Ambassador Birx on PEPFAR's budget, country ownership, and how to tackle the epidemic

WASHINGTON — The United States President’s Emergency Plan for AIDS Relief celebrates its 15th anniversary this year. While the program has enjoyed broad bipartisan support since it was created, there have been more questions about its future, and funding, during the Trump administration. Helming the organization — which risks budget cuts, and faces an epidemic that may well begin to backslide — is Ambassador Deborah Birx, the U.S. global AIDS coordinator.

Birx is one of the few officials that stayed on from the Obama administration. She has led PEPFAR to a greater focus on data, pushing implementers to find all the efficiencies that they can, and trying to identify where the program must go next in an effort to stay ahead of the epidemic.

Last fall the program unveiled a new strategy, one that was met with some skepticism, with questions on whether it was driven by needs, or by a skinny budget allocation. The strategy, which chose to focus on 13 countries, left many wondering what would happen in the other nearly 50 countries in which PEPFAR works, and what might be sacrificed.

Ambassador Birx sat down with Devex to discuss budget constraints, the new strategy, efficiencies, and how PEPFAR is increasing country ownership as the program looks ahead to tackling the challenges ahead.

The budget

While many PEPFAR advocates have criticized the Trump administration’s proposed budget cuts to PEPFAR, Birx looks at it a bit differently.

“Our job as program managers is to take the dollars that we have and make the best use of them,” she said. “I think the president's budget to foreign assistance in general is really a wakeup call to all of us to look precisely where our dollars are going and what we're achieving,” she said.

If Donald Trump didn’t want the program to continue, he would have eliminated its budget, so Birx interpreted the cuts as pushing the program to do better due diligence to ensure each taxpayer dollar is spent as effectively as possible — from headquarters down to local clinics.

PEPFAR’s new strategy focuses on 13 countries, which has led to questions from some experts on what will happen to the rest. But because Congress has held PEPFAR funding level with last year, funding from country to country is unlikely to change much this year, Birx said.

But the conversation about progress and success of PEPFAR shouldn’t be all about budgets and funding, she said.

“What has made the biggest difference over the last four years in the performance of the program are the policy shifts that the countries have undertaken to make our dollars, their dollars, and The Global Fund dollars more successful,” she said.

Moreover, PEPFAR has been able to double the number of people on treatment, triple the number of circumcisions, launch a new program accelerating children’s treatment, and start one targeting adolescent girls — all with a flat budget, she said. The money for those programs came from improvements in data collection and how it was used, allowing PEPFAR to create “greater and greater impact for the dollars we had,” she said.

And how PEPFAR tracks data has changed — it’s no longer about counting the number of people tested, it’s more about outcomes.

Birx called the proposed cuts helpful in pushing PEPFAR to make the right choices and to spend on things that will have great, rather than just good outcomes. Congress has been a strong supporter of PEPFAR, even when previous administrations tried to cut spending, Congress rejected it. It’s not as if these issues, or this back and forth on budget are new, Birx said.

“I think that kind of constraint allows us to be tough on ourselves in a different way than you can be when your budget is always going up,” she said. “We always default to more resources instead of really asking the hard things because then it's change and change is hard because you have to give up something to do the thing that's better. That is very hard to do.”

Some implementers have told Devex, however, that they have found all the efficiencies that they can and that at some point, with further budgetary pressure, won’t be able to serve everyone in need, and the epidemic will start to slide in the wrong direction.

“We will always be attentive to the president's budget and what he thinks we should have and utilizing that money in the best way, and always being very clear about [how] any additional resources would be utilized,” Birx said.

And there are needs — accelerating the DREAMS program to more districts, doing more work with community health workers, and continuing to lead efforts to create better systems, she added.

More efficiencies

Despite the progress PEPFAR has made, Birx said there are still efficiencies to be gained, particularly in building more efficient supply chains.

“I think we still have a supply chain that we planned for the 20th century and I think we need a supply chain for the 21st century — and really what that means, and what that looks like, and how we use blockchain, and how we use these new technologies,” she said.

Birx has been spending time thinking about this challenge, particularly as the Global Health Supply Chain Procurement and Supply Management contract has faced major challenges. What is unclear is whether the contract brought in the new technology and approaches necessary for such a large contract, and that is something that is being examined, she said.

That process has been a wakeup call, with PEPFAR learning that clients haven’t been getting a three-month drug supply, not because clinicians and nurses aren’t trying, but because they are worried that they will run out of the medications and are trying to ensure that no individual lacks what they need.

“The fact that we found out about that during this discussion, we should have known about that 12 months ago,” she said. “So that's what it is helping us see it's helping us see into the places where we thought things were OK.”

