Conversations With America: Discussion on the President's Emergency Plan for AIDS Relief (PEPFAR)

Eric Goosby, M.D.
U.S. Ambassador
Dr. Jeffrey Sturchio, President and CEO of the Global Health Council
Moderated by Deputy Assistant Secretary for Public Affairs Cheryl Benton
Washington, DC
August 10, 2010

MS. BENTON: Hello and thank you for joining today’s Conversations With America, the fifth in a series of video discussions launched by the State Department. This program allows you to watch a live discussion between a senior Department official and the leader of a nongovernmental organization. Conversations With America allows you the opportunity to join the conversation by submitting questions through the State Department’s blog, DipNote.

Over the past few days, we have received many questions on the President’s Emergency Plan for AIDS Relief, also known as PEPFAR. We’ve received these questions from across the United States and around the globe. We will select some of these questions for discussion toward the end of the broadcast. During today’s program, the U.S. Global AIDS Coordinator Eric Goosby will be interviewed by Dr. Jeff Sturchio, President and CEO of the Global Health Council. These two great leaders have distinguished records of public service for promoting global health worldwide.

Before we get started, our guests will tell you a little more about themselves. Dr. Sturchio, can you tell our viewers a little bit about yourself?

DR. STURCHIO: Sure. Well, good morning. It’s really a pleasure to be here with both of you. As you said, I’m the President and CEO of the Global Health Council, which is the world’s largest alliance of organizations and individuals devoted to improving the health of people living in developing countries, and it’s really a pleasure to be here for the conversation this morning.

Before I do that – I’ve been in this job for about a year. Before that, I worked about 20 years in the private sector, where I had experience working in global health and HIV and AIDS and neglected tropical diseases, mainly in different parts of Africa. So I’ve been committed to this field for many, many years and it’s really an interesting challenge now to be in the NGO community, to be able to work with many of our member organizations on these issues.

The council really spends a lot of time on HIV and AIDS. It’s a key issue for us and we chair the Global AIDS Roundtable here in Washington, and about a hundred of our 600 organizational members work on the issues around the world in Africa, Asia, and Latin America. So I’m looking forward to our conversation.

MS. BENTON: Okay, terrific. And of course, Dr. Goosby, could you tell us a little bit about yourself before we start the conversation?

AMBASSADOR GOOSBY: Happy to, it’s a pleasure to be here with both of you. I started my HIV/AIDS work in the early ‘80s, 1980-81, when the epidemic emerged in San Francisco, which was where I was as a faculty member right underneath us. So we had people coming in with mostly opportunistic infections during that period. It was before we had antiretroviral drugs. And then went through that for about 11 or 12 years, was the director of the AIDS clinic at San Francisco General, the medical director.

And then went on to work in the government with the setting up of the Ryan White Care Act, which was like a domestic PEPFAR in the early ‘90s. That set up care and treatment services for HIV-infected indigent patients in the United States and 50 epicenter cities and 50 states.

I then went back to San Francisco and set up the Pangaea Global AIDS Foundation, which started to do treatment in the late ‘90s, early 2000s for settings that were resource-poor and felt not to be really capable of doing and treating a complicated disease. And come back, been here for also a year as the Global AIDS Coordinator for the PEPFAR programs with President Obama and Secretary Clinton.

MS. BENTON: Well, very, very good. Thank you. I guess we’re ready to get started, and I wanted to go ahead first and put a question to you that was sent in from one of our viewers, and it’s an AMFAR fellow who asked: “How can we ensure that the Global Health Initiative and the PEPFAR-funded government’s commitment to serving marginalized populations, especially when the recent increased focus on health systems strengthening may actually dilute already-limited funding in sustained systems that discriminate against these populations?

AMBASSADOR GOOSBY: Well, I’d be happy to --

MS. BENTON: Dr. Goosby.

AMBASSADOR GOOSBY: -- take that.


