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The CGD Podcast
We Can Stop the Spread of AIDS, and Sooner Than You Think – Amb. Deborah Birx
00:15:18
It is now possible to talk of a day when the number of new AIDS infections will be lower than the number of people dying from AIDS — a day when the disease starts shrinking. Ambassador Deborah Birx, US Global AIDS Coordinator, joins me on this...
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Foreign.
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Hello and welcome to the CGD podcast with me, Rajesh Merchandani. Here at the Centre for Global Development. A lot of my colleagues spend a lot of their time working on global health issues, looking in particular at how aid in health can work better. One area we focus on a lot is pepfar, the President's Emergency plan for AIDS relief, and a massive scale up of resources and effort begun by George W. Bush in 2004 and regarded by many as hugely successful. In fact, one review found that in less than five years, PEPFAR had averted 1.1 million deaths in Africa and reduced the death rate from AIDS to 10% in countries where it was operating. But how can it do better in future, especially when that future is one where we can realistically talk of epidemic control when the number of new infections is lower than the number of people dying as a result of aids, in other words, the disease is shrinking. That day could be coming. And to discuss that prospect, I'm delighted to welcome Ambassador Deborah Birx, the U.S. global AIDS Coordinator who leads implementation of PEPFAR. Ambassador Birx, thank you very much for joining us.
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You're welcome. It's great to be here.
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Now, when you first started working in this field, what were some of the realities that you faced and how did the idea of what we talked about, a shrinking disease, fit into that then?
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Well, I've been working on HIV AIDS before we knew it was hiv. I was trained as a clinical immunologist, so I was called to patients at Walter Reed in the early 80s who were dying from a MST serious immunodeficiency. It wasn't until 1985 when we had the test for HIV, that we realized that these soldiers, sailors and airmen had hiv. I was working on HIV vaccines in Thailand. It was the mid-90s and it was clear that we were going to have to have sites outside of Thailand. And we went to Africa to look for HIV vaccine development sites. And when you're in the community, and you're in the community in the district hospitals and you see hundreds of thousands of patients dying from HIV coming in the wheelbarrow load, two year olds suffocating from pneumonia without treatment and knowing that we had full treatment in the developed world, it really brought that intersection of incredible science in vaccine development with the human need to watch the field go from certain death to unqualified life. As Dr. Fauci shows, that you can live a normal lifespan if you're started when you're first diagnosed is really, to those of us who've Been in the field, just incredibly inspiring. It's what we dreamed of 30 years ago and never thought was going to be possible.
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So let's talk a little bit about PEPFAR, what you call PEPFAR 3.0 which is focused on epidemic control. How do you plan to actually get to that point controlling the HIV epidemic?
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So we believe it has to bring together really four or five different components and we like to call it the right things in the right places. We used to say in the right time. Now we say right now because the toxic, the clock is ticking and the Sustainable Development Goals have been announced and then we say in the right way. And I think that really captures really the essence of what we have to do. We know precisely what the right things are. The right places and the right populations has been a more difficult discussion. But with the recent UNAIDS publication about right places and right populations, it really makes it clear to us that it HIV isn't everywhere. And though our responses need to be focused. And then right now obviously is that we're already a year in to where we're supposed to be declining in the epidemic and we haven't had the impact that we need to have. So it's really time is ticking and people need to really focus. And then we say in the right way. And this really gets to the issues of these new funding models, our new relationships with governments and the fact that shared responsibility can mean not just financial shared responsibility, but these core policy changes that we need in order to succeed. So we need the WHO new guidelines that were just released four months ago implemented immediately. Sometimes it takes months, sometimes it takes years. We're really calling on countries to implement those guidelines within weeks.
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So you just said that you don't think you've had as much impact as you'd like to have seen. So what needs to go better?
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I think when we look at the impact we've had in specific populations. So we've had enormous success in preventing mother to baby transmission. So pediatric infections have fallen by more than 50%. But when you look at the other side of that adult infections, we've impacted adult new infections probably by less than 20%. And then if you look underneath, because this really is, this is a human to human contact disease. So. So you really have to know each individual population and their risk. And if you look particularly at young women, that's where we've had some of the least impacts. So the new infections among women 15 to 45 in our countries that we had been focused on with UNAIDS for the global plan New infections have decreased by less than 20%. At the same time, we drove down new pediatric infections by more than 50 or 60%. So, so this is really a challenge to all of us about how we not only have children born free, but how we ensure children stay free. And I think that's the focus of the DREAMS program that's really standing for determined, resilient, empowered, AIDS free, mentored and safe young women. Recognizing that there's complexity of integration that needs to occur at the community level, at the individual level and at the country level to ensure that young women have the opportunity to remain HIV free.
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Plans to bring the epidemic under control. How important is data collection? Better data, more data?