PEPFAR, she said, has inserted itself into the process, not because others weren’t doing their job but because the supply chain challenges are “what keeps us up at night” and critical to the program’s ability to continue its legacy in supporting health systems.

Supply chains are one example, but as PEPFAR continues to look for efficiencies and deliver its programs, PEPFAR can’t lose sight of the fact that it must continue to “step back and always ask ourselves what are we missing,” Birx said.

Today’s challenges

There is a lengthy list of challenges in tackling the epidemic today — from a demographic shift to policy barriers, to successes making it more difficult to reach those who are yet undiagnosed or untreated, Birx said.

“We have to find the people who don’t think they’re at risk of HIV — and are at greater risk — and maybe 22 years old and don’t see themselves in the healthcare delivery system. So there's challenges all the time,” Birx said.

As PEPFAR continues to gather data through its operations and surveys, it continues to identify new challenges, which leads to a balancing act in how it invests its resources, she said.

In West and West Central Africa, particularly in Nigeria, the obstacles have been different. The HIV prevalence rates are relatively low at about 2 percent of the population, so there is a different social awareness and different issues around stigma and discrimination. In those places it’s particularly important to figure out what’s needed on a community-by-community level to ensure that resources are going where they’re needed, Birx said.

Progress in the region has been slower than in other parts of the continent and some of the key questions are around public policy and public fees or informal fees collected at different stages of the healthcare delivery system. While access to testing and antiretroviral therapy provided through PEPFAR may be free, getting blood drawn might cost money, which puts a burden on those living in poverty and can prevent them from getting the treatment they need. And as a result, PEPFAR is not making the same progress there for the dollars they spend as elsewhere.

By contrast, Eastern and Southern Africa removed fees over the last two decades, and the gains in epidemic control have been clear, Birx said. More recent tests in West Africa showed changing policy could make a difference there too. In some states of Nigeria, which has posed a particular challenge, when some states got rid of antenatal care fees for a year there was a dramatic improvement in women accessing care, she said.

There are also countries that have concentrated epidemics among key populations that are often the most marginalized and vulnerable that are critical to success, Birx said.

“We won’t have succeeded as a community if those epidemics remain unchanged despite the progress we've made. It's a little bit like missing the children,” she said.

Birx refers to the idea that epidemics can’t be controlled without reaching children, and particularly adolescent girls, which is why the 90-90-90 UNAIDS goals require getting 90 percent of people living with HIV to know their status, 90 percent who know their status accessing treatment, and 90 percent of people on treatment having suppressed viral loads, across every age band.

“We know you can’t get to 90-90-90 without getting all of the children. But that's why we said you have to get to 90-90-90 for every age, band every gender and every risk group, and we mean that for the epidemics that are smaller in number but just as serious in the impact that they're having to whole communities,” she said. “I think that's the question for the global community over the next five years.”

Birx is all about asking questions about what it will take and why progress hasn’t been made; And she’s a bit of a data evangelist. While PEPFAR uses data on a weekly, monthly and quarterly basis to track progress and learn about its programs, Birx said she’d like to be hourly, but there have to be some limits.

This fall, PEPFAR will convene all of its star countries that have what they call “concentrated epidemics” to figure out how to tackle the issues, especially in contexts where the country may be getting the investment it needs to attack the epidemic but it’s not reaching those in need. PEPFAR has hosted other convenings to address critical issues, for example, when the former president and health minister of South Africa denied that HIV causes AIDS.

If there isn’t political will, then the international community has to figure out if there’s a different way to work with indigenous organizations to try to pressure governments, she said. If governments are unwilling to support certain marginalized populations, PEPFAR must work with local organizations to reach them, she added.

Country ownership

While PEPFAR programming used to be dictated largely by decision-making by the program itself, country governments and community organizations are increasingly involved in the country operational plan process, leading to better ownership, Birx said.

In PEPFAR’s early days country governments were given two days to review the country operational plan, rather than helping to decide its direction. But now PEPFAR doesn’t plan anything without the government or the community, she said.

The country planning process this year was the most successful planning meeting PEPFAR has had Birx said, adding that she had been nervous about it because it increased community and government engagement.

“We had the most detailed and robust planning with real substantive input from communities,” Birx said. And increasingly PEPFAR is looking to deliver its programs through indigenous organizations, with a goal of getting to 40 percent this year, and to 70 percent by the end of 2019, she added.

“So do I think there's more country ownership. Absolutely. But it's owned by the country, not just the government. It's owned by the communities that we're serving. And the government. And that's true country ownership,” Birx said.