PEPFAR — For fifteen years, CDC played a critical role in PEPFAR's effort
Message from Hank Tomlinson, PhD, Director of CDC’s Division of Global HIV & TB
Since its launch in 2003, PEPFAR has altered the course of the global HIV/AIDS epidemic—saving millions of lives around the world, improving the lives of countless others, and preventing millions of infections along the way. Through the compassion and generosity of the American people—and through outstanding partnerships—year after year, PEPFAR has accelerated global progress toward controlling and ultimately ending the HIV/AIDS epidemic as we know it.
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This year, as PEPFAR marks “15 Years of Saving Lives through American Generosity and Partnerships,” the year-long #PEPFAR15 campaign will highlight the tremendous impact, efficiency, and accountability of the largest commitment by any nation to address a single disease in history. As we celebrate this significant anniversary, more than a dozen high-burden countries are nearing a heretofore unimaginable goal: epidemic control by 2020. Remember, when PEPFAR began, only 50,000 people in all of Africa were on HIV treatment, and today—with almost 21 million men, women, and children on HIV treatment (13.3 million of whom are supported by PEPFAR, with CDC accounting for a significant majority of PEPFAR’s treatment expansion)—we are talking about controlling this epidemic.
This is a remarkable achievement driven by transparent, accountable, cost-effective, and innovative efforts in which CDC is proud to have played a leading role. While we are proud of our contributions, PEPFAR has always fundamentally been about partnerships—among U.S. government agencies, between the U.S. and host-country governments, and with non-governmental organizations. Since 2003, it has been the power of partnership that has pushed this effort forward, made it successful, and ensured that it is sustainable.
This 15th anniversary is a milestone along a long road on which we are still traveling, but today, our destination is closer at hand than ever.
CDC – A Key PEPFAR Implementing Partner for 15-years
Meet the People Who Have Made CDC a Key Partner in PEPFAR’s 15 Years of Progress
Many CDC staff members have been a part of this remarkable effort right from the start.
Charity Alfredo: Getting Treatment to All Who Need It
As a medical epidemiologist in Zimbabwe in 2003, Charity Alfredo, MD, MPH learned the exciting news about PEPFAR’s launch and understood immediately how the initiative would bring an urgently needed influx of resources to respond to the global HIV epidemic. Perhaps most critically, for the 15 initial focus countries, PEPFAR’s support would allow the scale-up of lifesaving antiretroviral treatment (ART).
In 2005, with PEPFAR well underway, Charity moved to Mozambique and joined CDC’s Care and Treatment Team in Maputo. Mozambique was one of PEPFAR’s original focus countries and, as such, a recipient of increased funding and technical support to rapidly scale up ART and reduce AIDS-related mortality. To achieve PEPFAR’s ambitious treatment goals, the initial model of support was direct technical assistance through well-established international partners that possessed the expertise to quickly hire staff; bring technical knowledge in HIV prevention, care and treatment; and procure and distribute ART and other HIV-related medicines.
Over the years, Charity’s work with CDC has evolved as innovative strategies and new evidence has emerged to improve the quality of HIV care. That is one of the aspects she enjoys most about working on PEPFAR: “The work is not static, and there is a continuous endeavor to improve,” she says.
She hopes that, ultimately, these innovations will one day lead to achieving HIV epidemic control. For now, Charity credits PEPFAR with having a significant impact on reducing AIDS-related morbidity and mortality, as well as in bringing down mother-to-child transmission of HIV. She also applauds PEPFAR’s focus on multi-lateral partnerships with organizations like WHO, UNAIDS, and the Global Fund, which has positively influenced governments’ HIV policy. She also believes that PEPFAR’s partnerships with these host-country governments and local organizations lead to increased sustainability of HIV care and overall community health.
Fifteen years on from those early days in Zimbabwe, Charity currently serves as the Senior Care and Treatment Coordinator in the Care and Treatment Branch of the CDC Mozambique office. For her part, she is most proud of PEPFAR’s success in making lifesaving ART available to millions of people, and she notes with satisfaction how PEPFAR-supported ART helps millions to “enjoy life, provide for their families, and contribute to the development of their communities and countries.”
John Blandford: A Champion for Scientific Rigor in the Quest to Save Lives
When PEPFAR launched in 2003, and CDC’s Global AIDS Program (GAP) was moving quickly with its implementation, John Blandford, PhD saw a “wholly different level of pace and scale” than what previously existed under President Bill Clinton’s Leadership and Investment in Fighting and Epidemic (LIFE) initiative launched in 1999 (which was itself a turning point in the role of the U.S. government in the global battle against HIV/AIDS). While some of the infrastructure needed to quickly implement PEPFAR already existed under LIFE, It was clear to the PhD-level economist that PEPFAR was far more ambitious both in scale and approach.
For one, when John came to GAP after working with CDC’s domestic Division of STD Prevention, he had the distinction of being the Program’s first economist, sitting within the Monitoring & Evaluation Team. “The decision to bring on a PhD economist, someone quantitatively trained with this particular specialty, to advance CDC’s public health mandate was — in its day – a bold move,” he says. This move by GAP also demonstrated the essential role of public health economics in CDC’s contributions to PEPFAR.
John played a pivotal role in introducing economic analysis to the initiative, making accountability and transparency integral to PEPFAR planning, budgeting, and impact evaluations. “The challenge when coming into CDC in a technical role,” he says, “is to remain true to technical and scientific rigor while maintaining a tight connection to the exigencies of program planning and implementation.” He adds that, unlike purely academic researchers, “We have the responsibility to be relevant and timely while maintaining rigor.” An example of this was a multi-country study of treatment costs and drivers led by John early in PEPFAR’s implementation.
