Deborah L. Birx, M.D.
U.S. Global AIDS Coordinator & U.S. Special Representative for Global Health Diplomacy
November 29, 2018
HOST: Welcome to LiveAtState, the State Department’s interactive virtual press briefing platform. I’m delighted to welcome participants joining us today from around the globe. Today you’ll be speaking with Ambassador Deborah Birx, the U.S. Global AIDS Coordinator and U.S. Special Representative for Global Health Diplomacy. A physician and a former Army colonel, Ambassador Birx has been on the forefront of the U.S. Government’s fight against AIDS for decades. She is happy to take your questions today on the PEPFAR 2018 program results and the recently concluded Faith Communities and HIV Technical Summit held this week at the State Department.
Before I turn it over to Ambassador Birx for some opening remarks, I would like to make a few housekeeping notes. You can start submitting your questions now in the box on the top right of your screen that says, “Type your question.” If you see a colleague ask a question that you’d also like to see answered, you can up-vote that question by clicking the “like” button on the right. We’ll try to answer as many questions as we can, but our time is limited, so show your support for the questions you’d like to see us cover the most by up-voting. If you have difficulty submitting your questions, you can always e-mail them to us at [email protected] Finally, if you did not register through the Eventbrite link but would still like to see the audio and video files from today’s briefing, please e-mail [email protected]
And with that, let’s get started. Ambassador Birx, thank you so much for joining us today, and I’ll turn it over to you for opening remarks.
AMBASSADOR BIRX: Great. Hello, everyone. It’s wonderful to be with all of you tuning in from around the world. This coming Saturday is the 30th anniversary of the first World AIDS Day, and this year marks the 15th anniversary of the development of the U.S. President’s Emergency Plan for AIDS Relief, commonly known as PEPFAR. Fifteen years ago, before PEPFAR began, HIV was on the verge of wiping out an entire generation in many countries around the world. Then, in 2003, President Bush launched PEPFAR in his State of the Union address, catalyzing a tidal shift against this devastating disease.
Since then, across three U.S. presidents – President Bush, President Obama, and President Donald Trump – and eight U.S. Congresses, the U.S. Government has invested more than $80 billion in the global HIV response, the largest commitment ever made by any country to address this disease. This investment has saved 17 million lives through PEPFAR, prevented millions of new HIV infections, and transformed the global HIV response. In all of the time that we — have today – thank you – and we can go to questions.
HOST: Thank you, Ambassador Birx. Thank you for your opening remarks. And with that, we have some questions queued up from our journalists watching around the world already, and we’ll go to our first one from Haiti. The journalist is Violine Thelusma from Pasroadeh Social Media, and she asks: What are the latest medical advancements in AIDS treatment in 2018?
AMBASSADOR BIRX: Well that’s a great question and thank you for that question. We have a new drug, and I just want to make a comment about what has happened with the drugs that are available. You know we have innovators in pharma, and they have been transferring those innovative drugs, those critical drugs, to generic companies and allowing them to make them while they’re still on patent in many developed countries for the resource-limited settings. One of these new drug combination, and all of our HIV drugs that are effective, come in a cocktail.
We have a new cocktail called TLD. It includes a new drug that is highly effective, and we’re working very hard with governments and communities around the globe to make access to this new drug available. This new drug combination has much less side effects and has much less ability for people to develop resistance to the virus. And we know today that if you take this medication, not only do you thrive but you prevent infection of others because you cannot transmit the virus when your viral load is not detectable.
HOST: Thank you. Our next question comes from Elvis Chang, New Tang Dynasty, Asia Pacific TV in Taiwan. They ask: What is your comment on China’s scientists’ gene editing experiment on babies against AIDS?
AMBASSADOR BIRX: We would really like if all the geneticists would work with us to create a virus or a virus that can be controlled in a more direct way to find a way to cure HIV. So today, with our 37 million people infected with HIV, we cannot eliminate or eradicate HIV until HIV is actually cured. And so those 37 million people are waiting for a cure, a cure for HIV so that everybody can talk about eliminating and eradicating HIV. If we had a vaccine and a cure today, we could be talking about elimination, eradication, rather than just talking about controlling the virus.
