New Directions for PEPFAR? Setting the Course of U.S. AIDS Efforts

An Interview with Ambassador Eric Goosby

U.S. Global AIDS Coordinator, Ambassador Eric Goosby

TREAT Asia Report: PEPFAR is moving towards an approach to global health that strengthens health systems and emphasizes government ownership of health programs. But in Asia, it’s the vulnerable and often hard-to-reach communities—sex workers, drug users, and men who have sex with men (MSM)—that are disproportionately affected by HIV. How do we make sure that these populations get the attention they need?

Ambassador Eric Goosby: Our goal is to create an opportunity to identify more difficult-to-reach populations, bring them into care, and keep them there by creating a safe space where they can reveal themselves to the authorities. For that to happen, a safe space needs to be explicitly understood as a spot where they’re not going to increase their chance of being arrested or identified by the police.

Creating safe zones for vulnerable groups requires that we make a concerted effort to educate the authorities—police departments, health departments, politicians. There needs to be a better understanding of how these communities are impacted by HIV and how they relate to the general population. But we also need to support leaders within civil society who can help us make our arguments about hidden populations.

The educational process is sometimes slow but it is a critical foundation on which a sustainable, durable response is based. So our approach is to have all of those fronts of activity concomitant with what often turns out to be—because of a lack of willingness to engage on the part of governments—a strategy that relies on NGOs as our primary interface with vulnerable communities. They can create safe spaces and at the same time work with public institutions, law enforcement in particular.

We have observed progress towards providing services for injection drug users and other vulnerable groups in Viet Nam, China, and Cambodia. These countries have, over a relatively short time, expanded their understanding of HIV among vulnerable groups, and that understanding is now reflected in programmatic changes.

Many challenges remain, however. I can’t tell you the number of times we’ve heard people say that these issues with vulnerable communities are not a problem they have in their countries—with injection drug use in particular. There is also a lack of acknowledgment of the spectrum of human sexuality and its expression. Here, too, governments insist that this is not something that they need to develop a response to. But just by working with country leadership in the clinical setting, you can demonstrate very quickly that these are real issues that need and deserve attention because of the disproportionate impact on all of these populations.

We have made this a big part of how we relate to governments that have epidemics in which socially marginalized groups are particularly vulnerable. We have made direct comments aimed at countries that have laws, or are considering laws, that could deter the ability to engage with vulnerable communities. That will continue. When I—or the President or the Secretary of State—come to a country, we make sure that we meet with representatives of vulnerable groups in conjunction with our partner countries so that our commitment to these communities is a clear priority.

TA Report: PEPFAR’s new plans involve taking a strategic approach to HIV prevention. Can you tell us how prevention responses are progressing in Asia and around the world?

Ambassador Goosby: Because it’s difficult to show results in prevention, I’m most interested in concentrating our activity on those interventions that we know have the greatest impact. We are internally assessing our approach to HIV prevention in all 30 of the PEPFAR target countries and we aim to have a core set of prevention interventions for each country reflecting its demographics and its risk groups.

Prevention plans have to acknowledge that there are populations such as MSM, injection drug users, and transgenders who are not well recognized and have no clear access points to testing, prevention services, and treatment. We must have special strategies for these groups. The shift in PEPFAR’s prevention strategy is to increase the capacity to identify high-risk groups, matched with a core toolbox of high-impact interventions.

Needle exchange, as we know, is a major HIV prevention strategy among injection drug users, who constitute a significant segment of the HIV population in Viet Nam and in many Asian countries. The goal is to keep people from sharing syringes so that those who are infected with HIV and hepatitis don’t spread them. This is an effective intervention that has a direct impact on seroprevalance, morbidity, and mortality among injection drug users. By preventing HIV transmission in this community, we can slow the virus’s movement into the low-risk general population.

TA Report: Can you tell us what sorts of lessons have come out of PEPFAR’s efforts in Viet Nam?
 
Ambassador Goosby:  Injection drug users in Viet Nam present a challenge because the population is participating in behavior that is often illegal. As a result, governments frequently have a law enforcement strategy. But taking a law enforcement-dominated approach drives injection drug users underground. They don’t reveal themselves to get tested, accept safe injection instruction or syringes, or receive diagnosis and treatment of HIV and hepatitis.

There has to be cooperation between public health and medical responses on the one hand and the law enforcement response on the other. These interests have to come to an agreement that will maximize the ability to identify, enter, and retain injection drug users into HIV care and services.

These issues have been highlighted in Viet Nam, along with an awareness of how important issues of trust and understanding are between the government and the public health sector, law enforcement, and the community. It has taken time to orchestrate a strong collaboration between these groups but we are moving forward. Viet Nam is now planning to rapidly scale up medication assisted treatment along with needle and syringe programs.

TA Report: Recent reports suggest that PEPFAR may be decelerating the scale-up of AIDS treatment.  What do you see for the pace of treatment and prevention scale-up over the next several years?

Ambassador Goosby: In the countries where PEPFAR is working, we are moving thousands of patients onto drugs every month. How rapidly we’re scaling up is really specific to any given country, and requires understanding how that site is doing, what it is budgeted to be doing, and what resources are coming into that site for treatment support. Treatment will continue to be the central piece of many of PEPFAR’s activities, especially in sub-Saharan Africa. We will not renege on the commitment we have made to those already on treatment.

This interview with Ambassador Goosby was conducted by amfAR Vice President and Director of Public Policy Chris Collins.