Department of State press briefing with U.S. Global AIDS Coordinator and Special Representative for Global Health Diplomacy Ambassador Deborah L. Birx, November 25, 2019.
Hi, everybody. Okay. Today, we are excited to present to you key takeaways from our annual report on the successes of the President’s Emergency Plan for AIDS Relief, a program in continuous operation around the world since 2003. With me at the podium is Ambassador-at-Large Deborah Birx, who is the U.S. Global AIDS Coordinator and the U.S. Special Representative for Global Health Diplomacy. Ambassador Birx has been on the front lines of the HIV/AIDS response both in the U.S. and around the world since the earliest days of the epidemic in the early 1980s. Ambassador Birx.
Thank you. Thank you, Morgan. And thank you all for coming this morning and for your interest in this issue. I’m going to end, actually, with a request to all of you. So, later this week we head to World AIDS Day December 1st, which has been a continuous recognition of the people that we have lost to HIV/AIDS. And I’m sure you know that over 70 million people have been infected, about 75 million, and 32 million people have died, one of the largest pandemics and largest continuous pandemics in the history of the world. But HIV is not in the news that much anymore because of the decrease in mortality. And so, reporters have not really talked about the rate of new infections, where the most vulnerable groups are, the people that we are losing to new infections, and the fact that the epidemic has moved into young people, 25 to 35, 15 to 20, around the globe. And this has become our largest group of specific interest. But today I want to talk about the progress, and the progress is quite remarkable. Under PEPFAR now, about 15.7 million men, women, and children are on lifesaving antiretroviral treatment so they can now thrive with the disease and be part of the economic development in their country. But critically, as we also treat individuals, we’ve been very much focused on prevention, because we’ve been very concerned about the rate of new infections particularly in young people. So, we also announce today that we’ve done nearly 23 million voluntary medical male circumcisions. Those are circumcisions that prevent men, about 65% lower incidents of getting HIV because of being circumcised. That’s a program we started in 2009. But three years ago we started a program for young women called DREAMS, Determined Resilient, Empowered, AIDS-free, Mentored, and Safe young women. It stands for the structural interventions that need to occur at the country and community level to ensure young women can remain HIV-free. It’s focused on education, it’s focused on families and communities protecting young women, it’s focused on keeping young women safe from sexual violence at very young ages. And through that program, for the first time that we can announce in all districts, all 86 districts where we work around the globe in 10 countries, a uniform decline in incidents across the board. And indeed, the majority of the districts have a significant, greater than 25%, decline in just three years. This kind of progress has only been possible because of the bipartisan support we have had. From the very beginning, PEPFAR was a bipartisan program, and now through three presidents and nine congresses, we’ve had continuous and unrelenting support, transposing the generosity of the American people into these kind of effective programs where we’re measuring not only outcomes of saving lives but also clear impacts of decreasing the number of new infections. And that’s why today we have a series of countries around the globe, Cambodia, Namibia, Botswana, Ethiopia, and Rwanda, who are actually getting control of their pandemic, and a whole series of countries behind them, doing what many people thought was impossible just 10 years ago. Because still, we’re working on a vaccine and a cure, the NIH is still funding significant research in both of those areas. But to actually control an epidemic for which there is no cure and no vaccine, and actually decrease the impact that it’s having on populations, on communities, through programs and tools that we have today, would have been considered impossible even a decade ago. And I think that’s what happens when you have amazing communities and governments that we’re working with, and of course all the agencies within the federal government that we work through that really ensure that these programs reach the most vulnerable, the most in need, the young, the old, those who are at the far, far rural areas, and those who are in urban and formal settlements. We’ve had to create a program that reaches everybody where they are in a client-centered way. And so this year’s theme for World AIDS Day is controlling the epidemic, community by community. And I think that really gives voice to why we are making the progress we are, and what needs to be done in the future to ensure. So, now it comes to you all and why I also wanted to be here today. HIV/AIDS has not been in the press, and when I talk to the young people around the globe about their risk, they said, if that was really true, if still 25% of the population in Eswatini or Lesotho had HIV, I would know. But the communication, we have not made it real to young people. And we’ve not made that absolute understanding that HIV is still a disease that kills people, it still is a disease that is incurable. Yes, we have drugs that will lengthen their lives and ensure they can thrive, but what would be better is if they never became infected. And I think making sure that country-by-country, community to community, that there’s still HIV awareness, awareness of where it is in their community, awareness about what their risk are, and awareness that there is both prevention and treatment tools that actually can change the course of this pandemic. So, thank you for your time today. I really appreciate it. And I think we’re going to field some questions.
