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A look at PEPFAR's legacy: 20 years of fighting AIDS


This weekend, we're taking a look back at two of the defining legacies of George W. Bush's presidency - the war in Iraq that left tens of thousands of people dead and millions displaced and a global public health initiative that saved millions of lives. We'll have more on the Iraq War in a moment - but first, the ambitious program that helps developing countries get HIV prevention and treatment.

In his 2003 State of the Union address, Bush announced the launch of the president's Emergency Plan for AIDS Relief, or PEPFAR. At the time, rates of HIV infections and deaths from AIDS were stabilized and falling in the U.S. But in sub-Saharan Africa, HIV infections had reached a deadly peak. That previous year, almost 3 million people died from AIDS, making it one of the worst years of Africa's HIV epidemic.

I spoke with Dr. Helene Gayle, the president of Spelman College. Dr. Gayle has worked for over 20 years in international public health and humanitarian aid, focused on HIV prevention and treatment. As an epidemiologist at the Centers for Disease Control and Prevention, with the Bill and Melinda Gates Foundation and other international health groups. She told me about meeting the first person in Africa to receive HIV treatment through the PEPFAR program.

HELENE GAYLE: Just to hear from this person how this had just transformed their lives and that that was at a time when HIV was a death sentence if you lived in Africa - this was somebody who really miraculously, if you will, was able to go back to living a life, being a productive family member, a breadwinner, member of the community. And that happened millions of times throughout the history of PEPFAR. But we also, through PEPFAR, were able to develop a public health and treatment infrastructure that has been hugely important as we tackled other global challenges like what we just went through with COVID. And so PEPFAR has such long-lasting, long-reaching impact.

HUANG: What is the scope of the problem now? And, you know, what are sort of the major challenges that face PEPFAR and the fight against global HIV/AIDS today?

GAYLE: The biggest challenge is keeping people focused on why this is so critical, why it is so important, and why it's in our best interest to continue to make sure that we are generous and share our technologies with the rest of the world. So I just think this is so critical to continue - people having a commitment to this program that has been not only lifesaving for millions of people but has also had a huge economic benefit that, in the long run, you know, makes us all safer, more secure when the whole globe, the rest of the world has good economic well-being.

HUANG: I wanted to ask you about one criticism of the program, which, you know, focuses on a period where the program focused on abstinence education. The money that was provided to other countries as aid was sort of bundled with a message of abstinence, which imposed a moral message on other countries that were getting aid from the program. I'm wondering what your thoughts are as you sort of reflect back to that time.

GAYLE: It's obviously much better to prevent someone from getting HIV than to necessarily need to take treatments - and, as you mentioned, treatments that are lifelong. That said, you know, we know that for a sexually transmitted disease, the way to absolutely prevent is for people to not have sexual interactions. But we know that that is a natural part of life and that having a message that is abstinence only without thinking about the other parts of how you can reduce your risk, like condom use, like treating other sexually transmitted diseases, you know, is really not using all your tools in the toolkit. So we understand that, you know, there are lots of conflicting feelings about people who may have multiple partners, have risky sexual interactions. But at the end of the day, you know, this was about saving lives. And I think we had to use all the tools in the toolkit and not be confined to simply one.

HUANG: You know, over the past 20 years, the U.S. has spent more than $100 billion on responding to HIV and AIDS globally. And I know that it's made a huge dent in the problem. But I'm also wondering, like, how much more? I don't know if we can quantify it, but, like, how much more money will it take to sort of end the AIDS epidemic? And, you know, why is that a good investment for the US?

GAYLE: Well, you know, I'm not sure that I can talk about, you know, dollars and cents and how much more it would take. I guess the question is really, you know, what would happen if we didn't spend those resources? And I think returning to the days that - before PEPFAR, allowing a pandemic to ravage populations, to rob generations of their future and their potential is just not something that I think we, as the United States, can sit by and watch happen.

HUANG: And as you mentioned, you know, the infrastructure that was created to combat HIV/AIDS through PEPFAR has been useful through the global pandemic of COVID. I mean, as other health threats emerge, do you think that PEPFAR should pivot to reach beyond HIV and AIDS?

GAYLE: You know, PEPFAR was created for a particular purpose, and I think it has done a great job of extending that platform to make sure that as PEPFAR as a program is developed, that it is thinking about what's the capacity that it's leaving behind? How can it serve more broadly? But I do think PEPFAR's focus on HIV and AIDS is important because we need to finish the job. It is still a major cause of mortality and morbidity in countries around the world, and I think until we finish that job, you know, it is important to have that single-minded focus, all the while understanding that we're developing infrastructure that will ultimately serve beyond just HIV and AIDS.

HUANG: That was Dr. Helene Gayle speaking with us about the 20th anniversary of PEPFAR, the President's Emergency Plan for AIDS Relief. To hear an interview with the current head of the PEPFAR program, listen to the Consider This podcast. You can find it wherever you get your podcasts and at npr.org. Transcript provided by NPR, Copyright NPR.

Pien Huang is a health reporter on the Science desk. She was NPR's first Reflect America Fellow, working with shows, desks and podcasts to bring more diverse voices to air and online.