Q&A: Anthony Fauci on PEPFAR

WASHINGTON — The President’s Emergency Plan for AIDS Relief, a partnership between the United States government and African countries, has contributed to a transformation in health systems across the continent.

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, was one of PEPFAR’s key architects. He was also one of the first people involved in the early, perilous days of AIDS research, before anyone could diagnose the cause of the disease that killed everyone it infected.

When President George W. Bush sent him to Africa in 2002 to explore the possibilities of bringing lifesaving drugs and treatment to a continent under siege by an infectious disease, Fauci thought he was being tasked with creating a $500 million program. Eventually, he came back with a $15 billion investment over five years that would be sustained, with bipartisan support, through multiple presidencies.

“It's an extraordinary phenomenon,” Fauci told Devex. “It shows what the goodwill of a nation can do.”

On the 15th anniversary of PEPFAR’s creation, Fauci spoke to Devex about the initiative’s inception, its impact on U.S. global health efforts, and the challenges that lie ahead.

This interview has been edited for length and clarity.

PEPFAR has been significant for the sheer amount of resources that it has committed to the fight against HIV and AIDS. In your view, is there something unique about the initiative that has altered the way the U.S. government engages in global health?

If you look at PEPFAR’s magnitude and historic aspect — as we said when putting the wording together for President Bush's State of the Union address on Jan. 20, 2003, that this is far and away the largest investment in a public health project of any single disease in history — it was really something that completely broke all paradigms.

There were implications of it from a conceptual and symbolic standpoint, in addition to the extraordinary practicality and reality of the lives saved, and the infections prevented, and the people in care. And that was the development of a process that evolved into a partnership between the U.S. government in a bilateral way, with individual countries at various levels of capability of addressing the problem — some that were completely incapable because of lack of funds, and others that were a little bit more prepared.

PEPFAR came in with an unprecedented amount of resources. We started off with $15 billion over five years, and now investment has gone up to $75 billion in the global HIV and AIDS response, which is the largest investment made by any nation to ever address a single disease.

It's evolved into both a lifesaving venue and the establishment of the beginning of a structure within a country, with both capital of people and physical clinics that now can stand as clinics that transcend HIV and go into other diseases. For example, the spinoff of the Pink Ribbon Red Ribbon initiative for cervical cancer, the idea of joining it with vaccination programs in different clinics, the fact that it's trained 250,000 health care workers …

So you know, it started off with the PEPFAR, which was coming to the aid of countries with varying degrees of capabilities, and evolved into a major partnership. Even though AIDS is an emergency in some respects, it's more of a partnership for AIDS relief — if they were going to change the name.

I assume you're not actually announcing a name change at the moment.

No, no, no, no, not at all. There was a lot of discussion between me and Mark [Dybul] and the president and Josh Bolten and Mike Gersen and Gary Edson about what we were going to call it. I remember sitting around in the White House saying, well it's AIDS, and it's relief, and it's a plan, and we're in an emergency. And we kicked it around a bunch of times, and we said, well why don't we just call it the President's Emergency Plan for AIDS Relief.

You were there at the beginning. You were there before the beginning. Can you take me back to what it was like to work on HIV and AIDS before PEPFAR?

I happen to be — and I consider it a great challenge but also a humbling privilege to have been — one of the very, very few people who were there from the first weeks of the recognition of the AIDS epidemic. Well before we called it AIDS, when we used to call it GRID [gay-related immune deficiency] … Those were extraordinary years in my professional and even in my personal life, because it completely consumed me.

I made a decision in the summer 1981, following the publication of the Morbidity and Mortality Weekly Report by the Centers for Disease Control and Prevention about the five patients from Los Angeles who had pneumocystis pneumonia. I thought it was a curiosity, but it bothered me. I remember where I was, what I was doing in my office at the NIH. I thought, “maybe this is some sort of fluke,” some toxic substance that they had that destroyed their immune system. And then a month later, in July of 1981, when the second MMWR came out with 26 people — curiously all gay again, all otherwise previously well, presenting with PCP, as well as Kaposi’s sarcoma, and other [opportunistic infections], I made a decision to change the direction of my career. I decided I was going to start to admit these patients — at the time, all gay men — to our hospital at the NIH and try and study it even before we knew what the etiologic agent was.

The next several years, before I became the director of the institute and before we developed any drugs, these were the really dark years of my medical career, because I had been used to taking care of patients with rare diseases and developing cures ... So I was really on a high. I felt so great that I had been seeing patients who otherwise would have died, and yet they were all doing well. And then AIDS came along, and from 1981 until the time we developed therapy, it was a feeling that … Well, people can't appreciate what it was like when you were trained to be a healer and to make people better, and yet everybody that you took care of ultimately died a terrible death, with very few exceptions.

But it was the hope that we could do something about it that finally led us to get the first drug in 1987. Over the subsequent years, little by little, we got more drugs, and realized you need a combination of drugs. 1996 was the breakthrough year, when we had the combination of antiviral drugs, that all of a sudden completely turned around the death sentence for people who were HIV-infected — then, the median survival was one year from the time they presented.

From then on, we got better and better drugs, to the point now where we completely transform the lives of people who can get drugs.