HOST: Thank you. Our next question comes from a watch party at one of our embassies, this in Zambia: President Trump has emphasized the need for African countries to raise their own resources to fund their own developmental programs, including healthcare. Does the President’s position and America First policy threaten funding to Zambia and other developing countries?
AMBASSADOR BIRX: I think you know quite clearly how supportive President Trump has been of PEPFAR. From the minute he arrived, he worked on World AIDS Day, and he has been there and available to us whenever we had asked the White House to participate in our events and to provide support for PEPFAR. That’s why I opened with it’s been supported by three presidents. How unusual to have a program that was begun by a Republican president, supported by a Democratic president, and supported now by another Republican president, and eight Congresses that have moved through who was in control of the Congresses in the United States. This bipartisan support that transcends any one party is really unique around PEPFAR.
I think also, though, President Trump has made it very clear to us that his expectations are that we create a program that becomes more efficient and effective each year to really demonstrate that foreign assistance can have an impact and outcomes without ever-increasing resources. And at the same time, we have seen countries really step up to their investment.
Right now, Namibia, Botswana, South Africa, Eswatini, Ukraine, Vietnam –critical partners for us in this fight – are actually funding 70 to 80 percent of their response. For Zambia, they are funding many of the health care workers, many of the facilities, and more needs to be done both in investments to actually get control of this epidemic. Zambia is getting closer every day, but Zambia could actually achieve control if we were unified in our communities and in our government to really ensure that everybody knew their status, everybody knew how to prevent becoming infected with HIV, and everybody who was infected was on treatment today.
HOST: Speaking of “know your status,” the next question comes from Kenya, from Kevin Kelley, Nation Media Group. Is PEPFAR aligned with WHO’s “know your status” theme on this World AIDS Day? Specifically, is PEPFAR stepping up promotion of HIV testing in its core target countries? I’m especially interested in efforts in East Africa – Kenya, Uganda, Tanzania.
AMBASSADOR BIRX: Thank you for that question. That’s a very interesting question, and it’s a complicated question. Last year we tested nearly 95 million people, most of them from Sub-Saharan Africa. The year before we tested 85 million people. The year before that, 75 million people. So you can see in just a few years we’ve tested well over 200 million people, most of them in Sub-Saharan Africa.
What we’re looking at today is how do we get people to test that really are at risk for HIV, and this is how communities can really help us. We know that we’re missing right today 50 percent of the men between 15 and 35. That means 50 percent of the men who have HIV and who need to be on life-saving drugs for their own health don’t know their status, and often present very late in disease with tuberculosis. So what we need is a partnership to figure out: how do we get men who believe themselves to be healthy? Because remember, for the first 10 years of HIV infection, or eight to 10 years, you don’t know that you’re infected with the virus because you feel fine. And so we want to find what – your body is suffering the ravages of this virus, and your immune system is being destroyed.
So we want to find a way to get messages to men, particularly men between 15 and 35, to really come forward and get tested. Because we know within that 95 million people we tested last year, a lot of them were worried well – people who have no risk for HIV, but are concerned about HIV. We need the people who perceive themselves to not be at risk for HIV, can see themselves as healthy and vigorous, to be tested for HIV today so that we can get them treated before they develop the devastating ravages of a failed immune system.
HOST: Thank you. One of the trends emerging in new and emerging economies is overseas workers who come to that economy to work, and while there may turn to paid or casual sex or have multiple partners, which then promotes the transmission of HIV. How would you suggest this trend be addressed? Is there any special approach being given to this situation?
AMBASSADOR BIRX: There’s two things happening, and we’re just so thrilled that countries have come up with innovative solutions. Today in Lesotho, at the border where a lot of males and a lot of minors move back and forth, they have developed a system where before you cross the border to go to work, if you are HIV positive, you get to have a full six months’ dose of that drug that you need for your own health, to carry with you without having to come back to Lesotho to get additional drugs.