“For me, here was an extraordinary opportunity to engage beyond one’s comfort level,” says John, “Taking risks and innovating along the way.” He recalls GAP, in this infancy stage, as a handful of staff driven by passion and purpose. “There was always more work, more need,” he says. In spite of the tremendous amount of work and the constantly shifting landscape of the program, he considers it a “unique privilege” to have been able to participate in CDC’s work in the global HIV response. In the midst of all the change, what has remained constant—even a decade and a half later—is the extraordinary dedication, work effort, flexibility, and good spirit that marked GAP from the outset. And John has seen this work from all sides: as Chief of the Health Economics, Systems, and Integration Branch; Principal Deputy and Acting Director of GAP’s successor, the Division of Global HIV/TB (DGHT); and, currently, DGHT Program Director for CDC Vietnam.
Of the program to which he has dedicated the last 15 years, John says, “PEPFAR’s impact has been extraordinary, and to an extent I couldn’t have imagined at the onset.”
“PEPFAR’s underlying description—an ‘emergency plan for AIDS relief’— implies something far more modest than its impact to date would suggest,” he says. “Witnessing first-hand how the reconstitution of immune systems and lives through PEPFAR’s antiretroviral medical assistance and community support efforts continues to motivate me to do this work 15 years later.”
Katy Yao: Advancing PEPFAR’s Mission through Her Dream Job
Katy Yao, PhD was working as a corporate consultant in Atlanta in 2004 when she found her self-described “dream job” through an employment advertisement from CDC. Like many Americans at the time, she was only beginning to learn about the global impact of HIV/AIDS and how PEPFAR – the U.S. government’s response to this growing epidemic announced a year prior – was having a positive impact in the lives of millions around the world, but the initiative’s “mission” of saving lives made an immediate connection with her. When she saw that job listing, she knew this was her chance to play a part. And so began a rewarding personal and professional journey that continues to this day.
She fondly remembers her first assignment with CDC as an instructional designer supporting the laboratory team – a predecessor to today’s International Laboratory Branch – and her first project: helping develop the generic HIV Rapid Test Training Package. This “workshop in a box” directly supported the expansion of HIV rapid testing, a key tool in the fight against HIV/AIDS but one which depends upon accuracy and reliability. The package developed by Katy and her colleagues helped to standardize training and ensure the quality of these rapid tests. She also supported its roll out in multiple countries through a “training-of-trainers” workshop.
“While numerous challenges existed in the early years of PEPFAR and the global response to HIV,” says Katy. “Overcoming each obstacle brought a sense of joy.”
She describes her “most significant” accomplishment as working to develop and implement a laboratory quality and improvement program called Strengthening Laboratory Management Toward Accreditation (SLMTA). The program was initially met with skepticism and deemed a risky endeavor. At the time, most training was done as a one-time event without follow-up or accountability for implementing lessons learned. “There were many who thought delivering a series of trainings over a period of time, followed by project implementation, on-site visits, and mentorship was too expensive and couldn’t be done,” she recalls.
Jump ahead 10 years, and “SLMTA is a movement,” Katy says. She likens to a wildfire that has spread to 52 countries and been implemented in over 1,000 laboratories. Prior to its launch in 2009, laboratory accreditation was “inconceivable” in resource-constrained countries. Today, SLMTA has helped 64 labs in PEPFAR-supported countries achieve accreditation while improving the quality of many others. Katy echoes former International Laboratory Branch Chief, John Nkengasong saying SLMTA is widely recognized today as “PEPFAR’s flagship program for laboratory-system strengthening.” Where once unimaginable, accreditation is now a shared ambition for many. “This could not have happened without PEPFAR and CDC-support,” says Katy.
SLMTA has had an impact not just on laboratory systems but staff as well. Katy recalls Chrysta, a young woman from Cameroon who considered herself “just a lab tech,” unsure if she had a future in the field. That was before SLMTA training. In 2014, Chrysta invested all of her own money into a trip to South Africa to attend the African Society for Laboratory Medicine’s first international conference. Upon arrival, however, Chrysta had only $50 remaining – far short of the conference registration fee. Impressed by her resolve, however, the organizers arranged for Chrysta to attend the conference as a volunteer and waived the registration fee. To this day, Chrysta has maintained her excitement and enthusiasm for the role of strong laboratory systems in improving public health across Africa, and she now confidently envisions a long public health career – one in which she plays a meaningful role in controlling the HIV epidemic.
This “joy and excitement” exuded by Chrysta is a feeling Katy can relate to. The last decade-and-a-half working with PEPFAR has been, Katy says, “almost like hitting the jackpot.” No surprise for someone still enjoying her dream job.
David Nelson: Building a Public Health Response from the Ground Up
David Nelson moved to Lusaka, Zambia in 2000 to become the first director of the newly opened CDC country office there. During this period, much of sub-Saharan Africa was reeling from the effects of the HIV/AIDS epidemic, and Zambia was one of fourteen countries in Africa hit hardest by the disease. When PEPFAR was launched in 2003, David and his colleagues found themselves on the frontlines of the fight against HIV.
