The CommonHealth Live! Ambassador John Nkengasong: World AIDS Day 2023: A Journey of Hope

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This transcript is from a CSIS event hosted on November 30, 2023. Watch the full video here.

Katherine E. Bliss: The CommonHealth from the CSIS Bipartisan Alliance for Global Health Security, exploring how U.S. leadership can address our common health security challenges in this post-COVID moment.


Hello, and welcome to a new episode, and the very first of our video version of the podcast, The CommonHealth Live. I’m Katherine Bliss with the CSIS Global Health Policy Center. And it’s my pleasure to be here today with Ambassador John Nkengasong, U.S. Global AIDS Coordinator and the head of the Bureau for Global Health Security and Diplomacy at the U.S. Department of State. During the COVID-19 pandemic, Ambassador Nkengasong lead the Africa Centers for Disease Control and Prevention, and joined our earlier podcast, Pandemic Planet, in 2020 – or, 2021 and 2022, to discuss his work coordinating with governments across the continent to respond and support each other during the outbreak.

It’s the end of November, which means it’s almost December, which means the World AIDS Day, December 1st, is right around the corner. Ambassador Nkengasong, thank you for taking time out of what must be an incredibly busy World AIDS week to talk with me today.

Ambassador John Nkengasong: Thank you.

Dr. Bliss: So this is PEPFAR’s 20th year. There have been events and celebrations marking that milestone over the past 11 months. Now historically, PEPFAR has been authorized by Congress at kind of five year intervals – in 2008, 2013, 2018 – and with what has generally been bipartisan support. But this year has been a little bit different. PEPFAR’s authorization expired on September 30th, and so far Congress has failed to reauthorize the program for another five years.

In the House, PEPFAR initiatives have gotten tangled up with domestic politics around abortion access. And in both sides of Congress, the number of members who are knowledgeable about the program, or who were even in office for any of the previous authorizations, has decreased significantly. So I want to start by asking you what your greatest concerns are for the program in this period now that the reauthorization deadline has passed. And if PEPFAR is not reauthorized for a multi-year period, what steps will need to be taken to address some of those challenges?

Amb. Nkengasong: Thank you, Katherine, for having me once more on the program. And perhaps a good place to start this conversation is to look back at where we are coming from. This is saying that in order to move forward, it’s always good to review where the journey you’ve come from. Let’s look at 20 years ago, what the devastation that HIV/AIDS was causing across the world, especially in Africa – Sub-Saharan African countries, where the number of deaths were in the millions and where the number of new infections were in the millions.

There was no treatment. A diagnosis for HIV/AIDS meant like a death sentence. We saw coffins and coffins around markets in Africa, along streets in Africa. I remember going to Uganda. When I landed at the airport, in Entebbe, took a taxi to go to Kampala, the capital city, all you saw along the streets, that road, that highway, were coffins. I remember sitting in my office – when I joined the United States Centers for Disease Control and Prevention, I was assigned to Ivory Coast. Sitting in my office and looking over the infectious disease ward, which we shared with the U.S. CDC campus there, seeing nothing other than loved ones that would drop off at the parking lot – at the parking lot, because the beds were full of HIV patients. And people would drive their loved ones in, in taxis, and just drop them off. And one hour after, they were all – they were dead.

We remembered scenes where grandmothers became caregivers to their grandchildren because the parents had died. That was HIV/AIDS at that time. And thanks to PEPFAR, a program that started with bipartisan support in 2003, that nasty phase of HIV that we saw, which was an existential threat for most countries in Africa, had been taken care of. The fight is not over. You still have about 1.3 million new cases of HIV infections reported just this year by the Joint United Nations Program on AIDS. It means we’ve made progress, but we still have a lot of work to do.

I start there because it’s important that that spirit of bipartisanship that had characterized PEPFAR over the last 20 years is maintained. It’s very important that our leadership, the United States leadership, that has led the response against HIV in a significant way, in a way that we’ve not seen in the history of infectious diseases. PEPFAR is the largest bilateral program that ever existed in solving one single disease. And we should be proud of that spirit of solidarity, the spirit of leadership, the very concrete impact that PEPFAR’s achieved over 20 years – saving 25 million lives, preventing HIV infection from infected mothers to children in about 5.5 million children.