At the same time, if we know men are at significant risk, as just described in this question – and remember what I said in the last question, that you really need to know your status? Men who are in high-risk settings and they’re HIV negative, we have a drug called – that’s – in PrEP, that’s pre-exposure prophylaxis, that they could take every day that would keep them from getting the virus.
The other piece of this about men or others that are moving around: If you are circumcised, we know that it decreases your risk by almost 65 percent for life. So there are real options for men who are worried about being exposed or being worried about going into higher-risk environments, but the key to that is knowing your status.
HOST: I’m glad you mentioned PrEP. That’s made such a huge difference in the rates of HIV transmission. Our next question comes from Antonia Laborde from El Pais. They ask: Is your bet for the drug TLD or PrEP? Recently U.S. Preventative Services Task Force raised the category from PrEP to “A”. When is it estimated that insurers will grant the pills at no cost to the patients?
AMBASSADOR BIRX: Well, that’s happening in some areas today. I could tell you throughout PEPFAR, people can get PrEP at no cost. Now, there is a cost in that you have to come to a clinic or you have to come to a mobile unit and get tested. So this – and we all keep coming back to getting tested, because that is your gateway to the prevention activities that you need to engage in to remain negative, and that is your gateway, if you’re positive, to a healthy life.
So it all comes down to this is really our primary issue. PrEP is free in many of the places where we work. The issue is the people who are really at risk for HIV aren’t coming forward to get tested. And so if they come forward and get tested, and if they’re defined to be at risk, they can get PrEP for free.
HOST: Our next question comes from Mohamed Ataya in Egypt from Masrawy.com. He wants to know about the virus and how it’s spread in conflict zones like Syria and Yemen. Is there anything being down specifically to prevent or treat those with HIV from spreading the disease in conflict zones?
AMBASSADOR BIRX: Every place there is a refugee program, there is the ability to test and treat those who are in those programs, and that’s very important to us. When there are issues in South Sudan, as there are today, we’re ensuring that in the Uganda – northern Uganda area – that we have testing and treatment available. And I think this is really critical, again, that people know their status and are on their medication, if they have medication, they travel with it, but also that in zones that there’s availability for both testing and treatment. And so I think this is very important.
Traditionally, conflict zones have had a much lower rate of HIV in general, but it – and so I just – I don’t want to make – I want to make it clear we should not be stigmatizing refugees and others that are fleeing violence. They are not at a particular higher risk of spreading the virus. What often happens after they come into those refugee states there have been exposures. So we’re very careful now to ensure access to testing and drugs.
HOST: Kevin Kelley at the Nation Media Group in Kenya asks: Even though PEPFAR has made great advances against HIV/AIDS, wouldn’t U.S. efforts be even more effective if merged with the work of UNAIDS? Why should the U.S. run a separate national program?
AMBASSADOR BIRX: That’s a great question, but really illustrates kind of a misunderstanding. We are in deep partnership with UNAIDS. If you look at the UNAIDS reports, if you look at their fast-track strategies that countries have signed on to, you look at the 90-90-90, that is the strategy that PEPFAR utilizes. So UNAIDS, in collaboration with countries, including the country of Kenya, develops a strategy that then PEPFAR follows. And so we’re bringing resources to country-led strategies to ensure that they’re implemented with fidelity. So that’s our role.
UNAIDS works with countries to develop strategies and how to have a greater outcome and impact, like through 90-90-90, like through increased prevention activities, and then we use that document to ensure that we’re completely in sync. In fact, Michel Sidibe arrived here yesterday to participate in an event today, so I will tell you that UNAIDS and PEPFAR are completely aligned.
HOST: Our next question comes from another watch party: The – has the U.S. Government considered giving technical or financial support to nonconventional researchers in Zambia claiming to have developed treatment for HIV/AIDS from herbs? Does PEPFAR support such research?
AMBASSADOR BIRX: So the United States Government has supported research for all credible interventions, and where does that happen? That happens through our National Institutes of Health, who really look at different herbal – to really test them in the test tube, to test them against the virus and to see if they’re functional. So there is a special unit at NIH that specifically is looking at each of these types of remedies and validating whether they actually work or not.
