Release of the President's Emergency Plan for AIDS Relief (PEPFAR) Fifth Annual Report to CongressSecretary Condoleezza Rice
Ambassador Mark Dybul, U.S. Global AIDS Coordinator
January 12, 2009
SECRETARY RICE: Good morning. I am pleased this morning to release the President’s Emergency Plan for AIDS Relief 2009, the Annual Report to Congress. This report highlights the achievements of the first five years of PEPFAR, the largest commitment by any nation to combat a single disease in human history. In 2003, when President George W. Bush announced PEPFAR, many still doubted whether HIV prevention, care, and treatment services could ever be provided in a resource-limited setting where HIV/AIDS death -- was a death sentence. But just five years later, thanks to strong partnerships between the American people and the people of host nations around the world, we’ve seen what was once thought to be impossible become truly possible.
When PEPFAR was announced, the President set out aggressive goals of supporting treatment for 2 million people, preventing 7 million new infections, and care for 10 million people infected or affected by HIV/AIDS, including orphans and vulnerable children. It is estimated that in 2003, only 50,000 people living with HIV in all of Sub-Saharan Africa were receiving antiretroviral treatment. Ahead of schedule, the United States has fulfilled its commitment to support treatment for 2 million people. As of September 30, 2008, PEPFAR supported life-saving antiretroviral treatment for more than 2.1 million men, women, and children living with HIV/AIDS around the world.
PEPFAR has also supported prevention of mother-to-child HIV transmission services for women during nearly 16 million pregnancies, allowing an estimated 237,000 babies to be born without HIV, and we’ve reached millions with the ABC message developed in Africa.
Another milestone is in our goal for care. We now support care for more than 10.1 million people affected worldwide, including more than 4 million orphans and vulnerable children who represent the hope for a brighter future. But of course, the best way to help children keep their parents is to keep their parents from becoming infected in the first place and to provide treatment for those parents who do need it, because no program can ever substitute for a parent. So our investments in keeping parents alive are giving children a better future.
President Bush has said on many occasions, though, that one should not become lost in these remarkable statistics. Because what PEPFAR really has done is to provide, more than anything, hope. A disease that was once thought to be a death sentence, a disease that was once thought sure to separate parents from their children, is now a disease that America is helping people to live with and to manage, so that they can be a part of their children’s lives going forward.
I want you to know that over the years, I have been fortunate to be in many countries around the world, including places like Uganda and South Africa, to see the effect that PEPFAR is having. I cannot think of a better example of American ingenuity and American generosity, but also America’s desire to work with people who want to better their own lives in transformational diplomacy, than PEPFAR has been.
I’ve been enormously proud as Secretary of State to be the chief officer responsible for this program. I’ve been enormously proud to help the United States Government and our bipartisan supporters in Congress to make this program, which is a realization of President Bush’s vision, a reality. I’ve had the great honor to work first with Randy Tobias, and now with Mark Dybul, to make certain that PEPFAR is achieving its goals. And as we leave office, I don’t think that anything will stand as strongly in the hearts and minds of people around the world, but also in our own consciousness, as the work and the achievements of PEPFAR.
And so I’m now really honored to give the floor to Mark Dybul, who has led this program with enormous energy and strength. I had the chance, Mark, to thank your great staff a few weeks ago for their compassion and for their effectiveness, and now I will turn over the floor to you to report on the President’s program and our report for Congress for 2009. Thank you.
AMBASSADOR DYBUL: Thank you, Madame Secretary, and thank you for your extraordinary support going back to the days in the White House as National Security Advisor and now as Secretary of State. I’m only going to add a couple of comments to the Secretary’s comments. You have the report. I just want to make a couple specific points to build on what the Secretary said.
First of all – and I think you all have a fact sheet that’s got two rather extraordinary tables – figures, rather, showing not only the final result but the annual results. Five years ago, the President set a final goal, but also annual targets to achieve that goal, and we’ve pretty much met them every year. And that’s a rather extraordinary thing. Sadly, it’s not something that happens in government all that often, where you set goals with intervening annual benchmarks and achieve them. And that’s true for the treatment and the care goals, as the Secretary mentioned.
The second point I want to make which doesn't always come through is that PEPFAR is not only a bilateral program, it’s also a multilateral program. The United States is the largest contributor to the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The President gave the first gift to the Global Fund, the first second gift of any country, and currently we provide around 30 percent of the resources. So about 30 percent of every Global Fund grant comes from the American people through PEPFAR.
And actually, if you look at the numbers jointly right now, the Global Fund and PEPFAR are supporting treatment for around 2 million people globally, and jointly, particularly in these 15 focus countries the Secretary talked about, supporting treatment for 1.1 million people. So we closely collaborate on the ground.