I say all of this to say that the journey ahead, the fight against HIV/AIDS is not over. We – collective “we,” as part of the U.N. Sustainable Development Goals – have agreed – or, committed rather, that we should bring HIV/AIDS to an end by the year 2030 as a public health threat. We are six short years away from 2030. And this is not the time to relent. If we relent, then the investments that we’ve put into fighting HIV/AIDS over the last 20 years will be compromised. The gains we’ve made in the fight against HIV/AIDS is fragile. It’s fragile, because there are millions of people that are currently receiving lifesaving treatment. If they do not continue taking those drugs, HIV will come back. And in the next few years or so, millions of people will be dying of HIV, and HIV will be transmitted again, and will bring us back to where we were 20 years ago.

Dr. Bliss: So you’ve really emphasized the numbers of lives saved, of infections prevented, and the fact that so many millions of people are now you know, living longer lives, living with access to antiretroviral therapies. So that means they’re getting older, they’re, you know, perhaps also needing care for other kinds of infections, or just chronic diseases that are, you know, associated with becoming older. I wanted to ask you about the kind of global financing around the HIV response, because, as we look at the number of perhaps new infections, but also the number of people who will really need to be maintained on medication, you know, if you look at the financing trends for global health, the amount of overseas development assistance going for HIV has largely remained steady, even as the percentage of that has gone down over the course of the pandemic.

You know, we saw that 2021, out of $67-something billion in development assistance for health, 9.91 billion (dollars) went to HIV. And, of course, U.S. funding accounted for nearly half of that sum, both through bilateral and multilateral programs. That seems like a lot of money. But is that enough to really reach that goal of ending HIV as a public health threat by 2030, and really maintaining people, you know, in programs that can really enable them to live long, productive, and healthy lives?

Amb. Nkengasong: That’s a very good question, Katherine, because we live in a world that is – we are currently faced or challenged with competing priorities, both in the areas of climate change, food insecurity, the wars – Russia war in Ukraine and now the war in the Middle East. It’s a combination of all of these factors that is making fiscal space very challenging for countries, partner countries that PEPFAR works with. I visited a country recently and I was told that 90 percent of that country’s income goes in servicing debts. So it doesn’t leave those countries with a lot of maneuver to invest in HIV response.

Again, the point I want to make here is that the fight against HIV/AIDS is not over. And this is no time to be complacent. This is no time to leave our foot off the pedal, because if we do that the investments we’ve made over the years will be completely compromised. We are very close. We are indeed very close. So many countries are making progress towards achieving the goals set up by the Joint United Nation Program, UNAIDS. That is the goal to achieve, make sure that 95 percent of people who are infected know their status, 95 percent of those who know their status are on treatment, and then 95 percent of those suppress the virus below the level of detection.

I think we should continue to encourage the global community as a whole, not just the United States but the global community, to not relent. We’ve come a long way. We’ve come a long way and we can almost see the end of this fight, if we just focus on the right thing to do, which is commitment to the cause in fighting HIV/AIDS.

Dr. Bliss: So one of the things you mentioned was fiscal space for countries to really allocate their own domestic resources for health programs broadly, and for HIV response in particular. Now earlier this year the Department of State launched the new bureau that you head, the Bureau of Global Health Security and Diplomacy. And that really united a number of different offices and units that had previously been dispersed through different, I guess, entities or departments throughout the department. Now that the bureau has been launched, do you see U.S. diplomacy around domestic and donor financing for HIV programs kind of evolving? You know, how do you see that taking shape? And how will the diplomacy around HIV and health security financing kind of takes shape in the next phase of work?

Amb. Nkengasong: I think the United States has been a leader in supporting the fight against HIV/AIDS. We are the largest contributor, as part of the Global Fund to Fight HIV, TB, and Malaria. We are the largest contribution in the new fund that has just been established, the Pandemic Fund. The fund is still early – that is, the Pandemic Fund is still early, that is currently housed at the World Bank. And our hope is that we’ll continue to use diplomacy, the bureau will continue to lead with diplomacy, and rally others around the importance of growing that fund to the expected $10 billion a year.

If you recall, when the fund – Pandemic Fund was established, the goal was to get to $10 billion a year for the next five years. We are currently around $1.9 billion. And I remain hopeful that with the United States’ leadership, leading with diplomacy and rallying other countries around the importance of what this fund means – it’s not just a fund, but it is a way to protect ourselves, the collective selves, as part of global health security. We saw what the COVID-19 pandemic did.

Within two months, 165 countries were affected – within a short two months. That just shows you the interconnectivity that we are, as human species, as humankind, it shows you how quickly a virus can spread. A disease outbreak anywhere in the world is a threat everywhere in the world, including the United States. So using our diplomacy to enable countries to cooperate more, to collaborate, to coordinate efforts is key. And that is what the bureau will strive to do.

