Q&A with Ambassador Deborah Birx: 'This White House is very responsive to data'

While the top-line budget has been released by President Donald Trump’s administration, questions remain around how various foreign aid programs will fare. The budget stated that it “provides sufficient resources to maintain current commitments and all current patient levels on HIV/AIDS treatment under the President’s Emergency Plan for AIDS Relief,” but what exactly that means for funding levels is still up in the air. There are uncertainties about how funding and the reinstated “global gag rule,” could affect PEPFAR, which gets the majority of U.S. global health funding, and broader global health challenges. From the few data points available so far, there are already things PEPFAR implementers should know now as they prepare. Crucially, the agency will rely on the U.S. Agency for International Development’s expertise, and most of PEPFAR’s programs are already in compliance. Devex sat down with Ambassador Deborah Birx, the U.S. global aids coordinator, before the budget was released, to discuss the impacts of the reinstated global gag rule (also called the Mexico City policy), what PEPFAR implementers need to know about future priorities and the agency’s focus on prevention among girls. The interview has been edited for length and clarity. How will the global gag rule executive order impact PEPFAR? We don’t know precisely. We know last time during its implementation many of the partners signed the clause and continued to implement. We won't know until we start to implement whether it’s going to have any impact or not. Because we have data, we'll know precisely where the impact is. I think there’s a lot of flexibility to ensure that critical services are delivered, to give you transition time between partners. And PEPFAR is a very different place than we were when it was exempted [under the George W. Bush administration] because we have very mature partners. So we need to just start implementing so we can see who is it impacting, who do we have to move around. We have a real large partner base highly trained in implementation that could move and substitute for partners who feel like they can't sign [on to the policy]. Really at the time that this happened before, the Europeans stepped up and did more in health. They have not been as visible in health, so I really think it provides opportunities for individuals and countries that want to support health issues. I'm ex-military, so I look at this as how we need to execute the mission, and we have to figure out how to do it. When PEPFAR started, I think there was a legitimate reason to exempt the program [from the global gag rule]. But we have trained hundreds of thousands of people and thousands of partners. We know at every site how we've been doing at [Prevention of Mother-to-Child Transmission], who we've been testing, are less people coming, are more people coming. That’s really the fundamental issue. In many of these countries — except for two where we work — abortion except in the case of rape or incest or the mother's health is illegal. So except for Mozambique and South Africa. In every country we work under the government's strategy, and in the majority of these countries, the Mexico City policy is the government's policy. Programs that focused on abstinence have often fallen short in serving the vulnerable population of teenage girls, will there be a return to those policies? There are two sides to that story now. One is that the abstinence and be faithful programs didn’t have the data that we have today. If you look at Zimbabwe, Zambia and Malawi, the prevalence in young women is quite steady all the way up to 20. That means the risk and the risk avoidance that the girls have practiced has actually been quite effective. But that’s a group of girls, and what the DREAMS partnership has really sought to do is define who are the most at-risk girls within that group of girls, and what are we doing structurally to meet their needs. We need to go to the very core of those programs, and I think what you'll see hopefully over the next year is a real risk avoidance and sexual violence prevention program for 9 to 14 year olds that is really going to be one of our focuses. Because at DREAMS we started with, what are we doing for post-rape care and the vulnerability of those girls. This is going back and saying why aren't we just preventing this. I think there's a real understanding that we're at a different place from where the abstinence, be faithful programs were, so I think we'll see us talking about risk avoidance for the very young girls and that includes gender based sexual violence prevention. You have to understand population, location and age of risk so that you can prevent it. I think we're getting much more granular in understanding each of the different age bands of young girls and what we need to do to prevent both HIV infection as well as sexual violence. Budget projections floated so far has included major cuts to foreign aid. What have you heard about PEPFAR’s budget? We haven't seen the specifics, but what I will tell you is we often talk about how much more we have done on a flat budget. Because we have. Our budget's been flat since 2009. And I think it's our challenge, that we should accept: how do we look at every single piece of the program and decide where we're having the greatest impact. We're lucky we have comprehensive data now, so if there are budget cuts, we will be able to make them in the areas that won't impact our ability to control this epidemic. And that's our job. That's our job as Americans at a time when there's a need to free up resources, to really focus ourselves and use our data to do more with less. I haven't had any discussion that said, if I show that I have the most efficient program possible and this is what I truly need to control the epidemic, that we won't have those resources that we need. I feel a real moral obligation to make sure that every dollar that we're given is having the maximum impact, because we want to do two things: we want to save lives, we want to change the course of the pandemic, and resources are always limited. We have to be honest with ourselves of where we're really coming from and what we've been able to do and how we can do better. I think it's our job as senior managers to come up with a plan, no matter what our budget is, to really have it focused in a maximum way to have the greatest impact. What advice do you have for PEPFAR implementers? USAID has a lot of experience in implementing the Mexico City policy, and I think we are really being guided by their real experience on the ground and the White House's understanding of what we should be doing. I think those two come together in a place where we will utilize how USAID has implemented in the past through all of our groups. Remember this applies to NGOs. A lot of our funding goes to governments, so you know we may be in a different place than [those who work in] family planning. Much of our funding goes through government or public sector groups. So we're already in compliance. What you're asking is how hard is it going to be to achieve compliance, and I won't know until we start to do it, because you never know where the issues are going to arise until you start to roll it out. We have an umbrella of knowledge and data where we can really ask and answer the questions that you just posed. Does it have an impact on certain age groups and access? Does it have and has it had an impact on testing? Has it had an impact on treatment? What's happening to our incident rates? We'll be a group that can really answer. We don't foresee that those issues will arise. I think this White House is very responsive to data. So is your call to action to use more data? If you don't have data down to the site level, you cannot find where the inefficiencies are. We need more visualization of the data that we have, because I think it’s very difficult for program managers to look at excel spreadsheets. We spend just as much time on visualizing data and making it useful as we do in collecting it. Because you should not collect data that you cannot use to create a useful visualization. Devex delivers cutting-edge insights and analysis to the leaders shaping and innovating the business of development. Make sure you don't miss out. Become a Devex Executive Member today.