In the last article, I wrote about an announcement made at the 2019 State of the Union speech on a plan to end the HIV epidemic in the US. I was experiencing De Ja Vu. Something very similar had happened before, but far more serious and consequential.
In the 2003 State of the Union, President George W. Bush announced the creation of the PEPFAR program, a global initiative to assist developing countries with very limited resources gain access to HIV treatment. PEPFAR is the President’s Emergency Plan For AIDS Relief. So let’s put things in context.
On the eve of declaring war against Iraq with bogus justification, their administration perhaps felt there needed to be some kind of humanitarian initiative to balance things out. The Iraq war was an absolute nightmare (which many of us predicted) and we have paid dearly for it. While I have no fondness for the Bush administration, I have to give credit where it is due.
Whether or not the Bush Administration had an ulterior motive, the PEPFAR program helped change the trajectory of the AIDS epidemic in Sub-Saharan Africa and Southeast Asia.
Now, 16 years later, this program is one of the reasons we have 19 million people receiving HIV medicines throughout the world. This program has literally saved millions of lives. It is pretty emotional watching President Bush announce the initiative (please watch! https://www.youtube.com/watch?v=n75rfrHWawo).
The President makes this announcement 6 years after we had started using combination drugs that could totally suppress the virus. But in sub-Saharan Africa in 2003, of the 30 million people estimated to be infected, only 50,000 people had access to these treatments; just 50,000! There were literally communities in Africa where most adults had died and only children and the elderly remained.
PEPFAR was clearly more than just talk. The Bush Administration committed funds to the program to the tune of 15 billion dollars for the first 5 years. The US has contributed well over 70 billion dollars through the first 15 years. But in the early years, the situation for providing HIV medicines to low-income countries was a complicated one.
There were drug manufacturers prepared to produce generic HIV medicines at a low cost that developing countries in Africa, Asia, and Latin America could afford. However, the Pharmaceutical companies still had patent protection over their products and were unwilling to negotiate these patents to allow affordable drugs to be produced.
The Pharmaceutical companies were clearly the villains, willing to let millions of people die instead of allowing affordable versions of their medicines to be produced.
While we are talking about US Presidents, one other President must be mentioned. The Clinton Health Access Initiatives under the Clinton Foundation has played an incredibly important role in the global HIV epidemic. One of their major accomplishments was to negotiate the prices of HIV drugs to a level that made them affordable for low-income countries.
Without these interventions, many countries would have difficulty in treating patients with HIV disease. The Clinton Health Access Initiative works tirelessly to expand treatment and improve care for people in Resource-limited settings.
Over the decades, HIV drugs have gotten better and better. They have gotten stronger, safer and easier to take. Unfortunately, the drugs that became available early on through programs like PEPFAR were not the best drugs, but the worst ones. They were the drugs we weren’t using a lot in the US and Europe.
These included drugs like zidovudine (AZT), didanosine (ddI), stavudine (d4T), Viramune (nevirapine) and Kaletra. These drugs required multiple doses a day, had side-effects, and even some serious toxicities. But they worked!
Even having access to these not so good drugs was life-saving. Some of the more toxic drugs have slowly been phased out and now, even premium drugs like dolutegravir are available in many countries.
So the actions of Presidents Bush and Clinton have been unparalleled in changing the dynamic of the epidemic, literally saving millions of lives and giving people hope throughout the world.
President Obama carried the baton, protecting President Bush’s PEPFAR legacy and expanding its support. He also expanded support to domestic programs like the Ryan White Care Act and the AIDS Drug Assistance Program.
In contrast, the Trump Administration has not really embraced PEPFAR or any of the domestic HIV programs, and that is perhaps one of the reasons people were left scratching their heads when he announced the end of AIDS in the US at the State of the Union speech a few months ago.
Trump’s threatened cuts to the budget of the US Agency for International Development (USAID) and other agencies would devastate PEPFAR and put millions of people’s lives in jeopardy. Fortunately, that hasn’t happened yet. Let’s pray that it doesn’t.
When I first heard about the PEPFAR program, I was intensely curious. Is this for real? Can it really rescue AIDS patients in Africa with no other source of help?
The more I heard about it, the more I wanted to be part of it. I felt that my years of experience with HIV treatment and patient management could help my African brothers and sisters battle the epidemic but wasn’t exactly sure how that could be done.
Finally, my opportunity came when I took a position to head up research for the PEPFAR program under the Walter Reed Army Institute of Research. Not only did I develop and direct clinical and operational research with PEPFAR, but I also had to help build the infrastructure for research in African clinic and laboratory facilities.
I also developed programs to evaluate the quality of medical care and did training in HIV treatment and management for my medical colleagues. It gave me an opportunity to work with African physicians, nurses, pharmacists, lab technicians, research scientists. I understood the challenges of providing care in settings where resources are severely limited.
I learned how to get the most bang for the buck and help the most people with the dollars we had. I saw some parallels between the African patients and the patients from the clinics where I worked in underserved communities in Washington D.C. and Baltimore, Maryland.
It was an amazingly fulfilling experience and one of the highlights of my career. Let me just say as enthusiastically as I know how, that the PEPFAR program is a God-send, a true global health triumph!
Dr. Crawford has over 25 years of experience in the treatment of HIV. While at Howard University School of Medicine, he worked in two HIV-specialty clinics at Howard University Hospital. He then did clinical research as a visiting scientist with the AIDS Clinical Trials Group (ACTG) at Johns Hopkins University School of Medicine. He served as the Assistant Chief of Public Health Research with the Military HIV Research Program where he managed research studies under the President’s Emergency Plan for AID Relief (PEPFAR) in four African countries.
He is currently working in the Division of AIDS in the National Institutes of Health. He has published research in the leading infectious diseases journals and serves on the Editorial Board of the journal AIDS. Any views and perspectives in his articles on blackdoctor.com are not representative of any agency or organization but a reflection of his personal views.
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