Dr. Bliss: So you’ll be working through the Pandemic Fund, the Global Fund, and, of course, bilateral and regional programs. I wanted to kind of drill down to the country level a little bit. So last year, right around World AIDS Day, the Office of the Global AIDS Coordinator released, I guess, the new PEPFAR strategy that really set out a process by which countries would start to be asked to develop measurable sustainability roadmaps. And, you know, of course PEPFAR has had different approaches to this sustainability question over time. But I wanted to ask you to say a little bit about how the development of those roadmaps has taken shape over the past year, how the approach is a little bit different from some of the approaches to sustainability in the past, and what you’re hearing from countries as they kind of undertake this process of planning and thinking about mobilizing those domestic resources to really begin to, you know, kind of move to toward 2030 and beyond in a sustainable way.

Amb. Nkengasong: I think in a very simple manner, we have to step back and ask ourselves the questions – two questions. What is it that we must do that will carry us to 2030, which is a year we’ve agreed that will bring HIV/AIDS to an end as a public health threat. So that is important. Secondly is what do we do pass 2030? I mean, assuming that we are very successful, right, in getting – achieving our goals by the year 2030, past 2030 there will be millions of people that wake up in the morning every day, requiring to take one pill. That is a treatment for HIV/AIDS that has enabled them to lead productive lives, carry on with their businesses, take care of their families. We have to think through that.

That means we have to be very transparent with the way we approach the question of sustainability and say, what is the political leadership of the partner countries that we are supporting or doing? In other words, well, how does political sustainability look like? We started off this conversation by acknowledging the journey with work and the tremendous success, or successes that we’ve had. But because of that, HIV/AIDS is no longer so visible in the political checkerboard. And because of that, I don’t think that partner countries or globally, we’ve seen clinics or hospitals full of HIV patients. So because of that it has dropped by one or two notches down.

Second is the programmatic sustainability. What do we do to address those inequity gaps that exists in children, adolescent girls, and young women, and in key populations so that we get to 2030 by closing those gaps? Because if we do not close those gaps, and we keep treating people, you just get a large number of people that will be requiring of treatment even past 2030, right? So I call it the tap – the kitchen sink analogy. You turn off the tap while you’re mopping the floor. That’s what we should be aiming at. Then lastly is the financial sustainability, which is to say that this is what the international community is bringing to the table. The countries must mobilize their own domestic financing so that we sustain the response.

I call it joint responsibility and joint accountability, which is to say that we are not suggesting that the sustainability roadmap implies we are packing and leaving the countries. It’s rather that we recognize what is it that we want – the problem we want to solve, and then develop the right partnerships to get us to where we have to be. Just the three elements that should characterize any conversation around sustainability, i.e., political sustainability that is leadership, programmatic sustainability, and lastly, financial sustainability.

I’m very encouraged when I traveled in many countries, and I’ve done so in about 11 countries this year, where I see countries voluntarily saying, look, Ambassador, take our words: We are going to increase our domestic financing. I was in Nigeria recently in September, and the vice president just voluntarily said: We are going to increase our domestic financing for health, including for HIV. I was in Cameroon and the minister of finance just said, take – we keep with our commitment. We are going to increase our domestic financing. And so it was in Eswatini, where the prime minister said, watch our numbers; we are going to increase our financing to about 60 percent. And so was in Mozambique. So the conversation is ripe to have a very transparent and honest discussion as to what do we do between now and 2030? And then what do we do past 2030?

Dr. Bliss: So it sounds like it really has to be a partnership that is kind of – or has set of decisions, discussions, and plans that are tailored for each country. That there may be some broad – a broad framework of, you know, thinking about the financing, the community engagement, and the issues around political leadership, but ultimately those decisions will depend on the country’s situation, its history, and its current trajectory. You mentioned that equity is at the core of the new strategy and many of the discussions around sustainability.

And, of course, in East and Southern Africa, at least 25 percent of new infections are among adolescent girls and young women who make up a much smaller percentage of the population. And unfortunately, they are often at the age where they’re least likely to be really intersecting with the health system, and so frequently don’t know their status. I just wanted to ask you to say a little bit more about how PEPFAR is working with countries, NGOs, and the private sector to reach that population with prevention, testing, and treatment options. And if you could say a little bit about the steps that you see will need to be taken in the – kind of, the next six years and beyond, with respect to the Dreams Initiative and other programs really focusing on this critical population.