That's how we get to PEPFAR.

From 1996-2002, it became clear that it was what we were calling the "Lazarus effect.” People were essentially on their way to dying and they were turning around, going back to work, going back to school, going back to productive relationships and families. We were saying, “My god this is nothing short of breathtaking.” And it was at that point that some of us became very cognizant of the fact that the epicenter of the epidemic was in the developing world, particularly sub-Saharan Africa.

In my many trips to Africa, I would note that people did not have the advantage of drugs, because a) they didn't have the drugs as they couldn't pay for them; and b) they didn't have the health systems to deliver the drugs … Simultaneously, President Bush asked me to go to Africa to develop a plan that could bring these lifesaving drugs to people in sub-Saharan Africa.

Partly as a result of PEPFAR's success, the nature of the epidemic — the nature of the emergency — has transformed over the last 15 years. Do you feel that the initiative has managed to adapt and is still adapting at the pace that the HIV and AIDS epidemic is adapting?

Well, you know, it's complicated, and I think a yes or no answer would not do it justice.

There are things that are really difficult to do. It depends on what you want PEPFAR to do. Is PEPFAR adapting to the sense of saving more and more lives? Absolutely. Take a look at the numbers. Will PEPFAR — given the circumstances within which it must operate — as it's currently operating, with no other help, end the AIDS epidemic globally? Not sure about that, for the simple reason that there are pockets of epidemiological groups that are very difficult to access.

There are subsets of people, for example in South Africa, in KwaZulu-Natal, who are drivers of the epidemic: The extraordinary high degree of prevalence in young women of childbearing age and how older men in their 30s infect these women — the women get infected they infect their boyfriends; their boyfriends get older, then they infect the younger woman. It's a vicious cycle. Just the fact that you have PEPFAR and that PEPFAR's there to do its thing isn’t enough.

There are societal and sociological and other behavioral issues that you have to grapple with, with elements that go well beyond PEPFAR. It's cultural change, and you need leadership from the countries involved. You need resources that come from these countries.

I think PEPFAR is doing remarkably well in what it does, but it depends on what you want it to do. I don't think you're going to end the epidemic as we know it — and ending the epidemic means you get below a certain incidence level and that it starts to decelerate essentially on its own. PEPFAR alone is not going to be able to do that unless there's major input from the actual countries themselves, and they take the responsibility. But on the other hand, you're never going to end the AIDS epidemic without PEPFAR.

Mark Dybul, your old protégé, has said that we're at a higher risk of losing control of the HIV epidemic now than at any point since the global response began. That's an alarming thing to hear. Do you agree?

Yeah. Yeah of course. What Mark is really saying is that we are having — and he's correctly concerned about this — a youth bulge.

If you look at the number of people in a population who are the ones who are at risk and susceptible — particularly in certain countries in the developing world, particularly in southern Africa — if you don't continue to decelerate the infection rate in the drivers of the epidemic, you are at a risk of having a rebound. Given the fact that as the years go by, you have a higher relative proportion of younger people of sexually active age, and even though you have all the tools now, you have to really put your foot on the accelerator and continue to access people, get them into prevention programs, get them into circumcision, pre-exposure prophylaxis, and treatment as prevention.

It’s really alarming that you're doing so well and yet you're precipitously close to getting a rebound if you don't really put your foot to the accelerator and keep going. That's the reason Mark is correct. And I and he are right on the same page of saying, there's a lot to talk about, “you're on the 10 yard line.” “We just got to take it over the goal,” or “the last mile” and things like that. Epidemics don't end spontaneously. You got to nail them.

We've seen examples of this with other diseases ... like malaria. There have been regions of the world where you had a high degree of malaria and you brought it down and down and down, and then you inappropriately said, “oh well we got this taken care of, let's move on to something else.” And bingo, two, three, four years later, malaria bounces back in that country.

Infectious diseases are a very specific type of disease, not like cancer or heart disease. It spreads from person to person, and if you don't put the embers out to put the fire out, you go from a forest fire that you sprinkled a lot of water on to get to the embers, and then you walked away and you had another forest fire.

If PEPFAR were to stop adding new people to treatment, do you know how quickly the epidemic would grow?

You'd have to do a mathematical model on that. The only thing I could say with confidence is that it would rebound. I don't know whether it would take two years of four, but it definitely would rebound.

Are you are you concerned about the U.S. government's commitment to this issue given some of the proposals to reduce funding?

Obviously I am a member of the U.S. government, so I've got to be careful what I say, but I've always been known to be quite outspoken. I would be very concerned if the U.S. government decreased their commitment to PEPFAR and the Global Fund [to fight AIDS, malaria and tuberculosis], because it has been such a success story. If  we pull back, I think it would have serious negative consequences for global health and the issue of HIV and AIDS. So, yes, I would be very concerned if we pulled back on our support.

Given that many of the people who read this are going to be PEPFAR's implementing partners and the local health officials who are working on HIV and AIDS — is there anything, in your view, that they should know about what the next 15 years are likely to look like?

When you're implementing something that has a dynamic nature to it, you have to keep pushing it until you nail it down, and the implementers are so important to what we're trying to do.

You can't implement on automatic pilot. You have to keep pushing it — that's really the message.