AMBASSADOR GOOSBY: I think it’s a good question. We have also come into a period of economic severity that is severe. The President has put a no-expansion or hiring freeze on programs that aren’t related to security across government. And this is a dramatic step, I think, for what is a dramatic economic decline.

What I think we need to look at is that over the course of the last two years, the President has increased the budget for PEPFAR, although be it small because of this economic severity, and as a result, we have also looked at areas of efficiency, synergy, and have been able to drop the cost of care by about two-thirds over the course of the last 18 months, which has freed up resources for us to redirect into care, treatment, and prevention services.

As a result, over the last two years, we’ve gone from 1.7 million individuals on antiretroviral therapy to 2.5. That’s a rate of increase that’s more rapid than any prior year in PEPFAR funding. And we continue in large numbers to put people onto antiretroviral therapy all over the PEPFAR family of countries who need care and are triaged into diagnosing and treating their opportunistic infections and then deciding if antiretrovirals make sense.

There are a complex series of systems that need to converge to keep the drugs coming, to keep the human resources in place, to keep the lab-monitoring capability accurate and robust. All of that orchestration of services has continued and increased during this time period. And we have been able to increase the number of people that we have brought into care and kept in care in addition. So the 2.5 million who are now on antiretroviral therapy will continue to be on antiretroviral therapy as we ratchet up the numbers who come in over this time.

Finally, I would just say that at the end of this economic severity, it’s the intention of the Secretary and the President to increase funding for PEPFAR and the Global Health Initiative to keep up with the six-year commitment of $63 billion over six years. And I’m confident that saving a economic rebound, we are definitely in a position where we will not delay or hold up the ability to place patients on antiretroviral therapy who need it in this interval. So I’m confident that with the synergies and efficiencies that we’ve already identified that we’ll be able to keep the momentum up.

MS. BENTON: Very good.

DR. STURCHIO: I wanted to come back to some of the things you mentioned, Eric. But the question that Cheryl started with actually was about marginalized populations. And as you know, a lot of people – we were both at the Vienna International AIDS Conference just a few weeks ago – and one of the key issues there surrounded the Vienna Declaration, which was a statement about the importance of using evidence-based approaches to dealing with HIV in such marginalized populations as injecting drug users, commercial sex workers, men who have sex with men, and I wonder if you could just say a little bit about how those populations are treated in PEPFAR’s programs.

And particularly, I think the key thing that the questioner was after was there are governments in which – some countries in which homosexual activity is criminalized, and that’s going to make it very difficult to encourage people to come and use services that are available for people who are HIV positive. So that’s the issue I think that concerns people. I wonder if you’d just say a word or two about that.

AMBASSADOR GOOSBY: Sure, Jeff. It’s a good question. I didn’t mean to sidestep that. Marginalized populations have always been the challenge for any robust response that a municipality or a state or a province or a government tries to mount. The individuals who have to reveal themselves to institutions are hesitant to do that because they’re often participating in something that is either scorned by society or participating in a felonious act and risk getting arrested and put in jail.

I think that the approach that we have taken is to try to put our programs, both prevention, care and treatment, well interfaced available on issues of access to marginalized populations. When governments aren’t willing to engage, we have gone through an NGO strategy – nongovernmental organization strategy – that allows us to somewhat bypass government while we continue a dialogue on a diplomatic level with leadership within the government around the lack of wisdom associated with creating barriers to care for these marginalized communities. Men who have sex with men, injection drug users, commercial sex workers, and transgender populations are especially vulnerable and need specific strategies that identify access points and retention strategies over time.

DR. STURCHIO: Yeah, I think you’d agree that the reason that’s so important is that in many countries, because those most at-risk populations are often – when we say most at risk, we mean they’re most at risk of HIV transmission. And so if governments have programs in place that ignore those populations, they may actually be ignoring some of the main drivers of the epidemic in their country, and so that just works against all the investment that PEPFAR and other partners are making to deal with the epidemic.