According to David, PEPFAR was striking in its new approach to addressing a public health crisis – through the State Department, led by Chiefs of Mission at U.S. Embassies. This model wasn’t without its challenges, as David learned while developing Zambia’s Country Operating Plan 1 (COP)—a challenging exercise in which the State Department, USAID, CDC, and the Department of Defense all had to coordinate effectively to get the first COP out and begin implementation.
Before his work on PEPFAR, David began accruing public health experience while serving with the Peace Corps in South Korea as a tuberculosis-control volunteer. This experience has served him throughout his 35-year career at CDC, particularly in addressing HIV/TB coinfection. While at CDC, David has worked in a number of areas, first with the Division of Quarantine, next with the National Immunization Program, and finally with the Global AIDS Program, which is now the Division of Global HIV & TB (DGHT). David said, “CDC has been an organization that allows one to develop expertise in a variety of areas over time, and gives one new challenges to address.”
Working in DGHT for the last 17-years, David has supported PEPFAR from its inception and notes how its impact has been dramatic. When he first arrived in Zambia, David says, multiple funerals were conducted continuously, and coffin makers had a thriving business. The launch of PEPFAR meant that CDC, working with partners such as the Centre for Infectious Disease Research in Zambia, could offer HIV treatment programs throughout Lusaka, and, in those early days, it wasn’t hard to find those who needed treatment.
David noted, “PEPFAR has seen 15-years of steady progress” and with it “an opportunity to end the epidemic” something that was nearly unimaginable when PEPFAR launched.
One of David’s proudest achievements is the relationships he helped to forge with Ministries of Health in host countries. Public health diplomacy has allowed the U.S. to “strengthen our working relationships with governments around the world, making the world a better and safer place.”
”These partnerships have been our route to public health impact,” he says.
Alexandre Ekra: Turning the Tide of the Epidemic
For almost three decades, Kunomboa Alexandre Ekra, MD, MPH has committed his life and work to fighting the AIDS epidemic in his home country of Côte d’Ivoire.
After completing his Doctorate in Medicine at the Faculty of Medicine, National University of Côte d’Ivoire in 1997, he began work on CDC Côte d’Ivoire’s field research station Project Retro-Ci as Medical Research Assistant providing clinical care and treatment services to HIV patients and then on the Global AIDS Program as HIV Surveillance Team Lead and acting Strategic Information Branch Chief.
In 2002, an initiative aimed at the prevention of mother-to-child transmission was launched by President George W. Bush, which soon was broadened to become a part of the President’s Emergency Plan for AIDS Relief (PEPFAR). Alexandre joined the initiative and began his PEPFAR journey.
One of his first PEPFAR projects involved the 2-7-10 goals – putting 2 million people on ART, preventing 7 million new infections, and providing care to 10 million people infected or affected by HIV, but monitoring this data was a major barrier to success. As a medical epidemiologist, Alexandre was challenged to report on health indicators that were not routinely collected by his country’s health system before PEPFAR. “It was good to start working to strengthen the national system (health and community) monitoring program performance,” he said.
Over the years, Alexandre expanded his work from the development of monitoring systems to the delivery of HIV treatment. He is particularly proud of his work helping to promote access to antiretroviral therapy (ART) in Côte d’Ivoire, where—at the inception of PEPFAR–there were around 2,000 people on ART.
“For millions of HIV-infected persons, ART was not financially accessible,” said Alexandre. “Nowadays, thanks to PEPFAR, this has increased 110-fold. And these are people who would have died if PEPFAR was not implemented.”
As the current Prevention, Care and Treatment Branch Chief for CDC Côte d’Ivoire, Alexandre is responsible for the coordination, development, planning, implementation, and monitoring of CDC/PEPFAR Côte d’Ivoire-supported programs. He focuses on the delivery of comprehensive HIV prevention, care and treatment services. These include sexual prevention for youth and other priority populations, as well as stigma reduction, counseling and testing, and management of TB/HIV co-infection.
Today, he remains motivated by the true and concrete impact that changes the lives of people in his country. As PEPFAR marks its 15th anniversary, Alexandre reflects on the program’s value to the fight to control HIV.
Alexandre, who obtained a Master of Public Health degree from the University of California in Berkeley in 2007, points to the socio-economic benefits of a healthy population, saying “living longer obviously impacts individual lives; but it can also transform an entire country. It means that people with HIV can care for their families and contribute to the economic growth.”
“To me, PEPFAR has a significant impact on the lives of people in Africa and my country,” he said. “PEPFAR was able to turn the tide of the epidemic, making HIV a chronic disease instead of a death penalty.”
Katina Pappas-DeLuca: Changing Behavior to Stem an Epidemic
Like many of her CDC colleagues working on PEPFAR, Katina Pappas-DeLuca, PhD began her career combatting HIV/AIDS well before the massive global health initiative had been envisioned. For her, this work began in 1997 at Project San Francisco, a couples’ voluntary HIV counseling and testing program in Lusaka, Zambia. She soon joined CDC at the agency’s headquarters in Atlanta as a fellow in the Women’s Health and Fertility Branch in the Division of Reproductive Health, worked with the newly formed Global AIDS Program (GAP) in 2000, and today serves in the Division of Global HIV & TB (formerly GAP) in the Science Integrity Branch leading scientific publications clearance and reviewing of protocols for ethical and scientific integrity.
