Obama Dreams of an AIDS-Free Generation

But if Washington doesn’t put more money behind its ambitious rhetoric, HIV could make a major comeback. An investigation on the front line of the disease.

A nurse at an anti-retroviral clinic in Emmaus hospital in the town of Winterton, Kwazulu-Natal region, South Africa explains to a patient (up) how she should take anti-retroviral drugs on March 11, 2008. Emmaus hospital, nestled among the majestic Drakensberg mountains in the AIDS-stricken province is one of several rural hospitals recording astonishing successes in ARV-treatment, having already hit ambitious targets set for 2011. After the cabinet adopted on May 4, 2007 a five-year AIDS plan which aimed to halve new infections by 2011 and have 80 percent of patients on treatment, South Africa's once sluggish and embarassing AIDS response has taken new shape. AFP PHOTO / Alexander Joe (Photo credit should read ALEXANDER JOE/AFP/Getty Images)
A nurse at an anti-retroviral clinic in Emmaus hospital in the town of Winterton, Kwazulu-Natal region, South Africa explains to a patient (up) how she should take anti-retroviral drugs on March 11, 2008. Emmaus hospital, nestled among the majestic Drakensberg mountains in the AIDS-stricken province is one of several rural hospitals recording astonishing successes in ARV-treatment, having already hit ambitious targets set for 2011. After the cabinet adopted on May 4, 2007 a five-year AIDS plan which aimed to halve new infections by 2011 and have 80 percent of patients on treatment, South Africa's once sluggish and embarassing AIDS response has taken new shape. AFP PHOTO / Alexander Joe (Photo credit should read ALEXANDER JOE/AFP/Getty Images)

MAPUTO, Mozambique — In a 2011 speech at the National Institutes of Health’s rolling campus outside Washington, then Secretary of State Hillary Clinton announced a reset of America’s global HIV policy. She promised to alter the course of a pandemic that has claimed the lives of 39 million people and to secure a global generation free of AIDS. “Creating an AIDS-free generation has never been a policy priority for the United States government until today, because this goal would have been unimaginable just a few years ago,” Clinton said. She was referring to recent medical advances in blocking HIV transmission and halting its progression to AIDS that have made the prospect of stamping out the epidemic not just imaginable, but attainable.

Clinton’s announcement met with rapturous approval from HIV activists, donors, and researchers worldwide. It was especially welcome news in places like Maputo, the humid, bustling capital of Mozambique, where nearly one in five people is infected with the virus.

HIV activists here still recall, as recently as 2000, people dying on the lawn outside Maputo’s main hospital for lack of medication. But Clinton’s pledge, followed closely by Washington’s push for a strategic overhaul of its HIV programs, seemed to confirm to activists and officials alike that they truly had entered a new era. Dr. Kebba Jobarteh, who ran the U.S. Centers for Disease Control’s HIV treatment programs in Mozambique until the end of 2015, recalled thinking, “the trajectory that Mozambique stepped into is really encouraging” and that he had an “immense amount of hope that we will be able to get to a place where we see an AIDS-free generation.”

But the money needed to achieve that trajectory in Mozambique and elsewhere never came. Although Clinton had insisted that “investing in our future is the smartest investment we can make,” the Obama administration failed to request additional funds from Congress to pursue its ambitious new foreign-policy priority. Bilateral HIV funding within the President’s Emergency Plan for AIDS Relief (PEPFAR), America’s frontline international HIV response since 2003 and the initiative logically positioned to lead the push for an AIDS-free generation, actually peaked at $4.6 billion one year before Clinton’s speech. Two years later, it had been slashed by more than $300 million, eventually flatlining at $4.3 billion — the same request Obama made again in this year’s budget.

The result is that, since 2014, PEPFAR administrators have had to make big compromises — to triage, as it were. Instead of improving programs for everyone in need, they are now surging resources into areas with the most new HIV infections, while shrinking their presence in other areas, some of which still face substantial epidemics. Officials say this strategy offers PEPFAR its best chance to realize the goal of an AIDS-free generation within its funding constraints. But it’s an approach that compels the program to at least temporarily prioritize some communities over others.

“The idea is you look for the people who need treatment where they are, not where they are rare,” said José Enrique Zelaya Bonilla, the UNAIDS country coordinator in Mozambique. “But I’m not sure if that’s the correct approach for the country providing the fifth most new cases in the world.”

What the new strategy means, in short, is that thousands of people could die simply because PEPFAR can’t afford to save them. It also means that new so-called hot spots could emerge in areas that see service cuts, threatening to erode hard-won gains against the deadly epidemic.