AMBASSADOR GOOSBY: Absolutely does. When you have one of these populations as a main motor for your (inaudible) converting aspects of your community, you need to understand that, understand where geographically these individuals are, and you need to go from their location backward into care and treatment services and you need to maintain it.

Creating safe space for individuals so they’re willing to reveal themselves so going into a medical relationship is not increasing their vulnerability around incarceration or stigma is a trick and a difficult thing to orchestrate with medical delivery systems, civil society, as well as our NGO community. Building that dialogue and bridge of trust is the beginning of what is a long process to fully embrace, capture, and retain these communities.

DR. STURCHIO: And I think, as you were talking, it just occurs to me that extending treatment care, prevention support to the many millions of people who PEPFAR is helping is really a complicated puzzle. It’s not just a straightforward A to B to C, but as you said, there are a lot of moving parts and pieces that have to fit together.

I mentioned the Vienna Conference. One other issue that was a major issue there and it was one that you were necessarily engaged in discussion of, was the question of levels of funding for HIV and AIDS. There’s one school of thought that says the U.S. has ramped up funding dramatically – I mean, as you both know, the PEPFAR program has an investment now, since the beginning, of more than $32 billion. And as you said, the President’s budget request for Fiscal 2011 is nearly another $7 billion, so that’s a lot of money. And it is nearly three-fifths of all of the money that’s going to HIV support among major donor countries. So the U.S. is playing a major role.

But at the same time, some people feel that the momentum is flagging, that this has public health implications and that the U.S. should be doing more. But I think at – the other perspective on this is you also mentioned the Global Health Initiative, which the U.S. has focused on as an integrated approach to dealing not with just HIV and AIDS, but without flagging in our commitment to HIV and AIDS, also dealing with maternal and child health and with neglected tropical diseases and a range of other, both primary care and complex health issues.

So I wonder if you could just talk about how that integration works. What does it actually mean and how is it that, while the level of funding isn’t increasing as greatly as we saw before because of the economic crisis that we’re going through, that you’re still confident that we’ll be able to continue the commitment to the people who are living with HIV and AIDS that PEPFAR’s already supporting?

AMBASSADOR GOOSBY: Well, it’s a fair question. I think it’s one that we have struggled with from the very beginning of the Global Health Initiative discussion. The impetus to engage in a reconfiguration of how our vertical programs move to the ground aggregate and are or are not available to the patients in front of us, who are already in front of us in maternal child health, family planning programs, immunization programs, as well as in HIV/AIDS, TB, and malaria programs. These individuals have diseases that fall outside of their vertical conduit, so we, in the HIV/AIDS platform are seeing patients who have maternal and child health issues, agendas, have major family planning issues that need to be addressed. They have children who are in need of immunizations – they get malaria, they get tuberculosis, they get (inaudible) neglected tropical diseases – all of which to date we have been impaired in our ability to respond to the needs of the patient who’s sitting in front of us with their HIV/AIDS problem now presenting with symptoms that are related to these other diseases.

What we’re talking about with the Global Health Initiative is really a maturation of our vertical programming strategy, to look at what we’re doing with these vertical programs across the board – HIV to malaria – and look at what those human resources and bricks-and-mortar and lab support and procurement distribution systems that are already there can now accommodate in expanding their service capability for these other diseases. These are relatively low-cost interventions to add on to already existing platforms. We are looking to take advantage of that, to be economic, to be smart, but to expand the service capability of the patients we’re already seeing in one of these platforms.

The cross training, the formulary expansion for the pharmacy, the ability to change our monitoring and evaluation systems to still allow us to report back to appropriators as to how the dollars are spent by disease category, make it even a little more complicated in weaving the system together to allow for the expansion of services. But at the same time, not only continue and maintain those patients that are already on board with HIV/AIDS, but to really expand our capability to now see the HIV/AIDS patient who’s in the maternal and child health setting and the family planning setting but not in the HIV/AIDS setting. So I really know that our modeling shows that as we increase our testing capability in these other arenas – non HIV/AIDS – we will find more HIV/AIDS positive patients that we are not currently interfaced with nor retaining in care who we will now be referring back into care.