In 2000, as part of President Bill Clinton’s “Leadership and Investment in Fighting an Epidemic” (LIFE) initiative, Katina took part in GAP’s initial country assessment visit to Ethiopia. Katina recalls the gathering together of team members – CDC colleagues and in-country partners – often on short notice, equipped with intuition and inquiry, to conduct a critical needs assessment. These “whirlwind” visits (a descriptor she often attaches to those early days) made for day-long engagements and work sessions extending long into the night. Looking back, Katina see this hard work, facilitated by teamwork and collaboration, was foundational to PEPFAR’s efforts to stem the HIV/AIDS epidemic.
In 2008, Katina left CDC to work as a public health consultant in Africa, providing technical assistance to behavior-change communications programs. Focusing on couples, small groups, communities and mass media. She conducted formative research and summative evaluations of public health interventions and provided project management support and capacity building for HIV-prevention programs and activities.
While living in Namibia, Katina recalls an encounter with a Namibian acquaintance who had just returned from the north of the country. Katina had been consulting on a CDC-funded radio program and asked him if he had heard of it. With great enthusiasm, he told Katina how he and his wife loved the program and listened in whenever they could. He told her that they had even sought HIV testing as a couple when they were expecting a child – in part because of the radio program’s storylines on prevention of mother-to-child transmission of HIV. “That feeling of helping even one family was amazing and something I will always carry with me,” Katina says.
This fifteenth anniversary of PEPFAR has given Katina cause to reflect on the significant contributions of PEPFAR over the years. “PEPFAR’s impact has been tremendous—especially in helping to reduce the stigma associated with HIV,” she says. “The prevention and treatment services that are now available were what we were hoping could be possible when we started this work.”
It is PEPFAR’s continuous innovations that give her hope of even greater impact in the future. “Our ability today to collect information on HIV prevalence, connect people living with HIV to much-needed care, and guide our program efforts in real time is not only saving lives but I’m confident it will also lead us to control this epidemic in the not-too-distant future,” she says. “This is something to be proud of.”
Tekeste Kebede: A Long Journey to End HIV
By the time Tekeste Kebede, MD joined CDC Ethiopia in 2002, he had already been working in public health for more than a decade. His public health “journey” (as he fondly calls it) began in 1991 as an HIV clinical service provider in his native Ethiopia. Those were some of the darkest days of the epidemic, which Tekeste recalls as a time of “widespread denial, ignorance, fear, and neglect.” At that time, the outlook for people living with HIV was dire, and Tekeste relives that time through painful memories of patients suffering with life-threatening opportunistic infections and no viable treatment options. Antiretroviral treatment (ART) was not even available, and simple antibiotics were limited to palliative cases. He describes hospital wards packed with patients and says “death was rampant.” Many who died were young adults, he says, whose loss impacted not only households and communities, but the country at large. It was a discouraging time to be a healthcare provider.
By the time he joined CDC Ethiopia as a counseling and testing technical officer, however, he found reason to be encouraged as his new employer was supporting Ethiopia to introduce widespread voluntary counseling and testing for HIV. While this was a critical step forward in helping people to know their HIV status, ART wouldn’t become available in the country for another year, and, even when it finally was, it was an “out of pocket” expense that was unaffordable for most.
All of that changed with the launch of PEPFAR in 2003. “It brought a glimmer of hope,” Tekeste says, for both patients and the healthcare workers and officials leading the HIV/AIDS response. Thanks to PEPFAR and the Global Fund to Fight AIDS, Tuberculosis and Malaria, free ART became available in Ethiopia in 2005. Along with the provision of lifesaving medicines, he notes, PEPFAR also helped to transition some HIV-related clinical services from physicians (overburdened and scarce) to nurses who could easily be trained to readily provide these services to patients. Other innovations supported by PEPFAR included provider-initiated testing and counseling (introduced in all clinical service sites) and in-service training for healthcare workers in all HIV service areas.
PEPFAR’s success in a way exposed other challenges confronting Ethiopia’s fragile health system: many facilities lacked the basic capacity to accommodate increasing numbers of patients receiving ART. With PEPFAR support targeting health systems strengthening, Ethiopia’s Ministry of Health oversaw construction and renovation of comprehensive HIV care facilities, maternity wards, and regional laboratories. “PEPFAR was essentially responsible for building the country’s health care system,” Tekeste says.
Fast-forward to 2018. Still on his public health journey, Tekeste is currently the chief of CDC Ethiopia’s Health Systems Branch, with a professional portfolio spanning the continuum of HIV care and treatment. More than 420,000 people are currently enrolled on ART in Ethiopia, HIV-related death rates have reduced by 70-percent, and opportunistic infections are “rare.”
Most important, he says, is that patients who now have access to lifesaving ART are once more productive and able to support their families and raise their children. For Tekeste, this has been a journey worth taking. All, he says, thanks to PEPFAR and America’s generosity.
Luis Morfin: Marine Turned Public Health Pro on 15 Years of Progress
Luis Morfin was an active-duty member of the U.S. Marine Corps serving in the U.S. Embassy in Maputo, Mozambique when he heard President George W. Bush announce a new global HIV/AIDS initiative known as “PEPFAR.” Luis, who was about to complete 10-years of service with the Marines, recalls a “buzz” within the Embassy about the ambitious initiative, which was to be overseen by the State Department and Chiefs of Mission at Post. For his part, though, without a direct involvement in the program, Luis didn’t give much thought to PEPFAR at the start.
That changed soon after he left the Marine Corps, got to know the newly-arrived Country Director for CDC Mozambique, and ultimately joined the CDC office in 2004. As the foundation for this sprawling new initiative was being laid, little did Luis know how much PEPFAR would be a part of his future.