Let me just start by saying it’s nice to hear someone affiliated with this administration call for more press coverage of something considering the attention that the fake news, alleged fake news, seems to get. And so it would be appreciated if you could spread the word a little bit more amongst your colleagues. On terms of AIDS and PEPFAR, I’m wondering if you have been able to see any kind of a change in your result metrics from the shift in emphasis or the shift in the family planning money that this administration has instituted.
Well, I think you know our Secretary has asked us to be tracking that very carefully. He has done and issued one report, there’s another report pending. Because I think there always has been a concern, is what impact does it have at the individual peoples’ lives? Now, you’ll be happy to know if you go to pepfar.gov, we have all of our data down to the site level, testing data, treatment data, prevention data, all 55 to 60,000 sites, and we’re tracking that very carefully to look for impact. There have been some sub-recipients that had to be changed because they would not sign the Protecting Life in Global Health Assistance, and those changes have been made. And so we are, last year, we’ve tested I think about almost 80 million people, so we don’t see at the site level those kinds of impacts right now, but we watch for them, we track for them.
So, the services that are provided with the funding that you give you can say they have not been, you haven’t seen?
Currently, they haven’t been impacted. But when there’s a change, there may be, remember, we collect data quarterly, so we may see in a specific site a slight change that is immediately recovered. And that is something that the Secretary has been asking us to track to ensure that it hasn’t impacted these life-saving programs.
Thank you, Ambassador, for being here with us. Just a question about the President’s initiative on eradicating HIV/AIDS domestically, proposing a couple million, $100 million, to fund that while continually proposing budgets that would dramatically decrease the funding overseas. Have you had any response from some of the nations that you work with, what kind of message that sends to them about the importance of treating the disease overseas versus here at home?
Well, let’s make it clear, we have been fully funded throughout the past three years. And I think what the issue you always have to account for, that has actually helped me in communication with governments to talk about how the expectation of this administration is that our programs become more and more impactful with the dollars we have. So, it’s allowed us, and we’ve been on basically a flat budget since 2009. In 2009 I think we had about four to five million people on treatment. We now have 15.7. That doesn’t happen without developing amazing efficiencies and effectiveness. So, that message allows me to talk to governments about how we improve our programming to be more cost-effective. We’re excited about the announcement in the United States because it’s captured press attention again to raise awareness about this ongoing epidemic across the south, and it’s an epidemic in young men of color that are, again, young. Same issue we have globally. And that global-domestic interchange of understanding how we have learned from working overseas and what can be translated domestically and what can be translated domestically to overseas is making both of our programs much more impactful. And so we’re excited about that announcement and the focus, it has been, really brought a laser focus to what we need to do better. That’s the kind of laser focus we bring globally. So, today, we can tell you that our primary problem today as we speak is retaining well people on treatment, because they feel well when they come to the clinic, they are shocked that they have HIV. That’s a lot to process. And sometimes the drugs have side effects, so they don’t want to feel worse on a medication than they did before they knew they had HIV. So, tailoring a program to the well, which is the same we have to do in the south, is helping us both learn about how to reach people between 15 and 25 who feel themselves to be healthy and have no reason to interact with the healthcare delivery system. If we learn that, that will be a fundamental breakthrough both for the United States and globally.
You talked about places that you’re seeing a reduction in new transmissions. Are there any hot spots where you’re seeing an increase that are concerning you? I’m thinking South America, and I know this has come up several times in Venezuela because they can’t get access to medications. And then to follow up on Matt’s question a little bit, my understanding, I know the data is kind of preliminary because the policy is new, but one of the places people are most concerned about the Mexico City rule impacting distribution and treatment is in places like Sub-Saharan Africa, where family planning was more integrated into those clinics. Does that track and does that seem to be something that you’re seeing?