So I would look at the Global Health Initiative as taking a service capability that’s coming in vertical programming – all of those will continue – but we will aggregate the service capability resource above the level of the service site, so that provider in the clinic or in the hospital is not impaired in responding to the needs of the patient in front of them who now has a complaint in another area.

DR. STURCHIO: And of course just to give everybody who’s watching us a sense of just how complex this is, PEPFAR has something like 67,000 service sites that you’re supporting, so this isn’t a simple task.


DR. STURCHIO: But – and possibly, and it might be a good idea to just give people a little bit more of a sense of how this works on the ground. I know HIV and TB is an area where this is probably proceeded as further than in some of the other disease areas. Maybe you could just give us an example or two of how this integration works in that case.

AMBASSADOR GOOSBY: Well, you’re right to identify TB. TB is mainly occurring in HIV positive individuals on the planet. We have a 60 plus percent overlap with our HIV positive person and active tuberculosis. In Sub-Saharan Africa it approaches 70 and 80 percent. These – I think, maybe, an example of a patient would be probably a good way to do it. We have in a Rwandan setting a 30-year-old woman who came in to care in what appeared to be late stage disease. She had signs of very late HIV – lymph node swelling, but also had oral manifestations of other infections that are associated with late-stage HIV – and comes into the clinic with this complaint. We’re able to diagnose her as being HIV positive.

We indeed, with the complaint of shortness of breath, cough, and fevers, night sweats, and a 30 pound weight loss over about a month and a half – an extraordinary weight loss in this woman; we almost didn’t believe it – had found that she had active tuberculosis that was disseminated, included pulmonary but also probably included peritoneal involvement, and were able to diagnose that, initiate anti-tuberculosis mycobacterial therapy for her. Did it for about three weeks and then, because of CD4 count that was 34, which is very low, initiated antiretroviral therapy about three weeks after TB initiation.

She – stopped her fevers, stopped the weight loss. The cough stopped after about a month. She began to gain weight after about six weeks. She, energy-wise, in about a month and a half started to increase and started to go up over the next three months, incrementally. We found that she had four children at home – two of whom ended up being HIV positive; they were under eight years old each, but had survived. And at maybe five and nine – five, seven, and nine – the nine year-old was HIV negative, the seven and five year-old were HIV positive.

Her husband who was bedridden and in bed, caquectic, way below body weight, unable to rise – raise his own head, able to get out of bed, needed help with everything – was also found to have active tuberculosis. Two of the children were found to be positive as well for TB, but not with pulmonary manifestations but generalized lymphadenopathy. And we were able therefore to identify the mother, the partner the husband, two of the children, for HIV and tuberculosis, prevent its spread through the larger family unit and community. And every one of them, including the man the husband that was bedridden, are now back at work, working, able to sustain an economic reality for the family that brings stability to the family, makes the community more stable around them, and I think adds to just the stability of the country, overall, when you kind of extrapolate that to the number of people that we’re impacting.

That’s a good example of a one point entry with the ability to diagnose and treat multiple problems that impact that individual, and that family, and that community maximally. I would end it with the fact that the woman was able to begin on her own volition a – what I would call a letter writing service – where she got her old typewriter, the old type of typewriters, and was able to use that as something people could rent essentially to write letters both to family friends but also official letters, that she was able to generate an income from that supplemented her family’s living ability and quite dramatically improved the overall lot.

We were able to support that kind of minor micro financing effort with the typewriter effort. But I give that as an example of how one individual ripples into many individuals and that ripples into stability that affects a whole community.

DR. STURCHIO: And without the help that was made possible through PEPFAR, that family would have had a very bleak prognosis; wouldn’t it?

AMBASSADOR GOOSBY: Yes, a hundred percent. Husband, the wife, and both children, if undiagnosed and treated, would have died.