An impossible choice

From the beginning, PEPFAR was celebrated for its ambition. When President George W. Bush unveiled the program in his 2003 State of the Union address, he promised “to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.” At its launch the following year, it was already the largest-ever global health intervention targeting a single disease, with an initial authorization to spend $15 billion over five years.

The program has evolved from an emergency response initiative in just 15 countries to arguably the most significant player in the global AIDS policy arena, with programs in more than 40 countries. But its focus remains squarely on sub-Saharan Africa — 90 percent of PEPFAR’s planned funding for individual countries in the 2014 fiscal year went to the region. That focus makes sense because sub-Saharan Africa is where 70 percent of all people with HIV live — often still at a critical remove from the interventions that could keep them alive.

PEPFAR’s emphasis on treating HIV rather than attempting to prevent its transmission was informed by a groundbreaking 2011 study that found effective treatment for HIV reduces the risk of transmission by 96 percent – that treatment, in other words, is actually one of the most effective forms of prevention. Implicit in that strategy, of course, is the importance of access to treatment options.

But such access can’t be taken for granted. That becomes clear in a place like Mozambique, which faces one of the 10 worst HIV infection rates in the world — an estimated 11.5 percent of people between 15 and 49 are infected. And it’s most starkly illuminated in places like Catembe, a village just across Maputo Bay from the capital.

Catembe sprawls out haphazardly along the coast of the Indian Ocean, from a paint-flecked pier on its northern tip to thick settlements of sun-bleached huts that mark its terminus to the south. A sand-covered road runs the entire length of the village. The regular breaks in the palm trees that run alongside it offer occasional glimpses of Maputo’s modern high-rises jutting skyward across the bay.

For Catembe’s poor, that view is deceptive. The capital — and its superior health care — is at least a half-day’s voyage away. Most journey to the pier on foot or balanced precariously on the bed of a truck, and then board one of the brightly colored ferries that bob their way across the bay at irregular intervals. All told, getting from Catembe to Maputo can cost around $3 round-trip.

That was more than Alice Eduardo Nhaca could afford to spend each month to pick up her medicine. The 54-year-old doesn’t remember when she was diagnosed with HIV, only that it was a “long time ago” at a health center in Maputo — then the closest facility offering HIV services. Doctors there offered her free treatment — anti-retroviral therapy (ART), which can stave off the deterioration of the immune system and prevent the virus’s progression to AIDS — and she eagerly signed up. But the monthly visit to the clinic to check in with a health worker and prove she was sticking with the treatment regimen — a prerequisite for getting the next 30-day supply — quickly became overwhelming.

Nhaca sells charcoal from a roadside stall in Catembe. If she works every day, she makes almost enough money to scrape by. The time off required to collect the drugs, plus the expense of transportation, made this impossible — and all to treat a disease that has never made her feel as bad as a day without food did. So at some point — maybe five years ago, she estimates — Nhaca stopped treatment. She then started to notice subtle changes. It became harder to get out of bed in the morning, and she seemed to be regularly catching a cold. She wondered if she should start taking the drugs again but decided the cost was still too dear. All the while the virus was gradually overwhelming her immune system. If it weren’t for the expansion of HIV treatment facilities in her area, she would probably have died from an opportunistic infection her body was too weak to fight off.

Three years ago, Nhaca learned that the health center in her village had begun offering ART. The clinic is a 30-minute walk from her house, meaning that she doesn’t have to sacrifice an entire day of work to check in with the nurse and pick up her pills. She now sticks religiously to the treatment, which has restored her energy and reduced the illnesses that preyed on her weakened immune system. “My life,” she said, “has improved.”

Though she has never heard of it, PEPFAR is saving Nhaca’s life.

The health center in Catembe is supported by a national nongovernmental organization (NGO) called the Center for Collaboration in Health (or CCS from its Portuguese spelling), which is a PEPFAR grantee. In line with PEPFAR’s long-standing efforts to shore up domestic health care systems in the countries where it provides HIV services, CCS has been paying the salaries of some of the health center’s employees, providing them with training and even helping with data entry. And while the government stocks the medications, health officials in Mozambique say that 95 percent of their cost is underwritten by either PEPFAR or the Global Fund to Fight AIDS, Tuberculosis, and Malaria, to which the United States is the primary contributor.

In 2013, Mozambique’s government launched a new plan to combat HIV based on PEPFAR’s strategy of emphasizing treatment over prevention. By March of this year, Mozambique had enrolled more 676,000 patients on ART, up from 308,000 in 2012. PEPFAR supports nearly 620,000 of them.