And that leads me to my third point, which is the broader impact of PEPFAR. As the Secretary spoke about, this really is a partnership. And the importance of the fact that we are jointing with the Global Fund supporting programs on the ground is that we are supporting the national strategy, the national leadership. And this is something President Bush talks about often, that we have resources, but the leadership, the brilliance, the real success, is of the people and the country. And that includes government, nongovernment, faith, community-based organizations and the private sector. And that’s really one of the geniuses of not only this program but what the President has done in development overall, what he’s called the new era in development that leads with country ownership, that pushes good governance, results-based approaches, all sectors being engaged, including all of the ones I talked about, not just government.
And that’s had a broader impact. The New York Times has called this approach a “philosophical revolution”. It’s the first time we’ve actually trusted and believed in the country – countries to do the work. And you may have been an AP story that came out in the last few days that gives on-the-ground examples of how this gets down to the village level. Sweetness, a wonderful woman in South Africa, talked about how this demonstrates the American people care about people at the grassroots level and how this is changing the way people view themselves.
And that’s a couple of the spillover effects: deep-seated accountability that gets down to the village level that connects leaders and countries to their people through health programs. And it’s a tight connection. You can hardly have a tighter connection between leaders and people on the ground, and an accountability. That’s the importance of all these targets and goals, that people feel a sense of accountability and development that we haven’t had before.
And that leads to something extraordinary. A 19-year-old in Namibia actually told me that what we’re doing is building democracy by building these accountability frameworks. And as President Kagame and other presidents in Africa have said, what this does is the first time holds Africans to high standards. Just as in this country the President has talked about the bigotry of low expectations, it’s the same globally. If you expect a lot, treat people as equals, partner with them, support them to achieve things, they will achieve great things. And that is a tremendous shift in development, a philosophical revolution, and we’re pleased to be part of it.
One thing the Secretary didn’t focus on but I think is important is that – because we’re talking about PEPFAR today, the President has done this in development overall, and that’s why it’s a new era in development; tripling of resources during his tenure; quadrupling in Africa; doubling in Latin America. And that doesn't even include massive debt relief and increase in trade, which is the real engine of development.
So with those introductory comments, I’d be happy to take any questions.
QUESTION: Ambassador Dybul, why you have given to your AIDS report the title, quote-unquote, “Celebrating Life,” equal to, quote-unquote, “Celebration of Life,” which has been used during the funeral services? Is there any particular reason?
AMBASSADOR DYBUL: There is. It was actually drawn from something that occurred in South Africa, but is happening, actually, in many countries. When this program began, many hospices existed for HIV/AIDS in sub-Saharan Africa, as they did in our country 25 years ago. Basically, it was a place where thousands of people, tens of thousands of people every year, came to die. And as you know, 25 million people have died from this disease.
And so on World AIDS Day, which is every year December 1st, they would hold a commemoration for those who had died. In 2004, after this program began, these hospices began supporting antiretroviral treatment, and one in particular in South Africa, but I’ve seen quite a few of them. By the next World AIDS Day, people weren’t dying anymore because of the antiretroviral therapy. One of the interesting side effects is that they’re trying to figure out what to call themselves. They’re not a hospice anymore.
But the other is, they moved from having a commemorative ceremony for people who died to a celebration of life for the people who were alive. And that’s how they celebrate World AIDS Day. And so we celebrate life as they celebrated life, because this story is being repeated across the continent of Africa.
There’s a lot left to do. As the President said, you know, some people call this program a great success; he calls it a good beginning. We have a lot more work to do, and we’re very pleased that a bipartisan Congress with President-elect Obama as a co-sponsor in the Senate, with Vice President-elect Joe Biden as the floor manager for the bill – we wouldn't have the bill through the Senate without his work – we got a reauthorization which the President signed a couple months ago – strongly bipartisan, as the Secretary noted. And so we will continue to celebrate life as we move forward and do the rest of the work that needs to be done.
QUESTION: A follow-up. Ambassador Dybul, why your PEPFAR program be pursued since it was reported that 870,000 African mother (inaudible) infant (inaudible) were given the black box labeled (inaudible) Nevarapine only once, and this increased the viral resistance of (inaudible) HIV as much 87 percent. What sense does this make, Ambassador Dybul, to continue such a horrible program against the Africans and the American blacks?
AMBASSADOR DYBUL: Well, it’s hardly a horrible program when you avoid 240,000 infants from being infected with HIV. Now, we didn’t say it was only single-dose Nevarapine. We said it was antiretroviral prophylaxis, which in countries like Botswana, for example, is not only Nevarapine, it’s AZT, and as well as other countries. As they build their infrastructure, they’re expanding that out.
