the private sector, civil society, faith-based organizations, and communities who together contribute financially and otherwise to the fabric that is needed to establish a responsive and sustainable health care delivery system.

A crucial part of this shared response is the multilateral mechanisms. And this is the third thing that we need to achieve an AIDS-free generation. That is a robust multilateral response, particularly targeted to the needs at the country level. The Global Fund to Fight AIDS, Tuberculosis, and Malaria really is an indispensable tool, and remains a single conduit through which other countries that will never have a bilateral program can funnel resources to those countries in need. It provides a large-scale mechanism for combating these diseases, particularly for those donor countries without the bilateral programs.

By law, the U.S. cannot provide more than 33 percent of Fund contributions, so the money we provide leverages resources from other donors, multiplying impact beyond what our dollars could do alone. In recent months, since the United States demonstrated its increased commitment to the Fund, both new and old donors, including Saudi Arabia, Japan, Germany, and the Gates Foundation, have stepped up their contributions. We know that other donors are also doing the same.

Part of our shared responsibility is to ensure that all resources are used as efficiently and effectively as possible. With our support and encouragement, the Global Fund has taken a number of actions in recent months to recommit itself to this goal. The Fund’s new General Manager, Gabriel Jaramillo, has dramatically reoriented the Fund to assume a role as an active investor. I’m very optimistic about the impact of the Fund moving forward and that heightened impact, in turn, will strengthen its ability to generate additional new resources.

To support country-owned programs, PEPFAR and the Global Fund are increasingly engaging in joint planning, and now co-finance many components of country responses. For example, Global Fund resources covering the expense incurred by buying antiretroviral drugs, while PEPFAR focuses on technical assistance, monitoring and evaluation systems, patient information systems, voluntary counseling and testing, etc. -- weaving a series of resources together that at the individual site create a responsive medical delivery capability.

The reality is that we need both the PEPFAR and the Global Fund to be successful, but they need to be convened by the country. All country, Global Fund, PEPFAR, bilateral, foundations, etc., resources, are central to any vision of a sustainable future for global health, and it is through that responsible orchestration by the partner country that this will be realized.

Another important multilateral dimension is that of the technical agencies of the United Nations family, including UNAIDS and the WHO. The need for their technical contributions at the country level is great. These organizations have done a tremendous job in marshaling global support for health issues, but now we need to figure out how to best maximize their impact at the country level. And this is a dialogue I look forward to having with my colleagues globally. Multilateral activities in country must be assessed through the same lens of accountability as those of PEPFAR or our country governments, asking whether they are making a contribution that is truly additive. If not, it’s incumbent on the country government to address that and on all of us to support them in doing so.

When you look at the three issues we have addressed today – recognizing PEPFAR as the foundation for other global health successes, promoting country ownership and fostering shared responsibility—the thread that unites them together is that we are truly putting countries in a stronger position to ensure we can reach the goal we are all committed to – achieving an AIDS-free generation and creating a stronger and more secure world.

So, as we draw closer to AIDS 2012, the meeting, let me end where I began and that’s with a message of hope. We know what most of us know and have learned over the years, we know what must be done to end this epidemic.

And I have great hope that we can do it and get it done. Hope that we see in the science that guides our efforts. Hope that we see as the world unites to turn the tide against this devastating disease. Hope that has taken the place of despair. Hope that keeps everyone in this room pushing forward, getting up, and doing it again.

It’s an honor to be part of this effort. It’s an honor to be with you all as we move forward, as we begin to see the light at the end of the tunnel, and I want to thank you for this opportunity to address you this morning.

Thank you very much.

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