DR. STURCHIO: Well, I just had one last question –

MS. BENTON: Oh, yeah. Absolutely.

DR. STURCHIO: -- and then we can turn to some more of the questions from the audience. And that is a lot of the attention to PEPFAR’s programs over the last few years has been to the treatment component and the fact that there are now close to 2.5 million people on HIV therapy as you mentioned. But recently, there’s been a lot of excitement about some new developments in prevention. And I was thinking here of the CAPRISA trial. But I wonder if you could just say, does that mean that we now have an answer for HIV prevention or what are the implications of that trial. And then just say a couple of more words about what PEPFAR is doing in HIV prevention more generally.

AMBASSADOR GOOSBY: Well, the CAPRISA trial was a trial that looked at a formulation using a very highly active and effective antiretroviral called Tenofovir in a gel that allowed for vaginal application. It gives the woman the ability to modulate her risk without having to get in a dialogue at that moment with her partner. Its effectiveness, if done properly, at 12-hour interval twice, two applications, really showed a 54 percent drop in their ability to get infected. So in her infectivity – in her drop in infectivity and being infected, which was remarkable. If you’d used it kind of once and maybe again in one or two days after the scheduled 12-hour application, it drops down to 34.

So we see there a very clear indication that one, it does work. Two, it has variation if you do it more rigorously or less rigorously. There’s a movement with it, which – it means that there’s a dosing option that we can better identify and pushes us into identifying correct dosing, correct intervals. If there’s a delivery issue around gel versus foam, to try to increase that 54 up into the 70s or 80s. This all puts a huge amount of hope and anticipation in part of researchers and communities that would benefit from this. PEPFAR is helping with the Phase 2 and 3 studies to go rapidly, to get the number up so we can get the answer very quickly. We expect that in two years, three at the most, we would be with product that would be available, could be available to increase the options of women in the field. PEPFAR’s approach to this has been to support it, to anticipate and model what it might look like if it were to work as a number of other preparations have – that we’ve done in the past.

But it’s also – we are really trying to look at different strategies for combination prevention that allow for kind of a piling on of strategies instead of just one strategy, but multiple strategies, that impact the same population. We still know and need to identify high-risk behaving communities, individuals. Our strategy needs to center that as the central piece that defines where we deploy our resources. The general population messaging and behavioral modifications have a role to play in this. But I would say that we are not clear around what the appropriate combination is as a function of which population.

We are positioning our implementation effort in prevention to now look at different strategies that roll out, not at the same time, but sequentially, to allow us to compare approaches for similar populations over time. So almost in real time, we’ll be able to say this worked and that didn’t, stop that and do this, and move resources to allow for that capability to expand to both areas. This approach is really implementing. But we are taking advantage of the fact that PEPFAR is implementing at a larger rate, higher number of sites than any other effort on the planet and has a monitoring and evaluation capability that can capture the differences so we can in actual fact make kind of real-time decisions around what’s efficacious and what isn’t.

This approach, which I think is unique and is really a challenge, but it’s extraordinarily important that PEPFAR take advantage of the numbers and the monitoring and evaluation capability that we already do have in place to really answer some of the key questions, especially in prevention.

DR. STURCHIO: It is critical, as I know you’d agree, that that capability enables you to make sure that we get maximum health improvement for the money that’s invested, which is critical in a period when everybody is trying to get the most out of the straitened resources that are available.

MS. BENTON: Clearly a lot of challenges, but some successes as well. So I’m going to take another question or statement from Ashok – A-s-h-o-k – in Florida. His statement is, “There are several nonprofit organizations, such as the Clinton Foundation, the Gates Foundation that are also helping to fight AIDS. Are you planning to have a coordinated effort to combat AIDS, which he believes is much more effective than individual efforts?” Eric, do you want to comment on that?