So this is really very important. So if Zambia or any other country has a combination that they think is effective, it’s very important that it’s tested in very rigorous conditions, like all of our drugs today have been tested. We want to make sure that before anything is available to anyone out there that it’s as good as what we have available today, and so I’d ask that they would submit that to NIH to be studied.
HOST: One problem with treatment is that many men don’t come into a clinic until they begin to feel sick. How is PEPFAR addressing that?
AMBASSADOR BIRX: That’s really our biggest obstacle right now. As you know, in every country there’s a policy to test pregnant women. So if you look – and we’ve done surveys all throughout sub-Saharan Africa, 13 of them, and that’s why we know very clearly what number of men don’t know their status and aren’t on treatment. So we talked about men coming late to facilities, so you have to find them in the community to really define how many are missing. So it is because of that that I can clearly tell you that we’re missing 50 percent of the men and we’re – and that men are presenting with much lower what we call CD4 cell counts, which really illustrates how destroyed their immune system is.
And so because of this, we’ve launched what we call MenStar. It’s a public-private partnership, and what does that mean? We’re using the best of the private sector’s ability to go in and actually talk to men in communities and understand what precisely men want in order to be able to come to a facility, in order to be able – and we thought for many years that men were actually indifferent to knowing their diagnosis. But what we realize now that men actually have concerns about HIV and are scared to come to the clinic and find out if they’re HIV-positive or not.
And to those men we say to you today, and throughout sub-Saharan Africa and every place that we work, if you come in today, you’ll be received in what we call male-friendly clinic. You’ll see other male nurses, male physicians; you’ll have high levels of confidentiality. We want to make sure that you are healthy and thriving, and we know that the gateway to that is knowing your status and getting on treatment. So we’re excited about MenStar; we’re excited about that new public-private partnership.
We have another public-private partnership called DREAMS, really focused on preventing infections in young women. We released earlier this week our report showing in the 15 countries where we’re working and in the districts – in the 10 countries, the 63 districts – 85 percent of those districts continue to have declines in young women’s incidence through the work that’s being done on the ground through DREAMS – Determined, Resilient, Empowered, AIDS-free, Mentored and Safe Young Women.
So these public-private partnerships, where we harness really the intellect and insights of the private sector, have been absolutely key to our success, and we’re hoping that they bring their unique information and insights – like they did for DREAMS to prevent infection in young women between 15 and 24 – that they bring that same insight so we can really figure out how to reach men and get them into our facilities.
HOST: You talked a bit about DREAMS, and three out of every four new HIV infections in sub-Saharan Africa is in women 15 to 19. We talked about what PEPFAR does to bring men into the clinic. Can you talk a little bit more about what PEPFAR is doing to bring vulnerable women into the clinic?
AMBASSADOR BIRX: So the DREAMS partnership, which is a partnership with ViiV and Gilead, Johnson & Johnson, Gates, and Girl Effect, has been really an extraordinary partnership, because this partnership began as grassroot planning. And putting the adolescent girl into the center and really listening to her and creating programs around her and also around the community and around the families to support that young girl to make sure that she remains HIV-free. These are a series of interventions that alone showed promise, and we brought them all together to really wrap this comprehensive interventions around these young women.
And the exciting thing is for the first time we have such an evidence base: that when you put the young woman at the center, when you keep her in school, when you prevent her rape in those communities, when you have families and communities that are ensuring that young women are valued and protected, you can dramatically decrease the rates of HIV infection. All of that came about over the last three years.
So this really shows the power when communities – and we bring the best intellects from the private sector with us, with the resources that they represent, really the generosity of the American people. And I just want everybody around the world to remember: PEPFAR exists today because of taxpayers in middle America, in coastal America who give their really hard-earned dollars to ensure that people around the world that don’t have that same access to those resources can really remain HIV-negative or thrive with HIV on drugs and treatment because they’re virally suppressed. So it’s really – I just want to really always come back to thank the American people.
HOST: And how does PEPFAR use data to expand its impact and help Americans spend that dollar wisely?