“Really we are so, so far,” said David Magaia, a pastor who has been running HIV programs in the country for nearly two decades and recalls when treatment was restricted to only a handful of patients in Maputo.

In other countries where PEPFAR operates, the results have been similarly impressive. As of September 2014, the program had helped 7.7 million people around the world receive ART. These are the kind of numbers that led a sweeping 2013 evaluation of PEPFAR by the Institute of Medicine, an independent policy advisor to the U.S. government, to declare the program “globally transformative.”

But the gains underscore how much further there is to go. In Mozambique alone, new treatment guidelines the government is expected to adopt will swell the number of patients eligible for ART to 1.2 million, according to CDC officials. Those new treatment standards are still less inclusive than the recent recommendation by the World Health Organization (WHO) that all HIV patients be started on ART as soon as they are diagnosed, building on the promise of treatment as prevention. That would mean enrolling 9 million additional patients around the world. Unless enrollment accelerates, triggering a drop in the HIV transmission rate, that number will continue to climb — eventually beyond any response the international community can mount.

Defusing a ticking time bomb

The so-called youth bulge has Dr. Deborah Birx, the U.S. global AIDS coordinator, especially concerned.

Success in reducing the number of infant deaths around the world in the past decade has resulted in a massive surge in the youth population, primarily in Africa but also in other parts of the world. As these young people become sexually active, they become more susceptible to HIV infection. This is especially true for girls and young women, who are often pursued by older, wealthier, and sometimes-infected men. Among young people in sub-Saharan Africa, girls and young women account for 71 percent of new HIV infections.

Birx, who took over as head of PEPFAR at the start of 2014, told Foreign Policy that this potential upsurge in new cases could result in nightmarish scenarios. “What would it be like if we returned to levels where 50 percent of people with HIV are dying?” she asked.

Under Birx, PEPFAR began considering a shift in strategy to better forestall that looming threat. Officials noticed that they were easily reaching people who needed ART in some areas with low HIV rates, while they struggled to keep up with demand in other areas with higher HIV prevalence. Those findings fueled discussions about shifting resources from lower-burden sites into areas with the highest rates of HIV transmission in a bid to prevent explosive new infection rates.

But there is another consideration driving PEPFAR’s strategic pivot, which Birx hinted at during a 2014 discussion organized by the Kaiser Family Foundation soon after she took office. “You saw where [PEPFAR is] with flat funding. In order to achieve successive gains, we must focus on the core and the near core,” she said.

The new strategy engineered by Birx and publicly introduced at the end of 2014 reflects all of these concerns: demographics, coverage, and funding constraints. In effect, the strategy repositions resources to address the areas and populations most likely to reverse PEPFAR’s gains. “We feel an obligation to make sure our dollars are aligned for the greatest impact,” she said. “Then we can see how far that takes us.”

Choosing not to die

Around the world, PEPFAR officials are in the early stages of executing Birx’s plan. Out of Mozambique’s 148 districts, PEPFAR and its partners are surging additional resources and interventions into the 77 where the most new HIV infections are expected to occur. By scaling up in those priority districts, the country’s PEPFAR team expects to reach 73 percent of the people who qualify for treatment under the government’s anticipated new targets by 2018 — up from 68 percent in 2014 under the older, much less inclusive guidelines.

“Once that happens, the pace of acceleration of the epidemic will begin to subside,” the CDC’s Jobarteh said. “We should be able to get in front of the epidemic doing what we’re doing.”

That confidence is not universally shared. Because HIV is so widespread in Mozambique, even areas with relatively low prevalence often have rates above 1 percent — high enough to be considered an epidemic. In that environment — found in other PEPFAR target countries, like Zimbabwe, as well — the redeployment of resources toward harder-hit areas is going to feel like rationing. “PEPFAR is in a position of squeezing water out of rocks, so it has to focus on the hot spots,” said Sharonann Lynch, the HIV and tuberculosis policy advisor for the medical charity Médecins Sans Frontières (MSF). “But the issue is, what is a hot spot in an epidemic?”

Lynch is concerned about a possible “bifurcated reality” in which some communities enjoy a comprehensive response while others fall behind without the resources to track new patients, prevent avoidable deaths, or even stop the emergence of new hot spots where the infection rate matches or exceeds that of prioritized areas. Governments, with PEPFAR’s assistance, will continue monitoring the virus’s progression. But surveillance is tricky in rural, underserved communities, and officials could fall into a cycle of constantly being one step behind the spread of the disease. “There has to be the funding and some equity in terms of the response,” Lynch said. “Not only for those [existing] hot spots, but building up the competence everywhere.”