AMBASSADOR GOOSBY: Sure. I think that’s a good statement. Just as the Global Health Initiative within the U.S. Government is an attempt to take advantage of the fact that we have already up and running existing platforms off of which we can expand our service capability. So, too, in multilateral and other relationships between bilateral efforts should take advantage of integrating across these programs, such as with the Global Fund for HIV/AIDS, TB, and malaria to look for those synergies and efficiencies that we will only identify if we aggressively try to match our planning process as well as our implementation process.

Instead of doing two medical delivery systems with a bilateral program, a USG bilateral with PEPFAR, or a Global Fund program in the same capital city of a sub-Saharan African country, by collapsing our planning and implementation process, we immediately will find that there are significant savings to be identified and implemented and amplified and then reproduced in other cities within the country, but also in other countries.

We have seen this already in the collapsing of administrative individuals, so instead of having a site that has a HIV/AIDS capability and maternal and child health of family planning and immunization and malaria with five different directors of those efforts, having one director with deputies who actually monitor and implement in each of the respective sites, you immediately have those types of savings that we can incur. Using one procurement distribution system instead of five separate procurement distribution systems also affords another large savings. Same motor pool, same formulary for the pharmacy, for those aspects that needed a pharmacy.

Those types of administrative opportunities need to be teased out, identified, and taken advantage of, and we are actively moving in that direction between multilateral efforts. So it is the next big wave of savings. It’s also a smart thing to do.

DR. STURCHIO: And I might just add that, for instance, the Gates Foundation’s significant investment in vaccines is something that PEPFAR benefits from in the programs on the ground that you were just talking about, as well as, for instance, the Clinton Foundation has done a lot of work with generic producers of antiretroviral drugs to try to bring the prices down so that they can be procured more readily by countries that don’t have the resources to pay higher prices. And obviously, PEPFAR and the supply chain management system that PEPFAR manages also benefits from those kinds of negotiations as well.

So those are some of the ways in which there’s direct coordination between the efforts of some of the NGOs that our questioner asked about and the work that Eric was describing.

MS. BENTON: So in your work, can you give me other examples of the economies of scale that this questioner --

DR. STURCHIO: Oh, I think to take an example, I mean, our – as I mentioned, many of the organizations that are members of the Global Health Council are PEPFAR implementers. So they’re really on the frontlines providing the care in the clinics that Eric’s been talking about.

And so for one example, you might have a clinic in Kenya for HIV-positive mothers. Well, one may come in for their antiretroviral drugs for a regular checkup; they can also get information about family planning and reproductive health, and that’s – in the past, that would – might not even have been available to them. And family planning is one of the biggest gaps in global health coverage around the world. There are about 200 million women, people estimate, who need more information about family planning. And so by integrating those two services, the money that PEPFAR is providing on the HIV/AIDS front actually is extended much more by integrating it with information about family planning. Or you might have, in the same clinic, they can also be screened for cervical cancer, which is another major killer of women in developing countries, particularly in sub-Saharan Africa.

So those are things that might have been done in separate clinics in the past, and now, through one program that – an NGO who is working closely with PEPFAR can actually provide that range of services to the women in the community that they serve. And when you multiply that by the tens of thousands of sites where people are coming for care, treatment, and prevention and support, you can see the power behind that approach.

MS. BENTON: Good deal. I want to take another question from Diane in Texas. She asked: “What specifically is the U.S. Government doing to ensure that people infected by HIV/AIDS will be able to afford their medications?”

AMBASSADOR GOOSBY: Well, I think that there’s, in the international sense, in the 30 countries in which PEPFAR is doing a significant treatment effort, the partnership that we have with the country itself and now with increasing relationships with the Global Fund, which is also in the countries that PEPFAR – in many of the countries that PEPFAR is in, and in our ability to work in the private sector with public-private partnerships, we have a variety of strategies that are focused on ensuring that individuals who are entered in care, diagnosed, staged, and are determined to need antiretroviral therapy, that those individuals have access to free drugs.