Amb. Nkengasong: The population you just described, that is those same girls and young women, constitutes a key segment of the population that we have to deal with if we have a chance of winning the battle against HIV/AIDS. The rate of new infections is about six times higher in that age group for women in some countries than the corresponding age in young men and adolescent boys. So I think we have to admit that as we make progress into the fight against HIV/AIDS, what we call the low-hanging fruits will be more challenging. And this young – the young people that you just described, it didn’t necessarily see how nasty HIV/AIDS was 20 years ago, or 25 years ago. They didn’t see that ugly face of HIV.

So we have to be very intentional and use all – and be innovative in the way that we approach that population. We are very fortunate that we have a series of tools in our possession now. A treatment. We have PrEP, Pre-Exposure Prophylaxis. And we have prevention campaigns, like the Dreams Program is part of what I call a combination approach, right, that we have in our possession to fight HIV/AIDS, especially amongst young people. The Dreams Program has been very successful because it targets and empowers young women and adolescent girls in their community. And we’ve seen in many countries, including in South Africa that you mentioned and other countries, how that age group, or the Dreamers as I call them, have actually made very good progress, very good progress. They are empowered. They speak freely. And because of that, they are champions and leaders in their own communities.

I’ve been to several countries and visited with them, including in Tanzania, in South Africa, and Kenya. And I’m very, very impressed with that. It’s the kind of innovation along the lines of the Dreams-like program that we need to develop more and targeted – be more intentional in engaging with the youth. The youth will argue that nothing about us without us, which is a slogan I like a lot. And we will be launching a youth initiative at PEPFAR, which is really designed to bring the youth leadership in there, sit down with them, and design the program or cocreate the program that designed for a youth population there. It’s going to be complex, but it’s something we have to do because, as you rightly said, the rate of new infections is significantly higher in that age group than in other groups.

Dr. Bliss: Well, thinking about kind of changes in terms of, you know, kind of where infections are, the recent U.N. AIDS data also shows that while most new HIV/AIDS cases and deaths are still concentrated in Sub-Saharan Africa, recent years have also seen an increase in cases in Western Europe, Central Asia, and the Philippines, among other countries. And so I wanted to ask you to say a little bit about PEPFAR’s work in some of the regions that haven’t always been focus areas in the past. How is or will the program adapt its programming or work with partners to kind of share techniques and approaches and ideas to address a change in infections in some of these newer regions?

Amb. Nkengasong: The strength of PEPFAR, or one of its strengths I would say, is that it is a data-driven, evidence-based program, and has been over the years. And when you look at PEPFAR’s presence in the world, I mean, we are in 55 countries. Majority of those countries are in Africa, but we also have programs in Philippine, in Southeast Asia, in many countries. If you look at Philippines, for example, over the last couple of years the rate of new infections have increased over 200 percent. And that is very, very concerning. We just did our original program planning, and we hope to continue to use data in those regions to understand what is driving the increase in that region of the world, that is Southeast Asia.

But what is also true is that in those other regions outside of Africa, the epidemic is driven essentially by men who have sex with men and young people. Young people. So regardless of where you are, whether you’re in Africa or in Southeast Asia, the rate of new infections is in the young people. Whether you had a young person, a young man who has sex with men, or a young African who engage in other forms of sexual behavior, the story is the same. Young people are vulnerable. So we must target that group. In other words, we must bring them in and make them leaders and champions in the communities that they serve so that they can become the real implementers of these programs.

It’s not just about conceiving the programs and then feeding that into the young population in the community. My strategy will be to make sure that we sit around the table and co-create and conceive the programs we use, so that we fully understand where to get the youth and where to find them. I was in Namibia just a few months ago. And the young – and talked to a young person, in a roundtable setting. And he said, you guys don’t understand how we communicate. OK, we communicate differently. And that is very, very important. If we make them champions, and I’m sure they are going to be the leaders in their communities that will guide us as to how to effectively implement programs that will address the need for and tackle the rise in cases of new infections in those communities.

Dr. Bliss: And so it sounds like there may be opportunities as well for greater communication kind of across the different countries, among youth groups and others, to really share experiences and work together to create new approaches.

Amb. Nkengasong: No, absolutely. Regardless, as I said, where you are, it’s the young people OK? And I think we should just keep that in mind in our planning as we drive towards 2030 to bring HIV as an end to a public health threat.

Dr. Bliss: So World AIDS Day is this week. The week is all about this, but December 1st is the day. And the theme this year is, Let Communities Lead. And I had an event a couple of weeks ago at the Council on Foreign Relations, you and Anthony Fauci were having a conversation, you know, really, I think, looking back on the history of the HIV response globally, but also looking at the COVID-19 pandemic. And really kind of talking about the importance of community engagement, that, you know, if communities were not – had not been part of that pandemic response that things could have been even more challenging in many places than they were.