On his first day on the job as Operations Coordinator, Luis was struck by the tremendous diversity of the staff even within this relatively small, 8-person office. At that time, the CDC office was led by a Chilean-born Country Director, a Commissioned Corps Deputy Director, three expatriate technical staff (one German, one Spanish, and one Italian), and three locally employed Mozambican staff. Professionals from different backgrounds, specialties, and training, as Luis recalls, “All working toward the same objective—preventing the spread of HIV/AIDS.” For him, that diversity has come to represent PEPFAR’s unique approach to the fight against HIV/AIDS.
Working in management and operations, Luis was able to support CDC’s role in completing two major PEPFAR-funded facilities in Mozambique: a National Blood Reference Center for the country’s Blood Transfusion Services as well as its first biosafety level 3 National Public Health Reference Laboratory.
In those early days, Luis says there were occasional, inevitable challenges expected in the “introductory phase” of such a complex program. Questions persisted about PEPFAR’s purpose and objectives, and, interestingly, even about CDC, a U.S. government agency that was then little known in Mozambique.
Fast-forward 15 years, and Luis, who is now Deputy Director at CDC Malawi, says PEPFAR “continues to make history daily” as progress is made toward controlling the HIV epidemic, something unfathomable back in 2004. And that image problem for CDC? Luis proudly notes that the agency is now “an international force widely recognized for its expertise in global public health and for its dedicated and passionate staff.”
As he reflects on his public health career and the progress made in the global HIV response, Luis says he can now look forward to his retirement when he envisions sitting on his patio, rocking in his chair, and reading in the news about the eradication of HIV. “Knowing that I played a small part in this grand initiative,” he says, “will make all the effort worth it.”
Wolfgang Hladik: Putting Surveillance on the Frontlines of the Battle against HIV/AIDS
Wolfgang Hladik, MD, MS, PhD came to CDC in 1999 through the agency’s renowned Epidemic Intelligence Service, a postgraduate service and on-the-job training program in applied epidemiology. Assigned to the Division of HIV/AIDS Prevention, his primary research project, focused on the risk of transmission of human herpesvirus-8 (HHV-8) by blood transfusion in Uganda, foreshadowed his long career in the global fight against HIV/AIDS.
Within a few years, his work in this field would accelerate considerably with the advent of PEPFAR in 2003. Familiar with the global HIV epidemic through his academic training and professional work, Wolfgang nonetheless was struck by President George W. Bush’s announcement of the initiative for the clarity with which he described the epidemic and the “scale and scope” of the response which he was proposing. Wolfgang would soon deploy to several of the frontline countries earmarked for this unprecedented public health response.
For his part, Wolfgang initially supported antenatal clinic-based HIV surveillance in Ethiopia and Rwanda and would ultimately spend several years working with CDC’s office in Uganda. He recalls with pride the surveillance work that he and others were doing at that time that had to be “designed from scratch” and notes how far these efforts have come. ”Surveillance used to focus on a few key items – HIV prevalence, condom use, number of concurrent sexual partners,” he says. “While today, we are powering surveys for HIV recency and incidence; drug resistance; antiretroviral therapy; and viral-load suppression.” Following his time in Uganda, Wolfgang returned to CDC headquarters in Atlanta and is now chief of the Epidemiology and Surveillance Branch in the Division of Global HIV and TB.
“Over the last 15 years, PEPFAR has made significant and measurable progress and has overcome many challenges along the way,” says Wolfgang, but he also points to as-yet unresolved challenges including stigmatization and criminalization of HIV/AIDS which hinder efforts to reach global targets for HIV control. He’s grateful, however, that under PEPFAR, efforts to recognize “key populations” – including commercial sex workers, people who inject drugs, transgender people, prisoners, and men who have sex with men– have secured a place on the surveillance map, particularly in Africa.
When asked about PEPFAR’s greatest successes, though, Wolfgang weighs the long list from which to choose and ultimately settles on expansion of access to HIV treatment and prevention of mother-to-child transmission (PMTCT) as the top two. Summarizing the importance of both treatment and PMTCT programs, he says the early discovery that treatment suppresses viral load — both preventing morbidity and onward transmission – is what ultimately led to an understanding of antiretroviral therapy as the key pillar of biomedical HIV control.
Like others who have supported PEPFAR efforts around the world, Wolfgang sees its impact as more than just curbing the tide of an epidemic. He sees the compassion of an American president and the generosity of the American people transcending cultures and crossing borders to reduce human suffering and to save lives.
Aaron Zee: From Peace Corps to PEPFAR, A Decades-long Dedication to Public Health
It was 1982, and Aaron Zee, MPH was serving in the Peace Corps teaching Biology and Chemistry to high school students in Zaire – now the Democratic Republic of Congo (DRC). During this deployment, Aaron recalls meeting early AIDS-research pioneer Jonathan Mann in Kinshasa and learning more about the early HIV response efforts. After that encounter, Aaron says he was “smitten with the work” and knew then that he wanted to pursue a career in public health with CDC. In April 1986, he did just that, joining CDC as an STD Disease Intervention Specialist.