As you may be away, there – aware, there are actually studies that show that if women begin the Nevarapine immediately after they receive the short doses treatment, then resistance is a problem. But if you delay it by six months, 12 months, there are no difference between the short course of Nevarapine and any other regimen. They still respond equally well.
So there’s a shift globally from single-dose Nevarapine to more complicated regimens. We actually have a panel that just met this last Friday, PMTCT – Prevention of Mother-to-Child Transition activity panel, that expert panel that’s trying to move us more towards full antiretroviral therapy. But it takes some time to do that. But it’s hardly a horrible program when you’re averting all those births*, and we’re now treating the mothers to keep them alive, as the Secretary said.
Finally, what we’re trying to do mostly is keep not only the mothers alive, but prevent the new infections to begin with so the mothers will be around to care for their children in a family-based approach.
QUESTION: The former President of South Africa, Mbeki, was strongly criticized for not taking the AIDS threat seriously enough and, in particular, treatment programs. Have you noticed a change in the new South African Government, and do you think that sub – that southern Africa in particular is finally getting a grip on the AIDS crisis there?
AMBASSADOR DYBUL: The new minister of health has moved aggressively on HIV/AIDS. We are working closely with them to see how we can support their national program. But we’ve been doing that, actually, for the last five years. You know, beneath some of the things you talked about, last year or this year, South Africa had budgeted in the neighborhood of $800 million of their own dollars for HIV/AIDS support, compared to our about $600 million dollars. So they had moved towards a significant AIDS program. They have probably the largest – they do have the largest public treatment program in the world right now, and so there had been great movement in that direction. But the new minister of health has – have -- moving very aggressively and we’re going to do what we can to support her and the government’s efforts on behalf of their people.
Overall in sub-Saharan Africa, in the deep, southern parts of Africa, we’ve seen tremendous strides over the last four years. You know, people don’t pay attention to Namibia. Namibia has the highest coverage rates in the – on the continent. Now, it’s a small country, but it’s rather remarkable. They’ve achieved what’s considered universal access in the last five years. Botswana. Huge strides in coverage for care and treatment. And both those countries now are seeing declines in prevalence. Namibia just had a demographic national health survey showing a 50 percent decline in prevalence rates among 15- to 25-year-olds. Rather remarkable. And for the first time, we’re seeing the same in – a shift in Botswana in terms of prevention, but they have the care and treatment coverage.
Zambia’s made tremendous progress, not only in terms of HIV rates, which have come down, but also in terms of coverage rates.
Mozambique is doing an excellent job in coverage, or at least expanding coverage, but their physical infrastructure is a little more difficult, and the minister there is focused on it. They are – that is the one country in the deep part of southern Africa where we are seeing some increase in infections. The rest of the countries have stabilized or declined in terms of prevalence rate. So we’ve seen great, great strides in the deep parts of sub-Saharan Africa. And we are by far the largest supporter of those country programs.
QUESTION: But what about Zimbabwe? In Zimbabwe, that’s been another country where a lot of people have suffered and there has been a rise of AIDS. Have you noticed because of the deepening, sort of, political and economic crisis that that’s had a big impact on the AIDS programs there? And what are you doing to try and help?
AMBASSADOR DYBUL: Yeah, unfortunately, as in the rest of the other aspects of Zimbabwe, we have seen the destruction of what was a very strong infrastructure. They had one of the best health infrastructures, and now that is being effectively dismantled.
However, we do still see success. A few years ago in Science magazine, it was reported that Zimbabwe had a 23 percent reduction in HIV prevalence rates, and we’ve seen continuing declines. There are actually some interesting theories on that, that the destruction of the economy is actually leading to a decrease in HIV rates, because men who used to have the money for multiple partners no longer have the multiple partners, because they can’t afford them. Whether or not that’s true we don’t know, but we have seen – that’s speculation at this point, but we have seen declines in the HIV rates.
We’ve also seen expansion in services. And you know, although we have these 15 focus countries, Zimbabwe has been in the next five countries in the top 20 countries in terms of our support. We’ve significantly increased our support. Last year, when the country itself was no longer able to pay for the antiretroviral therapy for the 40,000 people they were supporting, we stepped in and provided the antiretroviral drugs. So we are working heavily in Zimbabwe. We’ve seen some success. We would hope that things would change so that we could get back to a strong enough infrastructure, because there is the opportunity to do a great deal of work there.
QUESTION: What’s been considered under the next administration as far as you know, in terms of this program? Is it going to run pretty much the same way in terms of the discussions that you’ve had with transition people, or do you anticipate some changes?
