Fighting HIV: Time to Focus, Says Debbi Birx

January 15, 2015

By Todd Summers
In a recent blog post, PEPFAR director Ambassador Debbi Birx outlines an aggressive agenda (called PEPFAR 3.0) for the next four years that emphasizes her commitment to focusing its resources better (their theme: “Focus, Partner, Achieve: An AIDS-free Generation”).  Overall, it’s a smart approach that capitalizes on the fact that the HIV epidemic, while global, is actually heavily concentrated in a few countries and populations: just seven countries account for more than half of the world’s HIV cases.  This mirrors the domestic epidemic here in the US, where over half of all HIV cases are in just five states.

Ambassador Birx also emphasizes the importance of partnership both with the countries in which PEPFAR operates and with other global actors like UNAIDS, the World Health Organization, and the Global Fund.  This is where things get harder.  On its own, PEPFAR can use its considerable financial and diplomatic muscle, complemented by significant technical prowess, to put its money where it can have the biggest impact – in her words, “doing the right things, in the right places, at the right time.”  Getting others to go along with its views on what’s “right”, however, is hard work indeed, and she’ll have to use some of her prodigious skills to get these partners all moving in the same direction.  Here’s where she should focus:

While there’s no doubt that more funding is needed, it’s also true that we could make better use of what we have.  Thankfully, research has shown that a limited set of interventions, focused smartly, can have a huge impact.  Bernhard Schwartländer and others demonstrated that a strategic investment approach in which proven interventions are deployed decisively could drive down new infections dramatically and bring the epidemic to its knees.  Subsequent scientific and operational research studies have provided further evidence of the benefits of this “right things, right places, right time” approach, especially when effectively targeted on “hot spots” where HIV incidence rates are highest.

So hats off to Ambassador Birx for her efforts to get smarter about using what we have, focusing resources on the proven tools, and getting them to those that can use them to greatest impact.  Now she’ll need to get UNAIDS and WHO better aligned to help countries get this right, and get more funding and technical support to the Global Fund to ensure that necessary resources are available.  She also needs to get them as focused on preventing new infections as they are on increasing treatment access.  While HIV treatment has preventive benefits, we still see far too many new infections – over 2 million in 2013.  Preventing the spread of HIV must be as high a priority as treating infection, but seems to have been pushed into the background lately (Mitchell Warren of AVAC did a great blog on this recently – and conflict alert: I’m on AVAC’s board). 

Ambassador Birx is headed in exactly the right direction.  She’ll just need to divert a little of her extraordinary energy to helping others keep pace.

• UNAIDS: While it has exceled at garnering international attention and funding to fight HIV, this UN agency with lead responsibility for the epidemic often falls short at the country level.  Its newest campaign, “90, 90, 90”, seeks to increase the number of people getting HIV treatment: by 2020, 90% of all people living with HIV will know their HIV status; 90% diagnosed with HIV will receive sustained treatment; and 90% receiving treatment will have viral suppression.  It has been widely adopted, including by PEPFAR, but what’s missing is clear direction for the many countries lagging far behind these aspirational targets.  UNAIDS needs to put more energy into helping, and sometimes pushing, countries to develop the smart strategies that align the “right things, right places, right time” with robust epidemiological analyses.  There seems to be some movement to improve its country-level work, but time is of the essence in fighting this epidemic; too much of it has been spent on global campaigning and not enough committed to mapping out the pathway from aspiration to reality – the grunt work in countries and communities that makes the real difference.  UNAIDS will also need to do more to help wean middle-income countries off external aid: putting more of their own funding forward, breaking down human rights barriers that block access to lifesaving services, and eschewing the wasting of precious resources that results from strategies derived from political compromise and cowardice rather than science and data.  This will take some serious wrangling.  Fortunately, few are better at it than UNAIDS director Michele Sidibe, but he’ll need backup and encouragement from the U.S. to get political leaders aligned.
• World Health Organization: The recent ebola debacle laid bare the challenges of WHO, a strained organization on which countries nevertheless continue to rely for determining standards of care and the effectiveness of new interventions.  The agency’s initial efforts to address the HIV epidemic failed, prompting the launch of UNAIDS, but it retained an especially critical role with respect to HIV treatment.  In the past, having UNAIDS focus on prevention and advocacy while WHO focused on treatment seemed to work, but over time things have gotten way out of balance: UNAIDS has hundreds of staff across the globe while the HIV team at WHO has dwindled in size and budget.  Now that science has clearly demonstrated that treating HIV is one of the best ways to prevent its further spread, UNAIDS and WHO need to find a way to come back together.  The United States is the largest donor to WHO and a significant funder of UNAIDS, so Ambassador Birx should use that leverage to make this relationship work better both in Geneva and at the country level.
• Global Fund: The United States is also the largest donor to the Global Fund, which is the primary vehicle for most major donors that have otherwise curtailed bilateral HIV activities.  Ambassador Birx represents the United States on the Global Fund board and is one of the few technical health experts at the table; she therefore has a huge opportunity to help the Global Fund align with PEPFAR’s new approach.  This shouldn’t be a big challenge, as the Global Fund’s current five-year strategy emphasizes the need to focus resources; its Executive Director, Dr. Mark Dybul, used to run PEPFAR and has also been proselytizing about the importance of using epidemiological data better to put resources where the needs are greatest.  However, despite their ideological and financial connections, the relationship seems strained and needs to be fixed.  While harder to control than bilateral aid, U.S. funding to the Global Fund has the notable benefit of leveraging other donors that would probably give much less if the Global Fund did not exist.  Rather than acting as competitors for funding, PEPFAR and the Global Fund need to see each other as essential partners if the world is going to end AIDS.  Politically, they’re in it together, and any competition between them is likely to result in both getting less.