Over his long career in global health with CDC, Aaron has supported a variety of initiatives and in multiple countries over the years. Since joining CDC, Aaron says, he’s “had the pleasure of working in 16 African countries – and visiting 4 others,” including nearly 4 years on loan from CDC to the Carter Center (1993 – 1996) working to eradicate Guinea Worm disease in Mali. (Aaron was knighted ‘Chevalier de l’Ordre National’ by the Malian government for his work on Guinea Worm Eradication.) Upon returning to the U.S. in 1997, he devised and implemented CDC’s International Experience and Technical Assistance (IETA) program, which trains agency staff interested in working overseas; that program is still in existence and sending people abroad every year.
Nearly 20 years in to his CDC career, Aaron’s first engagement with PEPFAR came in 2003 as a member of the initial country assessment teams for Rwanda, Namibia and DRC which were responsible for developing the strategic direction, targets, and budgets for the newly established country programs. Right from the start, the PEPFAR teams began to make an impact. He recalls an experience during the assessment in DRC, a “low-prevalence” country for HIV at the time with most cases identified through antenatal clinics. Most women, however, did not deliver their babies in hospitals due to the cost (around $30 per delivery then). Aaron and the assessment team recommended that the newly-launched PEPFAR program cover the cost for newborn delivery – as an “enticement” for HIV-positive women to deliver in Kinshasa’s hospitals. Once adopted, Aaron says, that relatively straightforward policy change “had an impact on reducing transmission from mothers to their babies—a rewarding result in a country that had so many obstacles to health care delivery.”
In the years since, Aaron has worked on supply chain in Uganda, annual country operational planning in Namibia, implementation science in Zimbabwe, and country-office management as acting Deputy Country Director in Nigeria. He is currently the Deputy Branch Chief for the HIV Care and Treatment Branch in CDC’s Division of Global HIV & TB at the agency’s Atlanta headquarters.
For Aaron, PEPFAR’s impact is “its most distinguishing feature.” He easily lists off the highlights: over 14 million patients now on treatment, millions of infections averted, incredible progress in preventing mother-to-child transmission, and significant success with voluntary medical male circumcision. He credits his smart, dedicated colleagues doing “amazing work in multiple countries” as key to PEPFAR’s success. “They’re constantly working to make their efforts more effective and impactful.”
Perry Killiam: A Focus on Mothers and Babies
At the time Perry Killiam, MD, MPH moved to Lilongwe, Malawi with his family in 2002, that country suffered under the third-highest maternal mortality rate in the world – a fact which troubled the University of North Carolina-educated obstetrician who’d accepted a position as an OB/GYN specialist in the capital’s Kamuzu Central Hospital. Perry quickly discovered that more than 20-percent of his patients were HIV positive, and it soon became apparent that many of his colleagues were not treating the disease effectively and, subsequently, many of these women were dying from complications of untreated HIV infection.
At the time, there was a small prevention of mother-to-child transmission project providing single-dose Nevirapine to prevent perinatal transmission of HIV. However, there was no program for provider-initiated HIV testing or antiretroviral treatment (ART)—but that would soon change.
Perry describes the announcement of PEPFAR in 2003 (combined with the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria the year prior) as “truly transformative.” Not long after PEPFAR came to Malawi, he joined the CDC office there and worked with colleagues from the Ministry of Health to roll out an HIV testing and treatment program.
Calling PEPFAR a “profound game changer,” Perry recalls vivid images from the early, pre-PEPFAR days of the epidemic: walking into a hospital to the sound of a mother wailing at the loss of her baby to AIDS, driving along Lilongwe’s so-called “Coffin Road” where former furniture shops now produced mostly coffins. But even within a relatively few years of PEPFAR’s existence, its impact could be felt through a noticeable reductions in AIDS-related deaths among mothers and infants as maternal-and-child-focused HIV programs were introduced and brought to scale. Within just a few years of its introduction, he recalls, PEPFAR’s message to people living with HIV became one of “hope”—instead of a death sentence.
Like many of his CDC colleagues, Perry’s work with PEPFAR spans not only many years but many countries as well. By 2005, he had moved to Lusaka, Zambia where he continued his work in hospitals and clinics rolling out PEPFAR-supported public health programs and witnessing the program’s impact.
By the time PEPFAR marked its tenth anniversary, Perry was working with CDC’s office in Cambodia. He recalls the moment, as he reviewed Cambodia’s national mortality reports, when he realized HIV/AIDS had dropped from the top of the list of causes of adult deaths to a much lower ranking – behind heart disease, stroke, and even motor vehicle accidents. Those statistics mirrored his experience in the hospitals and clinics there – an AIDS-related death had become a rare event.
Now, as PEPFAR marks its fifteenth anniversary, Perry reflects on the many accomplishments along the way. From a mother expressing gratitude upon learning her child had been born HIV-free to a successful program of integrated antenatal care and HIV treatment—all are moments of which to be proud. Perhaps none is more remarkable, however, than the fact that Cambodia is set to reach global targets for HIV epidemic control. As Perry puts it, this once unimaginable goal couldn’t have been reached “without PEPFAR’s support.”
Donna Kabatesi: Building Partnerships to Reach Epidemic Control
Donna Kabatesi, MD MPH is a public health specialist who has dedicated her career to fighting the HIV/AIDS epidemic in her home country of Uganda. With a hint of excitement, she recalls a brainstorming meeting with colleagues in 2004 to discuss a work plan and budget in support of the new U.S. government initiative called PEPFAR. In those early days, Donna says, the focus was on identifying partner organizations with prior experience in managing and treating HIV-positive patients which could begin to receive PEPFAR funds. With a medical degree from Uganda’s Makarere University and an MPH from University of California at Berkeley, Donna, who had previously co-founded THETA, a non-governmental organization that promotes collaboration between the traditional and biomedical health systems, was a key member of this cadre. Prior to joining CDC Uganda in 2001, she worked with Uganda’s Ministry of Health in the STD/AIDS Control Program. She also worked with the Mulago National Hospital’s STD unit, and both experiences would serve her well as PEPFAR was brought up to scale in Uganda.