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Well, data is really the key element because when we talk about best practices that we need to implement, those need to be data driven and we need to know best compared to what BEST implies, that there's a comparator. Yet we often denote things as best practices without really having a comprehensive programmatic analysis. So we've been working with governments and with our PEPFAR teams on the ground to really look at what we do at the site level because that's what saves lives and prevents infections. We need to know what we're doing in the communities where we're working. So around the DREAMS programming, around our children's treatment program, we're really looking very closely at the data and really becoming very performance oriented. So partners that don't perform or need to improve their performance, we have to see that or we can't continue to fund. So I think we think this is a way global health, we think it's a way global education and other significant programs can be approached. Where you're looking constantly at the analytics. Now that's incumbent on us in making those analytics understandable. And I think that's the real gap we've had. We have individuals who can see things on an Excel spreadsheet and they're enormously good at it. I can't. I need to see it graphically displayed or geospatially mapped so I can really see what we're talking about, populations and programs and impact. And so it's not only about collecting data, it's making data visual and real and understandable at the program manager level, at the country level, at the implementing partner level, so that all of us together can improve our programs for maximum impact.
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You're never going to run into trouble at the center for Global Development when you talk about the need for more data. As you know, that's what we love, Data, data and more data. And using data to inform decisions. But if you start to roll out, as you say, this performance oriented approach, there are many partners on the ground who perhaps don't have the resources to get involved in that kind of level of data collection or who also may have other objectives that perhaps don't align with your objectives. There are politics at play here. How do you get over that? And another question is just if you need more and better data and you need to know better what's happening at your sites, does that imply that there's been a problem at the sites in the past?
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All sites are not equal. And the exciting thing about using data down to the level of granularity that we're using it at really shows that there are solutions that sites have come to to have dramatic improvement in either their service delivery or their impact. And so you start seeing these positive deviant sites, the sites that are outperforming all other sites. And there's always, when you go into those sites, I find this incredible innovative individual or team of individuals who have figured out on their own how to do things better, more effectively, more efficiently. And when I say to them, why didn't you tell us? Why didn't you raise the alert? This is phenomenal what you're doing. They look at me and go, doesn't everyone do it this way? So this is the human spirit is so creative and innovative, but yet so humble. And it's feeling like if they thought of it, everybody else thought about it. So part of my job is to bring those solutions into the light so that everybody can see what is possible and we can learn from each other. Because I believe the problems we're confronting today already have solutions on the ground. We just have to be smart enough to find them. And that really transcends power politics. Data is like music. It really will transcend any amount of political interpretation because they really, in general, people want to make sure that they're doing a good job. Now you might say, well, what am I talking about? And was there bad data? It's that it wasn't that there was bad data, it was just that we weren't utilizing all the data that we have. And I find this very common among global health professionals programs and that you collect a lot of data, but you don't use a lot of data. And so we're trying to not only collect it, but use it in real time and make it really accessible to everybody who wants to understand what we're doing.
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It wasn't so much has there been bad data, but by Using good data to highlight good practice. Are you also inevitably shining a light on bad practice? And I'm wondering what kind of practice has there been? If you need more and better data, then the implication is that you haven't always known what's been going on at the sites that you've been working in.
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I think the issue has been that we always averaged and mean data. So although we had site level data, we would look at it at the country level. And by the time. I always call it the tyranny of averages. When you do that, and you know much data is a bell shaped curve, you have really positive performance and you have some negative performance and you have some in the middle that could perform actually more towards the center line and do more with the dollars that they have. There is nothing like the fiscal reality of what is needed to control this epidemic and the understanding of the resources that you have that will drive you to look for value for money in every single nook and cranny.
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I think the tyranny of averages is a really good name for a book actually. Either you write it down or I write it down, but one of us needs to use it. Let's cast your mind forward and let's return to, I mean we talked a lot about data, but let's return to what we're here to talk about, which is really how you end this epidemic. Do you see a day, one day in the future when PEPFAR is no longer needed?
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I do. I see a time when we probably still need some people on the ground to work with the countries in partnership, but the financial vehicle of PEPFAR will not be needed. And we might say, well, when is that? If we all do our job and we do what UNAIDS has laid out before us as possible and we seize this moment and we have countries achieve what we think is possible, we then and we have control of this epidemic. And of course not all countries will achieve it at the same time. So there are countries right now achieving epidemic control. And I guess what you're asking is when will the high burden, or at least 90% of the high burden countries, the cost driver for many of the HIV AIDS costs around the globe, reach epidemic control? I think we can get there by the time of the Sustainable Development Goals. But then you're asking, how do you stay there? And to stay there you need an HIV vaccine. Because we know that there will be retention issues, adherence issues, we know that there will be resistance issues. And so we have to both continue to turn off the tap, but we also have to ensure that we have a vaccine in the future and a cure in the future. So we're doing everything that we can to get to where PEPFAR funding could dramatically last in 15 years. But we need an HIV vaccine and we need the investment there for vaccines and cures.
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Ambassador Deborah Birx, Great to talk to you. Thank you very much for joining us.
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Thank you.
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You can find out more about the Center's work on AIDS and hiv, including our new report, Aligning Incentives, Accelerating Impact, all On our website, cgdev.org you can also subscribe to the podcast there or look out for us on itunes. And don't forget to join me, Rajesh Merchandani, for the next podcast from the center for Global Development.