AMBASSADOR BIRX: Well, we’re kind of a revolutionary program in foreign assistance. So when PEPFAR was begun 15 years ago, President Bush really wanted to do foreign assistance differently, came up with both PEPFAR and the Millennium Challenge Corporation. And so from the very beginning, PEPFAR was solely results oriented, very much based on data. We’ve taken that through the next step really because of the accountability that this administration has brought to foreign assistance that really demand to understand where those taxpayer dollars are going and the impact that they have.
So if you go to pepfar.gov today, you will find every site where we work represented on our website, showing precisely what the results are there. And that has allowed us to hold governments, communities, and partners accountable for the resources they receive to ensure that those resources really result in the impact and outcomes that we expect. And I talked about those surveys. Those surveys are a critical part of our data, and those surveys are supported by the CDC and what we call ICAP and University of Maryland in Nigeria.
Those surveys at the community level validate the data of the progress we’re making through our facilities and community work to really ensure that we are really holding ourselves accountable every day. But with accountability, you must have transparency. And that’s why all the data from all the surveys and all the data from all the sites are up on our website for communities and governments and everybody to share together to really understand what we’re doing.
The important part of it is – and you would never do this in sports. So imagine if you had a football team and you had a league and you said, “Oh, that league is 50 percent.” No one would say that. Everybody knows who’s winning the most games and who’s losing the most games. And what the data allows us to see is communities that are winning against the virus HIV and communities that are losing against the virus, rather than averaging them together in this tyranny of averages. And so that data has allowed us to find out what’s really working and take that to scale and find the areas where it’s not working and fix those, so that every community has the best services and prevention and treatment that we can provide. Data is what allows us to see through our perceptions to the individuals that we’re serving to ensuring that we’re having the outcomes that we need.
HOST: And on the topic of funding, South Africa has been in talks with PEPFAR about securing additional funding, which I understand has been successful. Can you share details of the extra PEPFAR funding that has been earmarked for South Africa? And that question comes from Tamar Kahn from Business Day in South Africa.
AMBASSADOR BIRX: We’re still working with the South Africa Government on this particular area. I’m hoping that you will see an announcement on December 2nd about precisely what we, PEPFAR, and our U.S. Government is going to do in true partnership with the Government of South Africa and the communities of South Africa that have been so devastated by this virus. And this virus still has communities where 25-30 percent of all the adults are HIV-positive. This is what we have to reverse today, and that’s why we’re working very hard in partnership with the Government of South Africa, to have a new future for South Africans.
HOST: We have journalists from two countries, India and Egypt, who are both curious about PEPFAR work in those countries specifically and any information you can share about trends in infection rates.
AMBASSADOR BIRX: So UNAIDS has released their new data, region by region, so I will ask Egypt to look very carefully at their data. You have a very, very small HIV epidemic.
India, you have between 1.5 and 2 million people HIV-positive that need service, and only about 50 percent of them know their status that are HIV-positive and on our drugs and have a full future ahead of them. And remember in India, there is a relationship between – and as well in the rest of the world – between HIV and tuberculosis. So when we talked about HIV crippling your immune system, some – often the first infection that you will get is tuberculosis, and unfortunately, a type of tuberculosis that’s often very much more resistant to the drugs that we use for tuberculosis.
And so we’re working in India very closely with the government and communities of India to really develop a comprehensive response so that everyone in India that is at risk for HIV knows their status and is on treatment. And I think this is a real challenge for us, but India is really making progress. They just need to accelerate their progress, and we want to be there in partnership with them.
HOST: And with that, Ambassador Birx, I’d like to thank you for joining us today on the program, for our inaugural return to LiveAtState. It’s the first one of these we’ve done in a little while. And I hope it will be the first of many. Thank you so much for joining us today and appearing on the program. And if you at home would like to see a transcript or video of today’s program, if you registered via Eventbrite that will be emailed to you. If you were not able to provide us with your email address send that to LiveAtState – the word “at” State – @state.gov. [email protected] And thank you so much for joining us, especially our viewing parties at our embassies throughout Africa and Zambia in particular. Thank you so much for joining us on the program today, and we look forward to seeing you here again soon.