Donna, now Deputy Director of Programs at CDC Uganda, says, “CDC Uganda’s achievements in implementing PEPFAR are down to the successful partnerships” developed over the years. As she recalls, the initial series of PEPFAR meetings were held with potential implementing partners many of whom, she says, have gone on to be “long-term PEPFAR and CDC implementing partners” these last 15 years. In what was a learning process for some, she helped the future partners navigate the landscape that was the Ugandan government with an eye toward accessing funding. Although she describes the early process as “straight-forward,” Donna says, CDC Uganda’s local partners required assistance navigating the local landscape, particularly the process for accessing local funding.
Looking back through fifteen years of PEPFAR, Donna says she does so with nostalgia. The early PEPFAR years, she says, were “characterized by excitement.” The first Country Operational Plans (required annual planning documents laying out each country’s roadmap for PEPFAR implementation) featured “simple Excel spread sheets and basic documentation” –compared to today’s far more complex process which includes specially designed tools and templates.
Over these fifteen years, “PEPFAR has had an enormous impact on Uganda,” she says. “This effort has saved many lives, prevented many deaths, and prevented many children from being orphaned.” She notes proudly that, today in Uganda, more than 1,000,000 people are receiving life-saving antiretroviral treatment (ART) – far more than the few who could afford it before PEPFAR.
Dr. In a very real way, she sees hope in these numbers. There are an estimated 1.3 million people living with HIV in Uganda, so, if 1 million of those already on treatment, Donna says, “We are in the last mile”—which is to “identify those last 300,000 individuals.” At that point, she says, “Uganda will have attained epidemic control.” Musing on this possibility after fifteen years, Donna simply adds, “The excitement continues.”
Marc Bulterys: In the Midst of Global Impact, Personal Transformation
Within months of President George W. Bush signing PEPFAR into law in May 2003, Marc Bulterys, MD, MPH, PhD and his family were moving to Zambia, one of 15 original “focus countries” of the U.S. government’s new “emergency plan.” Marc was assigned as CDC’s Country Director there as well as the U.S. Mission’s Health Attaché to the southern African nation. “I still remember the excitement of my entire family as we prepared to move to Zambia to work on PEPFAR, and the many wonderful memories,” he recounts.
Marc (who began his career at CDC in 1998 as an epidemiologist with the domestic Division of HIV/AIDS Prevention researching perinatal and paediatric HIV) remembers his arrival in Lusaka in 2004 as an “exhilarating” time, with the CDC office’s rapidly expanding portfolio, growing staff, and increasing health impact. CDC Zambia’s focus then was on funding and supporting programs that yielded maximum impact on HIV prevention, care, and treatment, and the office earned early accolades from the Office of the Global AIDS Coordinator (the coordinating body for PEPFAR based within the State Department in Washington) for its cooperative work with the Zambian Ministry of Health and its sister agencies within the U.S. Mission.
After his time in Zambia, Marc and his family moved to China where he served as Director of CDC’s Global AIDS Program from 2008-2013. His team’s focus was on policy development, strategic information, implementation science, and dissemination of lessons learned. The team collaborated closely with the Ministry of Health of China and 5 high-prevalence provinces, reflecting the geographic concentration of the HIV epidemic in the south and west of China, and the vulnerability of key populations, especially men who have sex with men and people who inject drugs. By 2013, the Chinese government provided 95% of the funds for its domestic HIV/AIDS program. The involvement of the CDC’s Division of Global HIV & TB allowed for innovations and pilots that could then be replicated on a large scale by CDC’s Chinese partners. The team also supported 3 rural HIV clinical training centers that trained over 250 local doctors working primarily among rural ethnic minorities.
Thinking back on an HIV prevention session at a teaching college for Muslim women in the west of China, Marc was particularly struck by one of the unique aspects of PEPFAR’s work globally: “It brought so many opportunities to raise the profile of young women and children in this epidemic.” Both of those groups remain a focus of PEPFAR’s work today.
During 2013-2016, Marc worked as Associate Director for Science at the Department of Defense HIV/AIDS Prevention Program (DHAPP) which implements programs in 50+ countries worldwide, focusing not only on individuals enlisted in the military, but also their family members and the surrounding civilian populations. Since 2016, Marc has been on loan from CDC’s Division of Viral Hepatitis as team leader of the Global Hepatitis Programme at the World Health Organization Department of HIV/Hepatitis, in Geneva. Building on the successes of the global HIV response, the team is responsible for normative guidance and global technical activities towards elimination of the high burden (1.3 million annual deaths) of liver cancer and cirrhosis due to hepatitis B and C viruses.
And while PEPFAR, to which he dedicated nearly a decade and a half, has transformed the lives of people living with HIV around the globe, Marc admits that this work has had a transformative effect on his own life as well: “Working on PEPFAR has had lasting impact on my own family – and how our children see their role in the world.”
Catherine (Cate) McKinney: Aligning Staff for Local Health Needs
Since PEPFAR’s inception, Catherine (Cate) McKinney, EDH, MED has worked tirelessly to expand the reach of this remarkable public health effort across the globe by making sure staff has the resources needed to get the job done.