AMBASSADOR DYBUL: Well, you have to talk to the transition team. I mean, we’ve had the pleasure of talking with them. It’s an extraordinary group of people, an extraordinarily dedicated group of people who know the area well. As I mentioned, the bill itself – the program itself has deep and strong bipartisan support – has from day one. It’s always been bipartisan, whether you look at the votes on the bills or the individual budgets each year, whether the Republicans were in the majority or the Democrats were in the majority, we’ve had very strong support. Not a single Democrat voted against reauthorization in the Senate; only one in the House. The Speaker of the House went and spoke on the well – in the well in favor of the bill. That’s not a usual thing to happen. And as I mentioned, the President-elect co-sponsored the bill. He was one of 16 co-sponsors in the Senate, and the Vice President-elect was the floor manager for the bill in the Senate. He really is the one who moved it in the Senate. It wouldn’t have happened without his support. So clearly, there’s strong support.
Now, will they have individual changes? I can’t imagine a new administration wouldn’t make changes. We change things every year in this administration. One of the things we have found most important in this plan is something the Institute of Medicine called is a learning organization. We look every year to see what it is, and then on a constant basis, what needs to change. So we would hope things would change. The greatest danger to this program is that it becomes part of a bureaucracy, that it doesn’t explore, question, and change based on available data. So I hope there are changes. If there aren’t, then we won’t be doing and the next administration won’t be carrying on that learning organization approach.
QUESTION: Ambassador Dybul, as a Global Coordinator and since this is still an issue, could you please release or mention for the records your original scientific paper about the existence of HIV virus, its pathogenic character that causes AIDS in the transmitted section.
AMBASSADOR DYBUL: Well, we don’t need to do that because every scientific organization in the world has already done that. So there is no question now in the scientific community -- there never really was -- that HIV causes AIDS. Twenty-five million people have died from this. It’s hard to argue with 25 million deaths. So we don’t have to do that, because it’s all over the place. So I’d be happy to talk with you more in-depth, off line on this. But there’s – we don’t need to do that because every organization in the world has already done it.
QUESTION: But can you mention for the record, just -- about the scientific paper, I am asking you as a Global Coordinator to mention something on the record.
AMBASSADOR DYBUL: Yeah. All I – you can look at PubMed. There are, I don’t know, tens of thousands that do so, so we don’t have to do that because they’re all on the record already.
QUESTION: Do you have –
AMBASSADOR DYBUL: Any other questions?
QUESTION: -- any progress on cure or on vaccines?
AMBASSADOR DYBUL: In terms of cure, we really shouldn’t be using the term “cure.”
AMBASSADOR DYBUL: Because we’ve never had a cure for a viral illness, and this is a very particularly difficult type of virus, a retrovirus. Hopefully, we will – there will be some technological breakthrough that allows us to have a cure at some point, but we can’t talk about that right now. What we have is long-term chronic treatment, and similar to diabetes or hypertension. So that is what – that is our target now, although we certainly hope that there is a breakthrough, as we hope there is a breakthrough in diabetes, hypertension.
I do think that’s a critical point, though. This is the first time in the history of development we’ve tackled a chronic disease. That’s rather remarkable. Usually, we do one-off things. And that means we’ve had to support national strategies that forces us to support country ownership because you need a national scale-up of a chronic healthcare delivery system.
And so we’ve supported a massive expansion of the health systems in these countries, whether it’s human capacity, physical infrastructure, supply chain management systems, things that didn’t exist before. And that’s building that nationwide accountability. And the data that are available suggest that this intervention on HIV/AIDS is actually building the healthcare for other areas and having a spillover effect. And that’s rather remarkable that the American people, for the first time, are supporting this chronic delivery. You know, when we started this, as the Secretary said, a lot of people said it was impossible. There was actually this terrible myth that there was no way for poor countries to build chronic healthcare.
One of the most remarkable things, and this is something The New York Times focused on in that philosophical revolution, is we have shattered that paternalistic approach to development, that horrible belief, once and for all, that we know now what -- and we can publicly show what the President and we believed five years ago, which is those were terrible myths.
On vaccines, unfortunately, we don’t have any good candidates right now that would tell us that we will have a vaccine in the near term. Again, we’re very hopeful that we will have a technological or other breakthrough. People are working hard on it. The American people provide about 80 percent of the resources from public expenditure for vaccine investment, and it’s important that we continue that, because in the end we need a vaccine. We also need a microbicide, and there are some efforts there as well. But we’re making progress.
QUESTION: One more thing. What are you going to be doing? Are you staying on as the AIDS Coordinator, or are you moving?
AMBASSADOR DYBUL: Well, I’m – I was appointed by the President, confirmed by the Senate so. As with everyone else, the next administration will make those decisions.
QUESTION: Thank you.
AMBASSADOR DYBUL: Thank you very much.
MR. DUGUID: Thank you very much, ladies and gentlemen.
Released on January 12, 2009