So, excellent series of questions, and thank you for asking that. No, really, because sometimes we get into this tyranny of averages, and so everybody looks good or everybody doesn’t look quite as good, and so it’s really becoming a tale of two different worlds that we live in with HIV. We’ve had governments and communities that have worked together successfully to design programs that are thoughtful and responsive to communities, and that’s where we’ve seen the declines. In many places around the world, epidemics that have been in key populations for the last 30 years have continued unrelented. So, if you look in Russia, if you look in Indonesia, if you look in Jamaica, you will still see very high mortality and high rates of new infection. We have changed our program over the last two years to really invest not only more money but also people to really talk about how we have to invest in communities. You cannot reach these individuals through the same standard practices that you’ve used for the last 16 years because it hasn’t worked, and I think that’s what we really need to learn. The countries that have made progress have continually evolved and adapted and innovated based on who they are serving. They don’t have a program that only serves the 50-year-olds. They have a program that serves a 15-year-old and a 50-year-old. And that is complicated, I know, but countries can do it. And I think that’s what, one take-home message is countries that have evolved and are sensitive between governments and communities are making progress. Countries that have not invested the time in understanding key populations, their unique vulnerabilities, their lack of access, their some cases human rights violations, are not making as much progress. And as a global community, if you go to UNAIDS data 2019, they have a country spreadsheet for every single country, and you can see where mortality, death rate, and HIV and new infections has not changed in the last decade. Those are the countries both the Global Fund and PEPFAR are really focused on to ensure. And I want to be clear, there is not a restriction on family planning. There is a restriction on abortion as a method of family planning. And so family planning is still available through Sub-Saharan Africa and our programs do utilize and that utilize part of that network. And it’s very important, particularly for our young women between 20 and 30. But some of our access to reproductive health commodities has nothing to do with whether it’s there in the clinic, it has to do with the community’s perception of reproductive health commodities. And there’s a perception out there that if you’re in your 20s and you haven’t had a child that you shouldn’t have access to reproductive health commodities because it may cause infertility. So, these are the pieces that we’re working on because it’s a matter of both education and access.
So, are you concerned that this policy may be impacting in a place where it’s needed the most? It seems like clinics that do offer abortion and are integrated with other family planning services are most likely to be in the area with the highest prevalency rates for HIV/AIDS.
Well, first, in most countries of Sub-Saharan Africa except for Mozambique and South Africa, abortion is illegal, so access and policies were basically following the current government’s policy, which we do in PEPFAR all along anyway. So, we function under the laws and the implementation policies that governments have. That’s not to say that we don’t advocate for key populations and for the human rights involved in access to health for key populations, but that is a legal restriction in the majority of countries where we work.
[Lara] Just by way of background, you said the budget’s been flat since 2009. What is your budget line right now?
In 2019 our congressional appropriation I think was about $6 billion. That includes our Global Fund contribution, which is about 1.4 billion at this current time a year.
Okay. And then I’m just curious. Why is it that you think that younger people are not understanding the risk of HIV? If you could talk a little bit more about that. This is an epidemic that’s been decades long, so why do you think that this hasn’t resonated?
I was privileged to work in Sub-Saharan Africa before PEPFAR or before Global Fund, and I think that’s why I am so absolutely committed to getting control of this pandemic with the tools that we have. In Sub-Saharan Africa, when, literally, a third of the adults were dying, it was a very stark reality. Everyone knew someone and it was from all walks of life, so the community was completely in this together. Two years ago, I talked to a minister of health from a country where the prevalence is 22%, so 22% of every adult over 15 to 64 has HIV. And when I said, it is still a problem in your country, he said, what are you talking about? There’s no one dying. And I’m like, well, yes, they’re thriving, but in order to thrive they need to be what we call virally suppressed. They need to take their medicine every single day. And so for a young person that is hitting their age of sexual debut, they never experienced the absolute despair of losing a third of your village, losing your doctors, your nurses, your educators. And so now we’re, it’s in textbooks and it’s in a line with syphilis and gonorrhea, both of which are curable. So, we’ve done that to ourselves. We’ve linked HIV as a sexually transmitted disease with other sexually transmitted diseases for which we have cures and for which you can be serially cured, which you cannot for HIV at the current time. And so I think we have to talk about it in the fact-based way, but we also have to talk, we have a lot of public-private partnerships which we’re so grateful for because marketers come and help us about how to be real with different populations. We’ve had to get very real with men because men believe that they are well no matter what, and so we’ve tried to figure out how do we talk to men in a real way where they understand us. And the same way with young women. And that’s why the DREAMS program seeks out peer educators from within that group and they become the educators to the communities of their peers of the reality of HIV and the reality of being on drugs potentially for life and the consequences of that. And so I think that’s a lot to take in when you’re a 15-year-old, so figuring out what message resonates so that people have the tools to prevent new infections. The tools are there and available. It’s making sure that everyone has the knowledge and awareness, and it can’t be a line in a textbook with syphilis, gonorrhea, and chlamydia.
