Interview of Ambassador Eric Goosby, U.S. Global AIDS Coordinator, by African Journalists


November 30, 2010

Via Teleconference

OPERATOR: Welcome and thank you for standing by. At this time, all parties are going to be on a listen-only mode. During the question-and-answer session, please press *1 on your touchtone phone. Today's conference call is being recorded. If you have any objections, please disconnect at this time. I now would like to turn the conference call over to Ms. Jennifer Peterson, and ma'am, you may begin.

MS. PETERSON: Perfect. Thank you so much, everyone, for joining us this morning. We're pleased to have the opportunity to speak with you today in advance of World AIDS Day tomorrow. We have on the line Ambassador Eric Goosby.

Ambassador Goosby serves as the U.S. Global AIDS Coordinator leading the U.S. Government's international HIV/AIDS efforts. He oversees the implementation of the U.S. President's Emergency Plan for AIDS Relief, also known as PEPFAR, and the U.S. Government engagement with the Global Fund to Fight AIDS, Tuberculosis, and Malaria. He also is on the operations committee that leads the U.S. Global Health Initiative, along with the heads of the U.S. Agency for International Development and the U.S. Centers for Disease Control and Prevention.

So with that, I'll turn it over to Ambassador Goosby to give brief remarks and then we'll have an opportunity for questions and answers.

AMBASSADOR GOOSBY: Well, thank you very much. I really appreciate all of you taking time to talk with me today. I'll begin with some brief remarks, and then I'll look forward to taking your questions.

PEPFAR was launched in 2003 to combat global AIDS, the United States President's Emergency Plan for AIDS Relief. It's the largest commitment in history by any nation to combat a single disease. With support from PEPFAR and other programs, the global community has made groundbreaking progress in saving lives through HIV prevention, treatment, and care services. These gains have meant better health for millions of people around the world.

Tomorrow, on World AIDS Day, we will announce the new information on the number of people reached with HIV prevention, treatment, and care supported by PEPFAR, cumulative through 2010. For World AIDS Day, our theme is smart investments building on success. It's a theme that describes what we are doing each and every day at PEPFAR. The smarter we are about the prevention, treatment, and care we provide, the greater the number of lives saved. That's something to celebrate on this World AIDS Day.

The Obama Administration's commitment to investing in HIV/AIDS prevention, treatment, and care is unwavering. The Administration's PEPFAR budget request for this year is the largest in any President's budget to date. The President has also launched the Global Health Initiative, which will make PEPFAR even more effective and efficient in providing services for people in need. Our yardstick for measuring success is not dollars invested, but lives saved. Years of experience in the field have taught us how to better use every dollar invested in battling AIDS.

These smart investments mean we are getting a bigger bang for the buck, allowing us to do more to fight not only HIV/AIDS, but other global health issues such as, well, malaria, tuberculosis, while also improving health outcomes for mothers and newborns.

Let's look at a few examples of how we're maximizing the impact of our investments through PEPFAR. First, we're saving lives and money by using more generic drugs. Recognizing that one of the biggest hurdles to rapid treatment scale-up was the high price of antiretroviral drugs, ARVs, PEPFAR worked with the U.S. Food and Drug Administration to bring more generics to market. By 2008, generic drugs accounted for 90 percent of the 22 million ARV packs purchased, increasing from 14.8 in 2005, and resulting in an estimated cumulative savings of $323 million.

Second, we're successfully implementing prevention to mother-to-child transmission. Prevention of mother-to-child transmission is one of the most effective and cost-effective interventions for HIV. By focusing on PMTCT, Botswana and parts of South Africa have had extraordinary success reducing the likelihood of infant infection to levels similar to those found in the United States and reducing the significant costs associated with new infections. Accordingly, PEPFAR's Five-Year Strategy set goals to reach over 80 percent of pregnant women with HIV counseling and testing, and to provide ARV prophylaxis or treatment as appropriate to 85 percent of pregnant HIV-infected women in PEPFAR countries.

Third, we're changing the way we ship our medicines. We have become more efficient in shipping needed medicines in a timely fashion by using water and land delivery systems instead of airfreight, reducing costs by as much as 90 percent.

