Nkengasong's vision for PEPFAR in an 'era of multiple pandemics'

Shortly after the World Health Organization announced its classification of monkeypox as a public health emergency of international concern last month, Dr. John Nkengasong, the newly appointed leader of the U.S. President’s Emergency Plan for AIDS Relief — or PEPFAR — encouraged using the initiative as a “platform” to assist with the monkeypox response.

“I urge all governments to work together with affected communities and international stakeholders to remain vigilant and design response efforts to protect all populations in need building on resources developed in the fight against HIV/AIDS,” he said in a statement.

That message reflects a significant evolution in PEPFAR’s strategy as it nears its 20th anniversary, and as other emerging infectious diseases threaten to undermine the fight against HIV. Managing that evolution will be a central challenge for Nkengasong, who was sworn in as U.S. global AIDS coordinator in May after serving as the first director of the Africa Centres for Disease Control.

At the International AIDS Conference in Montreal this month, Nkengasong described the balancing act PEPFAR has to perform.

The initiative was created by President George W. Bush in 2003 when treatment for HIV/AIDS was largely unavailable in Africa. The initiative has saved roughly 21 million lives, according to its own estimates.

Today, PEPFAR must keep global targets for ending the HIV epidemic by 2030 front and center. At the same time, in many countries, PEPFAR’s capabilities are critical for containing other disease outbreaks — which are often particularly dangerous for people living with HIV.

Through PEPFAR, the U.S. government has invested more than $100 billion in laboratory systems and networks, disease surveillance, health supply chains, health workforces, and information systems in more than 50 countries.

“If you have a monkeypox outbreak or a massive cholera outbreak, the best way to support the country that you're in is to … leverage some of those assets to respond to that disease outbreak,” Nkengasong told Devex during the conference.

Right now, with monkeypox not yet widely spread in countries where PEPFAR operates, the critical need is for surveillance, Nkengasong said.

“That doesn't require extraordinary new resources to do. It requires that we intentionally apply the assets that PEPFAR has in place,” he said.

PEPFAR’s supporters often point to how the initiative strengthens health systems in the countries where it operates in ways that improve their ability to tackle challenges other than HIV.

With the COVID-19 pandemic and now monkeypox, that pivot from one infectious disease to another has been more explicit.

Nkengasong said those decisions to leverage PEPFAR’s resources for other diseases are a reflection of the fact that health workers cannot deliver appropriate HIV services when communities are overwhelmed by other outbreaks.

“We have to recognize that we are in an era of multiple pandemics,” he said. “Until you get that outbreak out of your way you cannot do HIV work. That is not on people's minds.”

“PEPFAR was reauthorized [in 2018] for a specific purpose: to fight HIV. That's why ... I keep talking about reimagining PEPFAR, not a new PEPFAR, but reimagining our strategy to respond to HIV so that we can get to the 2030 goals — at the same time being aware that there are significant threats around HIV significant posed by other emerging infections that can erode the gains that we've had,” he said.

While PEPFAR has a large global footprint, its programs are still concentrated in countries with significant HIV epidemics. Asked if that means the U.S. government should consider expanding the number of countries PEPFAR works in to give it greater coverage of other potential disease outbreaks, Nkengasong responded that this is why partnership with other organizations is important.

“The penetration of Global Fund [to Fight AIDS, Tuberculosis, and Malaria] exceeds the 55 countries that PEPFAR is working in. So if we synergize efforts between PEPFAR and the Global Fund and others, I think that gives us the reach that we need,” he said.

In addition, through his work at Africa CDC, Nkengasong pushed for a regional approach to pandemic preparedness and response that he says can help fill some of the gaps between countries with variable capabilities.

For example, in West Africa, Ghana, Senegal, Côte d’Ivoire, and Nigeria all have effective biomedical research facilities, while Gambia does not.

“The intent there was that the Africa CDC, as a regional instrument recognized by the heads of state, can support them to work in a network,” he said. “That way, if a country like Niger or another country that doesn't have that same capacity sees something happening, they can rally around very quickly and support that country and detect it early and squash it,” he said.

Since the early months of the COVID-19 pandemic, U.S. government officials have debated the best way to organize global health agencies and initiatives so they are better positioned to stop outbreaks from spreading and respond to those that do.

Nkengasong’s view is that those tools already exist.

“The best way to prepare for the unknown is to invest massively in the knowns,” he said. “The known that we have is HIV.”