[Lara] So, what’s your kind of bumper sticker campaign to walking that line of raising education and not scaring the bejesus out of people?
I found with bumper stickers and billboards, not everybody, and particularly adolescents and 20-somethings ignore those, and so we’ve really, in Africa, Facebook is quite real and a lot of young people utilize Facebook, and so we’ve been working with private-sector partners to really increase the messages and the reality of messages on Facebook, not to scare people but to give people the tools to understand how they can protect themselves, and what to do and why they need to be tested, because remember you’re asymptomatic for eight to 10 years, and that means your own health is deteriorating but you’re also passing the virus to others unbeknownst. I mean, no one’s doing this intentionally. It’s really that core message that you can be infected and not know that you have the virus until it’s really very late in the disease. And so this is important to us because the next pandemic we may face may be the same type, so if we figure it out for HIV, these epidemics that have a chronic disease component where you’re well for a significant amount of time and don’t know you’re infected and are still transmitting to others, we need to figure out how to make these diagnoses earlier and how to get people engaged in the healthcare delivery system. Peter Sands, the executive director of Global Fund, just last couple of weeks ago said a lot of countries are interested in, it was at the United Nations Universal Healthcare Coverage. And what he said to us is, we’re the U in UHC. In other words, if we aren’t successful, if we don’t figure out how to reach 15-year-old young women who aren’t pregnant and don’t have a reason to interact with the healthcare delivery system, if we can’t figure out how to reach young men who perceive themselves as going to clinics make them perceived to be weak and somehow sick, if we can’t figure that out, then countries are not going to ever have universal healthcare coverage. So, I think there’s a unique intersection right now between the need that we have to really have young people and people under 35 understand their risk, get tested, get on life-saving treatment, or get the core prevention interventions that we know work so we can have this, we have already created a thriving generation. And I think if you look back in the data, you would have seen that we were going to lose an entire generation, as you stated, in Sub-Saharan Africa. We’ve saved that generation. That generation is in their 30s and 40s. We owe it to the generation behind to figure out how to get messages to them, which will be different than the original messages. And I think sometimes in public health we believe that you just say one thing, and everybody should just understand it. We’ve now learned that we have to tailor messages to individuals to really speak to them. You all know how to do that. That’s why I really wanted to be here today, to figure out how to tailor messages to get people’s awareness.
[Morgan] Don’t be too nice to them. Okay, last question.
Yeah, just a clarification that you seem to have said that you have no increase in budget since 2009. So, isn’t that a financial restrain you are feeling? How are you coping with it, and what is next for you?
I think that’s a great question. I think from the American people, the American people having just invested $85 billion in these three diseases, HIV, TB, and Malaria, and HIV in particular, HIV, TB, and Malaria through our Global Fund contribution, and HIV in particular through PEPFAR, I think when you have that amount of resources from the American people, I always have felt a deep moral obligation to ensure each one of those dollars are spent according to what is the strongest scientific evidence for the biggest impact. So, there’s a lot of things you can do, there’s a lot of nice things to do, and then there’s critical pathway essential pieces. And so what we have done is really focus on the critical pathway essential pieces, and that’s what has gotten us to this place of being able to announce these results in this day and age. So, so far, we have not been restricted because we’ve been able to develop more and more efficiency, do things better year over year. And it gives us the reason, because when we do things better and can reach more people in a flat budget, we launch DREAMS to protect young women. $800 million we’ve invested just over the last few years. It is having a dramatic impact. I couldn’t have told you that three years ago because no one in the world had launched a comprehensive program for young women that was primarily structural. Many people said it couldn’t be done, but we have amazing partners and amazing communities and governments that work with us, and we’re getting it done, and so we don’t let budgets restrict us.
[Morgan] Okay. Thank you.
It’s great to see everyone.