Since its establishment in 2003, the US President’s Emergency Plan for AIDS Relief (PEPFAR) has saved over 25 million lives and drastically reduced HIV infection rates through antiretroviral treatments. Now well established as the leading global funder of HIV prevention efforts, PEPFAR is supporting high HIV burden countries to meet the UNAIDS 95-95-95 targets by 2025 and aiming to end HIV as a public health threat by 2030. In conversation with PharmaBoardroom, PEPFAR's Dr Emily Kainne Dokubo emphasises the significance of partnerships in achieving PEPFAR’s mission - extending PEPFAR's reach and improving health systems globally - and how it is working to address paediatric HIV disparities, given children still remain disproportionately affected by HIV/AIDS.
Could you give us a brief overview of your career trajectory and the scope of your role at PEPFAR?
I am a physician and an epidemiologist by training and previously served as the US Centers for Disease Control and Prevention (CDC) director in Cameroon and in the Caribbean region. Throughout my career, I have had a focus on global health, primarily around addressing the HIV and tuberculosis (TB) pandemics through both clinical practice and research.
I currently serve under Ambassador Dr John Nkengasong as the Deputy US Global AIDS Coordinator for Program Quality for the US President’s Emergency Plan for AIDS Relief (PEPFAR) within the Bureau of Global Health Security and Diplomacy at the US Department of State. My office provides technical expertise for the implementation of PEPFAR-supported HIV prevention and treatment programs in over 55 countries. We help those countries reduce new HIV infections and provide quality care and treatment services to achieve the [UNAIDS] 95-95-95 targets: [95 percent of people living with HIV to know their HIV status, 95 percent of all people diagnosed with HIV infection to receive sustained antiretroviral therapy, and 95 percent of all people receiving antiretroviral therapy to achieve viral suppression].
What have been PEPFAR’s biggest impacts on the battle against HIV in the two decades since its foundation?
At the start of the HIV pandemic over 40 years ago there were rising new infections, ongoing transmission, and high morbidity and mortality, especially on the African continent due to limited access to prevention and treatment options. In response, during his 2003 State of the Union Address, then-US President George W Bush announced the establishment of PEPFAR, saying, “seldom has history offered a greater opportunity to do so much for so many.” PEPFAR has lived up to that commitment.
In the 21 years since its establishment, PEPFAR’s interventions have led to a rapid scale-up of highly effective antiretroviral treatments and prevention options, which have saved over 25 million lives. Moreover, thanks to PEPFAR support, almost 21 million people were on life-saving antiretroviral treatments as of the end of last year and over 5.5 million babies have been born free of HIV to mothers who were living with the disease. Finally, PEPFAR has also helped to strengthen health systems in the countries where it operates.
What will PEPFAR’s priorities be over the next five and a half years as the entire HIV community works towards the very ambitious UNAIDS targets of ending HIV as a public health threat by 2030?
PEPFAR has already helped to change the trajectory of the HIV pandemic over the past two decades. The data bears out that all-cause mortality has been lowered by a greater margin in PEPFAR-supported countries than in non-PEPFAR supported countries. In the short term – by 2025 – we want to support as many high HIV burden countries as possible achieve the 95-95-95 targets. This is beneficial not just for an individual’s own health but is also a public health measure for reducing HIV transmission.
HIV in addition to being a national and global health security threat is also an economic threat. That is why we are continuing to work to improve health systems in the countries we support. We have already made a big impact through the implementation of disease surveillance systems, for example. These surveillance systems can detect and respond to other diseases, such as COVID-19, mpox, and cholera. Additionally, PEPFAR-supported training programs have strengthened health workers’ ability to respond to new infectious disease threats. Finally, our work to establish national public health institutes has been a major factor in strengthening national health systems.
How does PEPFAR choose the countries on which it focuses its efforts?
One hallmark of PEPFAR is its data-driven approach. We work with host governments to support their response efforts in places with the highest disease burden. At the start of PEPFAR, this was predominantly in sub-Saharan Africa, where we still support a lot of countries, but we also work in Asia, the Caribbean, and South and Central America. PEPFAR, as part of the Bureau of Global Health Security and Diplomacy within the US Department of State, has a truly global reach and extends beyond HIV to support responses to other disease threats.
How does the fact that PEPFAR’s funding has recently only been secured for one year instead of the usual five affect its operations and long-term planning?
Since its establishment, PEPFAR has always counted on bipartisan support. Eleven congresses and four presidents have given their support to this lifesaving program, which we are pleased to see continue with PEPFAR’s recent reauthorisation.
We look forward to working with Congress on a clean, five-year reauthorisation which would demonstrate the US government’s longstanding commitment to end HIV/AIDS as a public health threat by 2030. This would allow us to plan for the longer term and continue to provide quality HIV prevention, care, and treatment services. A five-year reauthorisation would allow for improved planning so that our vital programs can be fully established, monitored, and evaluated.
How is PEPFAR adjusting its approach to ensure that more people can benefit from the HIV prevention and treatment solutions it helps provide?
One of the benefits of PEPFAR is that we have a clear mandate. We remain focused on the program’s founding mission and are still just as committed to serving all communities that we work with without discrimination. This is especially true for those key and priority populations that are at increased risk of HIV acquisition.
Reaching those underserved key populations is critical for advancing our global HIV/AIDS response. To do so, in potentially challenging environments, we are strengthening our support by accelerating person-centred care and differentiated HIV services. Knowing that a one-size-fits-all approach will not work for all individuals, we are intensifying our efforts to provide care to those who need it, when they need it, and in the most effective way for them to receive it.
PEPFAR is the major funder of HIV prevention efforts, but how important are partnerships with other stakeholders in carrying out its mission?