Strengthening our prevention programs is our final point. Medical male circumcision promises dramatic impact on prevention efforts. Male circumcision is an ideal prevention intervention for countries and donors, as it is a one-time intervention that provides lasting prevention benefits. The majority of the expenditure required to saturate a country with high levels of adult male circumcision takes place in the first one to three years, depending on the speed of the program, and expenditures drop precipitously following this initial investment to support neonatal and adolescent boys. Scaling up male circumcision to reach 80 percent of adult and newborn males in 14 African countries by 2015 could prevent more than 4 million adult HIV infections over 15 years, 2009-2025. It could also result in savings of $20.2 billion between 2009 and 2025 with an overall investment of approximately 4 billion - definitely cost-effective and protection on the scale of a vaccine.

Going forward, the United States is proud to be supporting countries as they take a leadership role in the fight against HIV/AIDS. As President Obama said in Ghana, Africa's future is up to Africans. To build a long-term response to HIV/AIDS, PEPFAR is supporting country-level leadership. This includes supporting partner government capacity to plan, oversee, and manage programs; to deliver quality services with the participation of local civil society and communities; and ultimately to support financial contributions to the health programs.

To date, the United States has signed 18 PEPFAR partnership framework agreements, including 14 with African countries. These frameworks help to strengthen country capacity ownership and leadership, building on successes achieved to date, and ultimately saving more lives. Continuing bold leadership and financial commitment from African governments is essential, because governments are ultimately responsible for promoting the health of its citizens.

We saw great success in the fight against HIV/AIDS, but the battle is far from over. It is only through working together that we can build on our successes to save more lives. I want to thank you for your time, and I'd now like to open it up for questions. Karen?

OPERATOR: Thank you. We'll now open it up for question and answers. If you would like to ask a question please press *1. I do ask that you give me your name and/or affiliation, and if you would like to withdraw your question press *2. And one moment please for the first question.

Once again, if you would like to ask a question, please press *1. Thank you. We do have a call coming in from U.S. Embassy Dakar, Senegal. Your line is open. You may ask your question.

QUESTION: Hi. My name is (inaudible). I'm with the national television here in Senegal. I would just like to ask what are the challenges you face when tackling this problem of AIDS regarding Africa?

AMBASSADOR GOOSBY: Well, I think our challenge has been to work with country leadership to develop effective programs that address the needs of the population in the prevention area, the care area, and in the treatment with antiretroviral drugs. Our challenge has been in developing continuums of care and services that are responsive to the needs of the community in day one, but also become evolved as the needs of the community change. In order to understand where the community's needs are, there needs to be a dialogue that develops between the government leadership, organizing and running the programs, and the people who are using these services. It is through country ownership at the government level and with civil society that our ability to transform and improve our programs over the duration- which as you remember with HIV is really the duration of a person's life; so we're talking 20 to 30 years - becomes the critical track through which we will have a continually improving program.

Legally, they will achieve this by supporting capacity expansion in the partner government around management, oversight, planning, and implementation of these programs where the partner government becomes the overseer and responder to improve the programs over time. It's a challenge that we've engaged with through our partnership frameworks and developing a five-year strategy with countries to decide in care prevention and treatment what each - the partner country as well as the U.S. Government - is contributing. We have been very gratified at the rigor with which the partnership frameworks have been engaged with in dialogue with our partner countries.

OPERATOR: Thank you. U.S. Embassy Nigeria, your line is open. You may ask your question.

QUESTION: Thank you very much. The WHO's new guideline for treatment requested that people whose CD4 count is reduced to 350 should be on drugs. And that put the number of people who are clinically fit to be on drug in Nigeria to about 1.2 million. Already the country is struggling to take care of the 800,000 that are supposed to be on drugs. Are we looking at a possibility for PEPFAR to help in Nigeria to finance the drug program? Are you going to increase the number of your funding for drugs for these people or what is in the (inaudible) for these increase that are necessitated by the increase in the occasion by WHO new guideline?

AMBASSADOR GOOSBY: We are supportive of the program in Nigeria and are supporting the use of antiretrovirals in the population in Nigeria whose T-cells are now at the 200 or lower range. If the person is a pregnant woman, she should receive antiretrovirals. And if the person has active tuberculosis, regardless of their T-cell count, with pulmonary TB, this individual, because of the risk to them and to those around them, should also be considered a candidate for antiretroviral use.

The 200 to 350 difference is something that the government needs to think through their ability to expand the resources to cover that difference and the use of other funding mechanisms, such as the Global Fund, is really the main resource that Nigeria has chosen to use for this. In addition, the Nigerian Government has agreed to increase its contributions to the treatment effort specifically in our partnership framework discussions. And over the next five years, the Nigerian Government has agreed to expand from up to as much as 50 percent of the cost of treatment. This commitment, together with the Global Fund, together with PEPFAR, joining the country's resources, we believe that you will be able to expand the numbers to approach the total for the 350 CD4 count. It's only through working together that we can address this huge, unmet need. And we remain committed to work with the Nigerian Government to make this possible.

