For half a decade, longtime U.S. health official Deborah Birx, M.D., presided—powerfully and effectively, by broad accounts—over a program known as PEPFAR. That’s the acronym for the U.S. President’s Emergency Plan for AIDS Relief, which was started in 2003 by President George W. Bush with the goal of bringing lifesaving HIV treatment and other tools to the world’s poorest, most AIDS-afflicted countries. Eighteen years and $85 billion later, the program is widely seen as perhaps the most effective U.S. global aid program ever, having saved 20 million lives and trained nearly 300,000 health care workers in more than 50 countries worldwide.
Since Birx assumed leadership of the program in 2014, she was widely seen as an effective and strict taskmaster in keeping PEPFAR on track toward its goals, which have been to eventually get its beneficiary countries to what’s called “90-90-90”—i.e., 90% of people living with HIV in a given country are aware of their status; 90% of people who know about their status are on HIV meds; and 90% of people on HIV meds have an undetectable viral load. Aiming for 90-90-90 has long been a formula seen by experts as one that can effectively end the HIV epidemic in a given nation—including, one might add, the U.S., which is still a long way from those benchmarks.
Birx was widely viewed as a very competent steward of that multi-part effort and was hailed by U.S. global-aid brass and in-country community HIV activists alike. She never hesitated to hold foreign government leaders’ feet to the fire for not doing enough to provide services to their countries’ so-called “key populations” bearing the highest HIV burden: men who have sex with men, transgender people, sex workers, drug users, prisoners, and detainees.
In Tanzania, for example, Birx led from the principle that key populations cannot be well served if they are also the targets of government discrimination and harassment. She consistently pressured government leaders to stop conducting anal exams on men suspected of having sex with other men.
“She was very forceful, very data- and evidence-driven, which put a lot of people under stress, but it paid off,” said Cheikh Traore, M.D., an LGBT activist and independent consultant in Nigeria for various agencies, including PEPFAR. Another activist, speaking anonymously, said, “There were health ministries that wouldn’t attend [their own country’s planning meetings] because they were afraid of her—but she understood that she was the last stop on the line in terms of program quality control.”
Her leadership was so forceful, in fact, that PEPFAR under her was the subject of a U.S. government report finding its approach with participating countries to be “dictatorial” and “autocratic”—claims that Birx then addressed by making the PEPFAR process more inclusive and democratic.
But Then Came COVID
Birx left her PEPFAR post in February 2020—in the middle of intense planning sessions in Johannesburg, no less—to lead then-President Trump’s COVID-19 response team. The outcome was, as is widely known, a typical Trump-fueled disaster out of which Birx, despite what colleagues call decades of impressive public health service, exited with a reputation so battered that she announced she was retiring from government. (She recently took a job as medical adviser for a Texas company that makes air purifiers.)
And despite a new Biden administration in which many key global health jobs have already been filled or even newly created, the top slot at PEPFAR, officially called U.S. Global AIDS Coordinator, remains empty—unnerving both U.S. and PEPFAR-country activists invested in the program’s future.
Although rumors have swirled that the U.S. State Department, which oversees PEPFAR, may name a new coordinator within months—and although acting coordinator Angeli Achrekar, who was No. 2 under Birx and holds a doctoral degree in public health, broadly gets good marks for keeping the program on track—activists wonder what momentum may have been lost in the past year, due to both Birx’s absence and the overwhelming new global health priority of COVID-19.
“What’s been missing without an acting secretary?” wonders Andrew Spieldenner, Ph.D., who advocates for PEPFAR in his role as executive director of MPact Global Action for Gay Men’s Health and Rights. According to Spieldenner, certain PEPFAR countries, including Angola and the Dominican Republic, are defunding efforts for key populations completely as a result of the absence of the direct pressure they once received from Birx.
“The people who are still there [in PEPFAR leadership] are doing the best they can, but this is a moment without leadership,” he said. “PEPFAR isn’t falling apart, but it’s at a critical juncture. HIV is definitely playing second fiddle to COVID right now, which is both understandable and worrisome.”
A representative for the U.S. State Department referred questions about the unfilled role to the White House, because it is a presidential nomination. More broadly, the rep said: “The Department strongly supports PEPFAR’s ongoing efforts, which have saved more than 20 million lives, prevented millions of HIV infections, and significantly strengthened local health systems in 54 countries. Despite the sizable challenges posed by COVID-19, PEPFAR continues to make remarkable progress, including by reaching people living with and most at risk for HIV with critical prevention and treatment services.”
Also worrisome, said Spieldenner, is that PEPFAR’s so-called Country/Regional Operational Plans summit, where PEPFAR leadership hashes out the details of each country’s PEPFAR plan with its in-country stakeholders, was weak this year. Due to COVID, the meeting took place remotely, which did not allow the usual richly informal conversations and breakouts that happen in person, Spieldenner said.
How Will PEPFAR Fit Into New Global Health Priorities?
Then there is the question of what exactly is going to happen to PEPFAR at a time when the Biden administration seems to be retooling its entire global health power map. For example, the admin is creating an office of global COVID response and health security, to be led by Gayle Smith, who led the agency USAID under Obama.
“HIV is not the global pandemic anymore,” said Emily Bass, a longtime global AIDS activist and author of the forthcoming book, To End a Plague, an account of the U.S. fight against AIDS in Africa since 1999, including the history of PEPFAR. “Now there’s a much broader conversation about pandemic response that is framing decisions about how much money is needed and how it should be spent.”
Despite those concerns, Bass said that PEPFAR—at least by its own account—admirably continued to make sure people in recipient countries had access to HIV meds and health care during the still-ongoing COVID-19 pandemic, and that health workers trained with PEPFAR funds ended up proving invaluable in their own countries’ fights against the new pandemic.
“The vacancy [of the top slot] has been read as a signal that PEPFAR hasn’t been functioning,” said Bass, “but programmatically, it really has.”
Traore agrees. “We don’t see the strong leadership right now we saw under Birx”—who, he said, once pressured his home country, Nigeria, to do a countrywide survey to get the best new HIV data possible as a planning tool. “But from the few countries I’ve seen, the program still seems to be running above average.”
Traore said he hopes the program’s next coordinator will be “one who really will be able to bring it down to the community level. The services are still often delivered by very large international NGOs [nongovernmental organizations, which are nonprofits] and rely on existing government health facilities, and we’d like to see smaller community organizations get funding to deliver their own programs. PEPFAR declared that intention three years ago, but we’re not there yet.”
Bass echoed these hopes. “I’d love to see the appointment of somebody who’s a real ally to activists, who reaffirms the commitment to data transparency and to addressing HIV as a global health pandemic,” she said.
In February, Devex, a website for the global development community, explored a list of five people who are regarded as top picks for the job: Charles B. Holmes, M.D., M.P.H., of Georgetown University; Chris Beyrer, M.D., of Johns Hopkins University (who wrote a recent article for Devex on the future of PEPFAR); Shannon Hader, M.D., a deputy executive director of UNAIDS; Paul Farmer, M.D., Ph.D., a longtime global AIDS expert; and Vanessa Kerry, M.D., founder of Seed Global Health and the daughter of former U.S. Secretary of State John Kerry. Like Birx, all five are white; the people and countries served by PEPFAR are overwhelmingly Black.
Also in February, a Kaiser Family Foundation analysis found that “across 46 PEPFAR countries and among six different indicators of progress, the majority (40) has met at least one target, 17 countries have met at least half of the targets, and one country has met five targets. No country has met all targets, and six have not met any target.”