Catembe, which sits across the bay from PEPFAR’s Maputo offices, is one of seven municipal districts that make up the larger Maputo city district. Under Mozambique’s new plan that was informed by PEPFAR’s strategic shift, it is the only one not designated as a priority.

That doesn’t mean PEPFAR is abandoning Catembe, said Maria Inês Jorge Tomo de Deus, the technical director for CCS, PEPFAR’s implementing partner in Maputo. The agency will continue to fund staff salaries and conduct training and workshops, though the latter will be less frequent than Catembe’s health workers are used to. CCS will also map out a transition plan that ensures all current patients, including Nhaca, will continue to receive ART and that new patients are able to sign up for treatment (although outreach efforts could be reduced.) And PEPFAR will monitor the district, ready to redeploy services to combat any spike in new cases. But if Catembe wants to expand services — to introduce new interventions or to cut the time patients travel to collect their drugs — it will have to source the funds from somewhere besides PEPFAR.

The numbers just didn’t warrant Catembe remaining a priority, de Deus said. She offered an example: Over three months last year, less than 200 pregnant women came to Catembe’s clinics for a counseling session, which includes HIV testing. Of those, less than 20 were positive. Meanwhile, during the same period in Maputo’s KaMavota district, more than 3,700 pregnant women were tested; nearly 400 were positive. The percentages aren’t so different — 10.1 percent versus 10.7 percent — but the outsized scale of KaMavota’s patient visits means additional resources there will have a much larger impact than they would in Catembe.

Officials in Mozambique were quick to tamp down expectations that money from non-PEPFAR sources will be forthcoming for Catembe or other nonprioritized areas. The country elected a new government at the start of last year and Diogo Milagre, the deputy executive director of the National AIDS Council, told Foreign Policy that under this administration he couldn’t predict “to what extent the resources that we come up with domestically can actually respond to the challenges that we have.”

Milagre does not anticipate receiving any additional assistance from other international partners. Outside of PEPFAR and the Global Fund, he described global support for the country’s HIV programming as “very meaningless, compared with what we used to get in the past,” before the international financial crisis.

It all makes Lili Gervasio Ngongo uneasy. The head nurse at the Catembe Health Center, Ngongo can’t fathom why the shift is necessary. “The numbers seem to be increasing,” she said of the center’s HIV patients. “People now are aware that they cannot die of a disease they can prevent. Now they are choosing whether they want to die. And if they don’t want to die, they come here.”

The door of her office leads into the center’s waiting room. When she opens it, the rough-hewn benches are crowded with people waiting for HIV medication. They have chosen not to die. Ngongo said their presence is a credit to CCS and ultimately, PEPFAR. The U.S. program’s teams “are always here. They do almost everything. I wouldn’t say it wouldn’t be possible without them,” she said, but she doesn’t want to find out what happens when they leave.

AIDS: not in recession

Given the current funding constraints, there is some consensus — both within and outside PEPFAR — that Birx has hit on the model that will save the most lives. But critics fault Congress and the Obama administration for promising to usher in an AIDS-free generation while forcing PEPFAR to ration the expansion of critical HIV services.

The administration and Congress started talking about ending the epidemic and, in an environment of manufactured austerity, frankly didn’t have the bravery to find the additional resources,” said Asia Russell, the executive director of Health GAP, an international health rights group. “AIDS wasn’t in recession.”

Birx was quick to defend the government. “If anything, we have greater and more clarity and breadth of support than at any time,” she said, pointing to new treatment and prevention targets the White House released at the end of September 2015. PEPFAR is now aiming to support the treatment of 11.4 million people by the end of this year, and add 1.5 million people in 2017.

International activists, who waited nearly two years for the White House to issue these targets, were frustrated with the delay. But MSF’s Lynch said it is possible to read in their eventual release a renewed commitment from Washington to expanding access to treatment. “Now they need to make good on that financially,” she said.

Instead, there was only disappointment when Obama’s latest budget request failed to increase bilateral PEPFAR funding – or even to restore the $300 million in cuts that have been made since 2011. “Even $300 million can mean a lot, especially for an agency that has had to learn to be efficient,” said Lynch, adding that this figure represents a fraction of the overall budget.

It would probably be enough, she said, to put an additional 1.5 million people on treatment and expand PEPFAR’s acceleration — maybe even across the Maputo Bay to Catembe.

This reporting was made possible in part by a grant from the International Reporting Project, an independent journalism organization based in Washington.

Image credit: ALEXANDER JOE/AFP/Getty Images

Andrew Green is a freelance journalist based in Berlin. Previously, he was based in sub-Saharan Africa for more than five years.