OPERATOR: Thank you. Once again, if you would like to ask a question, please press *1 on your touchtone phone. And our next question comes from the U.S. Embassy, Addis Ababa, Ethiopia. Your line is open. You may ask your question.

QUESTION: Thank you. I'm (inaudible) from (inaudible) radio. My question is what the status of research (inaudible) vaccination, and also is there support in Africa for vaccination research? And what is the reason behind why the medicine, the medication and the vaccination is late? Thank you.

AMBASSADOR GOOSBY: What was your last - the last part of your question?

QUESTION: What is the reason behind why the medication or vaccination is late?

AMBASSADOR GOOSBY: Well, okay. The research that has been advancing in the AIDS field has really, since the Vienna meeting last summer, really focused in the prevention arena. The CAPRISA trial that identified the ability of an antiretroviral, tenofovir, in a gel preparation, to effectively prevent the transmission of the virus to the woman who is using this protective vaginal gel with the antiretroviral in it, protects her 54 percent of the time. This is a huge breakthrough for microbicide research in allowing us to, for the first time, realize that we can develop a tool that women can use who cannot negotiate the use of condoms or - in their sexual relations now have the option, once this approved of using a protective gel that she can insert and decrease her chance of transmission and becoming HIV-positive.

The other study that has come through has also used antiretroviral drugs to be taken in an HIV-negative person before they are exposed to HIV. So a pre-exposure prevention tool, taking the antiretroviral agent, and then when exposed to HIV their chances of transmission are markedly decreased as well, in the 90 percent range. This study has just been released. But both of them give us two new potential tools that over the next year to a year and a half, as we understand specifically the correct dosing and the correct way to apply the gel, that we will indeed be able to add this to our armamentarium in preventing HIV infections. Again, tools for those who are in a position where they cannot negotiate or where they know they're going to have continued and repeated exposure.

OPERATOR: Thank you. Kenya Broadcasting, your line is open. You may ask your question.

QUESTION: The question is how much moneys are located to fight HIV/AIDS in Kenya and how does the U.S. money - the use of this money - that it is not used in (inaudible) to present PEPFAR that the money reaches down to the needy? And also, there's a belief in Kenya that the cure for AIDS was found two years ago, but the western world, the western leader, political leaders, in collaboration with the pharmaceutical company, still do not want to release the cure, because they want to sell the drugs. How true is this?

AMBASSADOR GOOSBY: The cure for HIV has not been identified. We have been looking for this for 30 years. Our ability to identify the virus, understand how it infects the body and what organs in the body it infects, and the manifestations of that is well understood. And it has given us targets to develop antiretroviral drugs that effectively prevent the replication of the virus when taken. Unfortunately, they're very - when the antiretroviral drug is stopped, within weeks you begin to see viral replication and it continues to crescendo, go up, to the point where the person is back where their immune system is again devastated.

So the antiretroviral drugs need to be continued for a lifetime. When they are continued for a lifetime, the person will live for 20 to 30 years and indeed is expected to die from something else other than HIV. We are beginning to see that individuals who are on antiretroviral drugs - we have learned the long-term side effects and how to manage them. We have also seen that individuals on antiretroviral drugs can lead a normal life and return to work, continue to care for their families, et cetera.

Our ability to develop new treatments for HIV continues. We continue to look for a cure. That is still on the table and researchers are still aggressively trying to figure out how to permanently remove the virus from an infected individual.

In terms of Kenya and our commitment to Kenya, we are in - now the United States supports over 70 percent of the resources that go to Kenya's Ministry of Health's treatment of HIV and AIDS. This is a commitment that we have established early. Kenya has developed some of our strongest care, prevention, and treatment services, and indeed has featured - developed many of our models for becoming more efficient in developing programs that allow us to expand into many provinces over - with the same amount of money.

An example of that is the AFIA project in Kenya, where one manager now manages programs over HIV/AIDS, family planning, maternal and child health, immunizations, and neglected tropical diseases, all coming from - all now in one shop. So one manager, one procurement system, one pharmacy, formulary, et cetera, all of which saves resources to allow us to put these capabilities in eight provinces at the cost that we originally were putting these services in one province. So Kenya continues to be a strong partner and we continue to remain committed.

