PEPFAR’s New Leader Faces Challenges as Program Enters Second Decade

The US President’s Emergency Plan for AIDS Relief (PEPFAR), which has provided life-saving antiretroviral therapy (ART) to more than 6.7 million HIV-infected people in developing countries since its launch in 2003, is beginning its second decade with a new leader and shifting strategies.

In April, the Obama administration appointed Deborah Birx, a US Army colonel and physician with deep roots in the global AIDS fight, as the new Ambassador at Large and US Global AIDS coordinator, placing her in charge of all international HIV/AIDS efforts, including PEPFAR, making her the program’s fourth leader.

Prior to joining PEPFAR, Birx led the US Military HIV Research Program (MHRP) during the launch of the RV144 AIDS vaccine trial in Thailand, which drew intense criticism at the time but eventually made history as the first and thus far only vaccine trial to demonstrate efficacy (see VAX Sep. 2009 Spotlight article, First Evidence of Efficacy from Large-Scale HIV Vaccine Trial). Birx left MHRP in the midst of the trial to head the US Centers for Disease Control and Prevention’s (CDC) global AIDS program.

Nelson Michael, who worked for Birx during the early days of the RV144 trial and took over the directorship of MHRP when she left, said the US$105 million trial would probably have derailed were it not for her single-minded determination. “It was a rocky time, and there was obviously a lot of discussion in the scientific press,” recalls Michael, referring to a policy forum in Science magazine in which leading scientists raised questions about the scientific rationale for the large trial. “But if she thinks something is right, nothing will deter her.”

One challenge facing PEPFAR, and now Birx, is the process of shifting responsibility of PEPFAR-established programs to the host country’s government. PEPFAR, which has already committed more than $52 billion to fight HIV/AIDS, malaria, and tuberculosis, is now trying to strengthen capacity in recipient countries so they can manage their own treatment and prevention programs (see VAX Dec. 2009 Spotlight article, A Year of Progress). Eric Goosby, the previous head of PEPFAR, began this process before leaving PEPFAR late last year to lead a new center at the University of California in San Francisco.

This process of shifting control over to the recipient countries and getting them to shoulder the costs may be more difficult given the increasing political tension over new anti-homosexuality laws passed in several countries, notably in Uganda, the largest recipient of PEPFAR funding. In her first official comment, released a day after her swearing-in ceremony on April 10, Birx responded to this situation. “No matter how challenging the conditions, PEPFAR has never been deterred from continuing to do all we can to support comprehensive, non-discriminatory HIV services for all individuals, and we will not back down now,” she said. “As public health practitioners, our core ethical responsibility is to the people whom we serve, and this holds true even when we may disagree with host government policies that are at odds with sound science or good public health.”

Along with the anti-homosexuality bill signed into law earlier this year, the Uganda Legislature passed a bill on May 13 that includes mandatory HIV testing for pregnant women and their partners, and allows medical providers to disclose a patient’s HIV infection status to others. The bill, which Uganda President Yoweri Museveni is yet to sign into law, also criminalizes HIV transmission, attempted transmission, and behavior that might result in transmission by those who know their HIV status.

Birx responded quickly to the most recent legislation passed in Uganda. “I join with the many health practitioners, HIV/AIDS and human rights activists, multilateral institutions, and individuals everywhere—in Uganda and around the world—in calling for the people and the Government of Uganda to reject this regressive bill,” she noted, in a May 14 release.