So I wanted to ask you to reflect kind of more broadly, kind of beyond the work with youth that is so important this year, but why is it important that organizations of communities of people living with or at risk of HIV really, you know, have a leading voice in designing policies? And, you know, how can we ensure that future pandemics keep that lesson in mind, and so it’s not something that has to be kind of relearned each time we enter that cycle?

Amb. Nkengasong: Yeah. HIV has offered a lot for all of us who are in global public health to draw a lot of lessons. And some of those lessons include what I call sustained leadership, partnerships, developing the right partnerships, and, of course, leading with data and science. And a community plays a critical role in this. And community in this broader sense, which – including the faith-based organizations, the civil society, and just the young people that we just described. There’s a saying that it starts in the community and it ends in the community. The HIV response tell us that without using the whole of community approach, the whole of community approach, i.e., if we are in a certain community the faith-based organization must be engaged, civil society, the activists must be engaged. That’s the only way that you can truly address the issues of a disease threat such as HIV or the COVID response, that pandemic that we just had to deal with.

So our strategy, if you look at the five years strategic plan that we launched last year, has a cross-cutting element community leadership. Not community engagement. Community leadership, which is that you place the communities at the center of the response. You co-create with the communities. You listen to the communities. And I think that’s what we have – we are promoting actively. We believe that if we do that, then the communities will be able to get the last mile and make a strong case as to why people should come out, know their status, why people should be put on treatment or received their treatment, and why they should maintain the virus that is below detectable level.

I think those lessons can be applied to other emerging infections or other outbreaks. Who knows what the future is. We’ve all said that it is a question of when a new disease outbreak will occur, and not if it will occur. And if it does, I think the community plays a role. We saw during the COVID-19 pandemic, or at least in my experience leading the COVID response in Africa, that the faith-based organizations were the megaphone of trust in the community. Especially when vaccines – COVID vaccines became available. There was a lot of hesitancy.

And the churches were the most – went in and called on people to come get their vaccines. And you saw a long line of worshippers after the services, whether they were in a mosque or in a church, winding and meandering out to get the vaccine. Which was not true when the government was doing that all by themselves. So the community have always played a critical role in the HIV response, and will continue to if we have to get to the last mile. But there are lessons we must learn to prepare us to fight other disease outbreaks.

Dr. Bliss: So it sounds like with political leadership or building partnerships, kind of demanding transparency around financial issues, building confidence in either countermeasures or government guidance, that the community has a critical role to play in both building advocacy but also confidence and community support for initiatives, whether for HIV or other pandemics.

As you – this is kind of a last question asking – we started out kind of looking back over 20 years. But as you – as you look back over the past two decades and, of course, ahead to 2030 and beyond, and even taking into account some of the uncertainties around reauthorization and the murky kind of financial picture globally in terms of the allocation of funds, just wanted to ask you what aspects of the global effort to end HIV give you the greatest hope, and where you will really be looking for progress and change over the next few years.

Amb. Nkengasong: The journey of HIV/AIDS has been a journey of hope. We started off this conversation by recognizing the strong bipartisan support that PEPFAR have enjoyed over the last 20 years. And that is a story of hope. When so many people in the world were hopeless, PEPFAR offered hope. So going forward, I remain hopeful that that strong bipartisanship that has characterized PEPFAR and has come to symbolize our values, the values of what the people of the United States bear and have shared their generosity of heart with the rest of the world, will prevail. That despite the challenging conversations we’ve all had around the question of reauthorization, a clean reauthorization for five years, that everyone will step back, look at the progress we’ve made together, look at values that we’ve promoted across the world, the values that speak to our ability to care for others, and say: We have to get this fight done, completed in the next – or the journey to 2030.

And an important element of that is the hope that PEPFAR will be reauthorized in a clean manner for the next five years, so that we engage and accelerate our response to bringing HIV/AIDS to an end. So it is hope around what we’ve done over the last 20 years, and hope that we can bring this epidemic to an end, and the history books when they are written. I hope that the cover page will be HIV/AIDS, a journey of hope. And PEPFAR and the bipartisan nature of what we’ve done over the years will characterize a big chapter of that book.

Dr. Bliss: Well, Ambassador John Nkengasong, U.S. Global AIDS Coordinator and head of the Bureau of Global Health Security and Diplomacy, thank you very much for taking the time to talk with me today and share your perspective on this journey of hope, over the past 20 years and into the future. I hope that we’ll be able to meet again over the coming months to discuss the state of PEPFAR as its new decade is underway. Thank you.

Amb. Nkengasong: Thank you. Thank you. It was a pleasure.