OPERATOR: Once again, if you would like to ask a question, please press *1 on your touchtone phone. And our next question comes from U.S. Embassy Dakar, Senegal. Your line is open.

QUESTION: I would like to ask, is Senegal supported by the PEPFAR program in any way? And if not, why? And if so, what is the funding that has been made available to us?

AMBASSADOR GOOSBY: Senegal has been supported in care and prevention services. We've also supported a large amount of research that Senegal has taken the lead on for many years. In our understanding of different HIV strains, Senegal has been at the forefront of adding to our understanding of what differences in HIV viruses appear on the continent of Africa and elsewhere for that matter.

I can't give you a number, a specific number for how much money we have in Senegal, but I can have my office phone you a little later today, in an hour or so, and give you that number. I just don't recall that.

OPERATOR: Thank you. Our next question comes from U.S. Embassy Cameroon. Your line is open. You may ask your question.

QUESTION: Yes, Doctor, my name is (inaudible). I am a Cameroonian journalist. Cameroon has suffered the last four years with the absence of (inaudible) from the Global Fund, and I remember visiting the country (inaudible) executive director said PEPFAR is an alternative to Global Fund. What can Cameroon expect from PEPFAR and the contribution of PEPFAR to public health in Cameroon?

AMBASSADOR GOOSBY: We are very - the United States gives about a third of the money to the Global Fund and we sit on the board of the Global Fund and we have been in dialogue with your political - with your Ministry of Health and your political leadership around our concern, our shared concern, that the Cameroonian applications to the Global Fund - indeed there have been eight of them - have all been turned down.

We have developed a technical assistance strategy to help the applications as they move forward into round ten with Cameroon as a principal target for the Global Fund to make sure that the application is done properly and is supported. PEPFAR's resources - Cameroon was not one of the target countries when PEPFAR started. We - as we move and achieve goals in other Sub-Saharan African countries, and we are in 33 of them now, as we achieve goals in other Sub-Saharan African countries, it frees up resources for us to move to countries that we have not engaged aggressively with. Cameroon is high on our list to move into that category, and we are in dialogue with your Ministry of Health and your political leadership about this.

OPERATOR: (Inaudible) Botswana, you're next. Your line is open.

QUESTION: Yeah, I actually just have one question. I would like to know what sort of relief you will be extending to countries such as Botswana already have a number of measures of countering the disease. For example, Botswana is giving our free antiretroviral drugs to its people, so what sort of relief do you plan to provide for us?

AMBASSADOR GOOSBY: The United States Government spends hundreds of millions of dollars in Botswana and has since day one in supporting the Botswana Government in continuing their continuums of care and services. Botswana has been fortunate in having its own resources to put toward this effort, but we are your principal donor in supporting other areas in care, treatment, and prevention for Botswana.

I would say that Botswana has also been a leader in the region in aggressively developing strategies that are government led and owned, in planning and changing their prevention efforts to target those individuals who are at highest risk. So we are very - in a long-term relationship with the Botswana Government and people in joining them in supporting what is a robust effort. Botswana's numbers are approaching 95-plus percent. They really are approaching universal coverage. Their maternal-to-child health numbers are the best on the continent in terms of preventing transmission in an HIV-positive mother to her newborn infant.

So we will continue that partnership and look forward to positioning Botswana to play a technical assistance role for other countries in laboratory development, in prevention strategies, and in the delivery of treatment services in remote areas.

OPERATOR: Thank you. Swaziland, your line is open. You may ask your question.

QUESTION: My name is (inaudible) from Swaziland Broadcasting Information Services in Swaziland. My first question is: Since tomorrow is the World AIDS Day, what does the world expected to do and what is the theme for the whole world? And the second question is: How is USAID partnering with (inaudible) in fighting HIV and AIDS, and how is their relationship so far? And the third question is: What - is there a way forward since you've started assisting the country?

AMBASSADOR GOOSBY: Well, the World AIDS Day theme is Smart Investments: Building on Success, and it's a theme that we are taking up in PEPFAR because we're looking at PEPFAR as the platform and - off of which we now can expand services for HIV/AIDS patients but also to expand into responding to the needs of these same people for other diseases, other than HIV/AIDS.