Those drugs indeed are actually not free; they’re a combination of strategies that converge on finding the resources to pay for them. One big one is the movement that we are now over 90 percent in PEPFAR using generic drugs, which is a big change from the way it was before with the brand dominance. But those savings have enabled us to increase the number of patients that we’re able to bring into care as we lower the cost of care per individual. That drop has been about three-quarters of a drop from the original cost during PEPFAR in the first two years.

So we have found and had and enjoyed huge savings in that regard that we have been able to turn right back into program. So there are really, in PEPFAR programs, no individuals that we determine need antiretrovirals with whom we are not able to access those drugs with no concern around cost.

MS. BENTON: That probably is a myth that you rightfully debunked, that there are not treatments that you can get or medications that you can get that don’t cost, and people can come and get those treatments.

AMBASSADOR GOOSBY: It’s true that the cost of care is real. We have developed our systems, so we are addressing that. This is not to say that there won’t be situations where resources temporarily have been saturated or numbers create queues for people to have to wait. But those queues are rational and put in place only when they have to be, and people are prioritized as a function of their stage of disease as to when they get on antiretroviral therapy. But it really is the exception in the PEPFAR family of countries.

MS. BENTON: Good. Good deal. Okay, we’re going to take another question from someone who wrote in from Michigan: “How much does PEPFAR cost the U.S. each year? What concrete steps are you working with other countries to get them to take responsibility for funding their own HIV programs?” And “How are you measuring the progress following those steps?”

AMBASSADOR GOOSBY: Well, one of the, I think, major contributions that the PEPFAR experiment, if I could say that, has created is a outcome-driven program. We are very aware, more aware than any programs in the past, of who we’re treating, what we’re treating, what our goals of treatment are at a site level as well as a country level in terms of numbers treated, numbers retained in care, numbers lost to follow-up, and how that relates to the percent of the population that we think we’ve identified, captured, and entered in care.

Those types of hard outcomes for both opportunistic infections, for in-patient/out-patient care, for a specific diagnosis and a treatment, monitoring of their laboratory responses for safety and efficacy of treatment – all of that is part of the PEPFAR machinery in the treatment arena and allows us to, in a very specific way that is geographically labeled – we are able to tell you what we’re doing, where we’re doing it, and who we are doing it to.

Those types of reporting measures are unusual for USG-funded programming and has been part of our success in going back to appropriators in Congress and explaining to them what their dollar has bought. I believe it’s also told – showed the world, along with the Global Fund for HIV, TB, and malaria that a large concentration of resources, when deployed appropriately, can have a profound impact on a complex progressive disease. That was not generally accepted. People would think this is a much too complicated disease to take on in a resource-poor setting, but just as Jeff alluded to, we’re now thinking about diagnosing and treating malignancies for the first time, which suffered from the same assumption.

And in my lifetime, to see this progression from “No, we can’t do it, they can’t handle it,” to “Yes, we can do it,” and really focusing on resource issues is a profound sea change that has positioned us to really, for the first time, start talking about can we really look at a basement of healthcare for the planet where resource-rich countries converge their resources in such a way to increase the number of people who are entered and retained in care over time, a huge change in the way we view global health.

DR. STURCHIO: And I think the – what you’re just talking about, the fact that we do have the monitoring and evaluation capacity to see how these investments are paying off, I think, will help to answer the second part of the listener’s question, which is what are other governments doing and why aren’t they stepping up to the plate. I think having the evidence that this is value for money, that it really does have an impact on people’s lives in a positive way, will help with the arguments with other governments.

But of course, that’s coming up. You mentioned the Global Fund a couple of times. The Global Fund replenishment exercise is happening this fall. And we certainly hope to see that other governments will follow the U.S. lead and increase their commitments as well.

AMBASSADOR GOOSBY: We hope so. I think, though, that the portion of the question that really gets to that around country – the role of the country that we’re working in, their responsibility to their population.