Extremely. This is a huge effort that cannot be achieved by any single entity. The partnerships that we have formed are one of our key strengths. This includes partnerships with other departments and agencies within the US government; multilateral organisations such as WHO, UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and UNICEF; and private entities.
One success story from our public-private partnerships is the development and introduction of new long-acting options to prevent HIV infection among high-risk populations. Over the past three months, PEPFAR has begun to roll out a long-acting pre-exposure prophylaxis (PrEP) for HIV – in addition to the already-initiated oral PrEP. Long-acting injectables are administered every two months and are a safe and highly effective prevention medication for people at high risk of infection.
We will continue to seek more of these partnerships to advance our work and long-term sustainability to 2030 and beyond.
The pharmaceutical industry tends to launch new treatments in developed Western markets at a high price to recoup their R&D investments before they are later brought to places like Africa at a lower price or as a generic. HIV necessitates a different approach, so how do you go about engaging pharma to rapidly bring new products to the patients that need them most?
The beauty of PEPFAR’s partnerships is that we have been able to engage in good faith. We have been fortunate that many of our partners understand the importance of our mission.
In many of the places where we work, governments have limited ability to provide treatment to their populations on their own. Therefore, PEPFAR, by purchasing HIV-related commodities, brings in the volume and guarantees our pharmaceutical partners that we will procure to supply to those countries.
For example, PEPFAR is rolling out the limited available doses of long-acting PrEP, and we plan to deliver doses to more countries soon. This means that PEPFAR is helping to support the R&D of innovative therapeutics through our rapid scale-up of long-acting prevention tools, along with some of our other innovative strategies. This has the potential to accelerate the downward trajectory of new HIV infections globally.
Even without a vaccine, we already have the prevention and treatment tools at our disposal to achieve the 2030 goals, However, the difficulty lies in access and delivery. What do you see as the key gaps to getting these treatments to an even wider swathe of the population that needs them?
Having the right systems in place is crucial to the sustainability of HIV programs and ensuring the quality of HIV service provision. Commodities do not deliver themselves. That is why PEPFAR is also focused on health system strengthening: PEPFAR support has helped train over 346,000 health workers and we also help bolster sample delivery systems, drug delivery systems, delivery to remote communities, and third-party logistics.
Reaching clients where they are is also key. Every individual has a personal preference for receiving care: some want to come into health facilities, others prefer to receive care in the community, while others may want to receive care at their place of work. We also must consider stigma and discrimination, which is prevalent in many countries where we work and even here in the United States. Some people may not want others to know their HIV status, which we must factor into our programming.
One of the groups most disproportionately affected by HIV/AIDS is children. In 2020, children accounted for 15 percent of all AIDS-related deaths despite being just five percent of the total population living with HIV; 46 percent of the world’s 1.7 million children living with HIV were not on treatment compared to 74 percent of adults; and over 1/3 of children born to HIV-positive mothers were not tested for HIV. What initiatives is PEPFAR undertaking to address this disparity?
In our programming, we have supported many countries to achieve the UNAIDS 95-95-95 HIV testing, treatment, and viral suppression targets, with many others now close to achieving them. Much of that success reflects service uptake among adults and has not necessarily been replicated among children or adolescents.
While our data shows that PEPFAR has significantly reduced paediatric HIV incidence and AIDS-related deaths since its inception, there is still a lot of work to be done. Modelling studies have shown that without PEPFAR intervention, more children will be infected with HIV by 2030 and more will die. Therefore, PEPFAR has rolled out targeted interventions for those paediatric populations, scaled up early infant diagnosis, and increased pre- and post-natal care for pregnant women. At prenatal care visits, expectant mothers are tested for HIV and if they are positive, they are put on antiretroviral treatment to reduce the risk of transmission during pregnancy and through breastfeeding.
Additionally, we also ensure that women who are HIV positive are on treatment and inform them that, if they stay on treatments, their viral load will be suppressed and there is very little likelihood of transmission to their child. This is the concept of ‘Undetectable=Untransmissable’ (U=U).
Thirdly, we are now seeing higher incidence among adolescents, who were born after the start of the HIV/AIDS pandemic. Because of their age, they were not exposed to the devastation of HIV before the advent of safe and effective treatment and prevention and the various awareness campaigns. To combat this, PEPFAR has recently launched a $20 million Youth Initiative to increase awareness of HIV, educate youth on how to prevent acquisition of infection and, for those who are positive, on how to stay on treatment for their own health and to prevent transmission to their partners.
It is vital for PEPFAR to ensure that this younger generation has the tools they need, are empowered to manage their own health, and can take on leadership roles to stay healthy, educate their peers, and prevent further HIV infections. The way that young people today receive information is quite different from that of previous generations, meaning we must be very deliberate in terms of tailoring our message to them.
Do you have a final message for our international industry-focused audience?
PEPFAR is the largest investment by any government to address a single disease in the history of global public health. Our programs have helped change the pandemic’s trajectory from a death sentence to a manageable chronic disease. Millions of lives have been saved, millions of people are on treatment, and millions of babies have been born HIV-free. We have achieved a lot, but there is still work to do.
Globally, there are approximately 1.5 million new HIV infections annually, and 600,000 people die from HIV-related complications every year. This is therefore not the time for us to be complacent or take our foot off the pedal. Efforts are needed to continue to identify undiagnosed persons living with HIV, get them on treatment, support them to remain on treatment for their own health and to reduce the risk of transmission to their partners, and prevent new HIV infections.
Additionally, as people with HIV live longer, other comorbidities need to be addressed to continue to improve their health outcomes. PEPFAR, therefore, remains committed to working to end HIV/AIDS as a public health threat by 2030 and welcomes partnerships with both public and private organisations to achieve this goal.