So the Global Health Initiative that the United States is now engaged with is that expansion, building on the success of PEPFAR, using the platforms that are already up and running to more efficiently start to address other diseases, maternal and child health, family planning needs, neglected tropical diseases. Also diabetes, hypertension, coronary artery disease will be focused on in our Global Health Initiative.

Swaziland has had a remarkable story around the male circumcision need in the community. The leadership of the King in identifying this as a priority, in being an example of an individual who has raised this to a level of importance in his dialogue with his people, has resulted in us converging on Swaziland with PEPFAR resources, some Global Fund resources, and some private foundation resources to really move male circumcision to scale in the country. This is an exciting moment for the world, because it will be the first time we're able to demonstrate the extraordinary impact that male circumcision has in preventing transmission to men, and we are positioning ourselves to be able to not just implement and set up the male circumcision project, but also to document the impact on transmission in the subsequent months and years that follow.

OPERATOR: Thank you. U.S. Embassy, Addis Ababa, Ethiopia, your line is open. You may ask your question.

QUESTION: Thank you. Ethiopian AIDS Prevention Center and the UNAIDS says there is progress to minimize HIV transmission in Ethiopia. Do you agree with that? What was your contribution? Thank you.

AMBASSADOR GOOSBY: Sir, could you repeat - the problem to minimize what?

QUESTION: Minimize the progress (inaudible) - Ethiopian AIDS Prevention Center and UNAIDS says there is progress to minimize HIV transmission in Ethiopia. Do you agree with that? And tell us please about your contribution.

AMBASSADOR GOOSBY: Yeah. Well, I think that the importance of focusing on HIV transmission continues to be a focus for all of us. Ethiopia has been very aggressive in developing prevention strategies that have reached out to the most rural areas of your country. Your Minister of Health has been a leader globally, in speaking to the needs of country ownership and allowing the countries to be in the planning and implementation role with donor resources. We have supported this in our relationships with the Ministry and are in early dialogue on how we can expand our relationship to support further country ownership around both planning and implementation.

I think the prevention strategies that have been developed have taken into account both people who are infected as peer counselors, have engaged health care workers who have been instructed in both prevention care and treatment services for those who are HIV-infected. And health care workers - these same health care workers - have also been instructed in other diseases, immunization, how to diagnosis hypertension, and how to diagnosis and refer patients in the care for these other problems. We're confident that Ethiopia will be a model for an expansion of the mid-level provider to play a critical role - such as the health care worker, the nurse provider - to play a critical role in care, prevention, and treatment service availability in remote areas.

MS. PETERSON: Karen, we have time for one more question.

OPERATOR: Thank you. And our final question is coming in from the Kenya Broadcasting. Your line is open. You may ask your question.

QUESTION: My name is (inaudible). I'm from Kenya. My question is the Kenyan Prime Minister recently made remarks about the gay and lesbian community, that they should be arrested should they be found. And this is - the gay and lesbian community contribute to about 15 percent of new HIV infections in Kenya. So what impact do you think this could cause on the fight on HIV in Kenya and the reduction of new infections in Kenya? And also what strategies can the Government employ to ensure that as much as they want - as much as this is illegal in Kenya, the gay and lesbian community are still reached in HIV prevention, care, and treatment.

AMBASSADOR GOOSBY: I think that it - in looking at the responses over 30 years of experience with HIV in the world, there has been - there has never been an effective strategy that includes repression of gay and lesbians, the gay and lesbian community, as a kind of target for diminishing HIV transmission. Indeed, the strategies that have been most effective in decreasing transmission of HIV have been those strategies that include embracing the gay and lesbian community, creating a safe space where they can get - come and get tested for HIV and other sexually transmitted diseases without fear of incarceration or incrimination and allow that individual to benefit from prevention interventions so they don't get infected and for the HIV-positive individual to be brought into treatment.

Strategies that create an access point for these individuals in the community are more effective at curtailing HIV transmission in the general population than those that aren't. This is something that we have seen in every country we've worked in, including the United States, and Western Europe, Canada, Australia, in the developed countries. And we really feel that we have a clear understanding of how we should position ourselves with portions of the community that are participating in higher risk behavior. So we really feel that a strategy that creates a safe space for this community is the way to go.

MS. PETERSON: We wanted to thank everyone again for joining us today, and thank Ambassador Goosby for his time. And we look forward to continuing to dialogue with you in the future.

AMBASSADOR GOOSBY: Thank you very much.

OPERATOR: Thank you. That does conclude today's conference call. Thank you for participating. You may disconnect at this time.

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