A central piece of the Global Health Initiative and of PEPFAR as being part of it has been to refocus our attention on the role that the partner country plays in contributing human resources, bricks and mortar in the setting of the clinic or the prevention opportunity or the outreach opportunity – what their contribution is to the overall care of the population, what USG’s contribution is, what the Global Fund’s contribution is to follow over time. So we hold each other accountable, understand how each is contributing or not contributing.

But it has created a baseline for discussion with countries through our partnership initiatives that looks at a five-year timeframe in the future – here’s where we’re starting with our relative contributions, here’s where we need to go as defined by the unmet need; how and who are going to play the role to get there.

And I believe that our partnership framework strategy has enriched the relationship with the USG, with our partner countries in a way that will only enhance our ability to respond to this extraordinarily large unmet need by the convergence of resources, as orchestrated by the partner country. They are clearly in the best position to orchestrate other bilateral programs, other multilateral programs to define their unmet need, to prioritize their unmet need, and to make the allocation decisions.

The U.S. Government is committed to really enhancing the capacity of our partner countries in doing that in an excellent way. And I think the Global Health Initiative is the forefront of that activity and PEPFAR is a cornerstone of that initiative.

MS. BENTON: Okay. We’re just about at three, four minutes. I’m going to get one more question in and perhaps we can use that question as the wrap-up for each response. Patricia K. in West Virginia asked: “What are you doing to promote better nutrition for women and children under five years of age in the Third World? Since the immune system is made up of protein globules and it is the immune system which is so deficient with regard to AIDS, it would seem that making more protein available would be a must in all underdeveloped programs – countries.”

AMBASSADOR GOOSBY: Well, I think nutrition is a must for human beings to live, and I think a person who is infected with HIV has a increased protein requirement that needs to be addressed. An individual who is started on antiretrovirals needs to have a full stomach to place the pills on because they get nauseated and have really profound vomiting if they take it on an empty stomach. So those types of relationships are there. Nutrition is a cornerstone for all health and there are critical periods of nutrition, nutritional support that happened early on in development that impact size of brain, developmental landmarks, height, weight, but also ability to perform in school, to learn and to maintain that throughout their childhood and early adolescence.

All of those are nutritionally linked. I also think that the Global Health Initiative allows us to now, on these HIV/AIDS platforms or on maternal child health platform, to address the nutritional needs of the individual in front of us. I think that most of that takes care of itself as the patient gets healthier, feels stronger. Their ability to find and get resources by working and bringing in nutrition, food into the family is enhanced. So it is not one single thing that we need to put on the plate. It’s really a variety of things that an individual needs to successfully respond to this disease and to reenter and return to what is really a normal trajectory life, and die from something else.

Nutrition is a critical point of that – part of that. I think the child issue, with the Global Health Initiative, we expect to address nutritional needs in children in general, especially focusing on children less than five. And we have every reason to believe that we will be able to do that aggressively and rapidly on the already-existing platforms that we’re building the Global Health Initiative on.

MS. BENTON: Perfect, thank you.

DR. STURCHIO: I might just add – Eric’s done a very good job of spelling out the links between nutrition and health in HIV-positive people. I would just add that this general question of the links between food security and health is getting much more attention internationally. In fact, another initiative that the U.S. is leading on is a food security initiative that was announced at last year’s G-8 meeting. And the U.S. program Feed The Future would probably be a good subject for another Conversation With America. But it is a topic that’s getting more attention.

MS. BENTON: Good. Well, I think we’re at the end of our discussion and I want to thank Dr. Eric Goosby and Dr. Jeffrey Sturchio for a fascinating discussion from two of our distinguished Americans who are coming together and working on one of the most intractable problems that face us on the globe in America.

So thank you for joining us with Conversations With America. These conversations tend to inform and educate citizens about the Administration’s efforts to address such challenges. Thank you all for submitting your questions and for joining us live. The video and transcript will be available on shortly.

To continue today’s conversation with State Department officials, please visit the official State Department blog, DipNote, and continue to comment on current issues and policy developments. We look forward to engaging with you again very soon. Thank you.

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PRN: 2010/1083