In 2000, she began her HIV career on former President Bill Clinton’s “Leadership and Investment in Fighting an Epidemic” (LIFE) Initiative, which had been announced the year before and provided funding to address the global HIV epidemic among adolescents between the ages of 15-24.
With the launch of PEPFAR in 2003, Cate says, the landscape of the HIV epidemic was dramatically altered. After a temporary role in the Office of the Global AIDS Coordinator, she became one of CDC’s core team of representatives tasked with guiding three African countries in the new directions of PEPFAR. Given her expertise in the human resources aspects of health systems, Cate served as one of the initial co-chairs for PEPFAR’s Human Resources for Health Interagency Technical Workgroup – from 2004 to 2005 and again from 2015 to 2017.
In 2005, Cate moved from CDC headquarters in Atlanta to CDC’s office in Mozambique where she led several projects including the launch of CDC’s Field Epidemiology Training Program and PEPFAR’s donor coordination of Human Resources for Health. During her time there, she worked closely with Mozambican Ministry of Health counterparts on a variety of human resources-related issues and initiatives. While her strength was human resources for health, working on PEPFAR efforts in the field required stepping in where efforts were most needed. This even included helping to build a site for HIV testing and treatment services.
Cate then moved on to CDC’s office in Ethiopia where she served as the Chief of the Health System Strengthening Branch and as a technical advisor on the staffing issues related to infrastructure activities and quality improvement. She is currently the Senior Health Systems and Human Resources Specialist in the Division of Global HIV and TB at CDC headquarters.
As PEPFAR commemorates 15 years, Cate notes how “CDC’s global AIDS work expanded its international presence from a few research centers to fully staffed offices in many impacted countries.” However, she recalls most vividly the change PEPFAR has brought over the years. Cate says, “We changed the dialogue from one of planning for death when a person tested HIV-positive to one where we talk of planning for life and the prospect of living with HIV.”
Keith Sabin: Building Systems to Monitor an Epidemic
In the spring of 2003—a few months after then-President George W. Bush had announced his emergency plan for addressing the global HIV/AIDS epidemic in his January State of the Union address—Keith Sabin, MPH, PhD moved from CDC’s domestic HIV program to its Global AIDS Program (GAP). (He had joined CDC seven years before working in sentinel surveillance for viral hepatitis.) Word soon came down that appropriated funding for PEPFAR was imminent—and was expected to be considerable—so Keith and his then-supervisor began brainstorming a process for strengthening and expanding global HIV surveillance given this remarkable new opportunity. What he didn’t realize at the time, he says, is that global HIV surveillance would become his specialty for the next 15 years and take him around the world.
In the early stages of PEPFAR as CDC began deploying staff and resources, Keith focused on expanding behavioral surveillance (a tool for tracking trends in knowledge, attitudes, and behaviors in populations at risk of HIV) as part of these efforts. His initial deployments were to Vietnam and Mozambique, followed closely by Kazakhstan. Keith’s job in these far-flung places was to review the existing HIV surveillance system, determine its efficacy in monitoring the epidemic and the response, and then design improvements to it as needed. Following his visits, he would draft a detailed set of recommendations on how to strengthen and expand these systems as well as how to implement bio-behavioral surveys targeting key populations (which typically include men who have sex with men, commercial sex workers, transgender people, people who inject drugs, and prisoners or other incarcerated people).
Like many of his CDC colleagues working on PEPFAR, Keith has worn many hats over the years and seen both the scope and nature of his work evolve. He now considers himself as much an “end-user” of HIV surveillance data as a collector of it and has seen his initial role as the primary point person for a single national system with six sites expand to working with data from 194 countries – drawn from hundreds of sites – today. For Keith, this growth has felt like a “natural progression” in a program as expansive and broadly impactful as PEPFAR.
In considering PEPFAR’s impact, the “obvious” part, Keith says, is the millions of lives saved over the last fifteen years. But beyond the numbers, he notes, PEPFAR has “impacted societies and energized public health systems in manifold ways.” PEPFAR, as he sees it, is as deserving of praise as the early visionaries of the global response—including WHO’s Jonathan Mann, pioneering researcher Peter Piot, and Jim Chin, an early leader in global HIV surveillance—whose work predated PEPFAR. With PEPFAR’s arrival though, Keith says, leadership of the global fight could suddenly “focus on something other than funding” for fledgling programs, and a “can-do” attitude was born—which he believes has become a pervasive trait of the global HIV/AIDS response and a contributor to its remarkable progress.
Though Keith admits, at times, this progress has been slow to come. He remembers his first visit to Vietnam in 2003 when he was asked by the Ministry of Health to review the country’s HIV surveillance system. He did so and submitted a set of recommendations to the Ministry. He was then told that any further movement on his recommendations would require an official action by the Vietnamese National Assembly. Many countries and assignments later, Keith found himself on a return visit to Vietnam in 2015 during which he encountered a colleague he’d met in 2003. This colleague happily informed him that the National Assembly had just recently approved the HIV surveillance system he’d recommended back in 2003! Rejoicing with the team, Keith joined in “toasting the results of a 12-year effort” to improve Vietnam’s national HIV surveillance.
As his colleague reminded him that day, “Patience and persistence together are rewarded.” Such is PEPFAR’s story too.
15 Years in Words and Numbers
CDC’s contributions help PEPFAR accelerate progress toward global targets for HIV epidemic control.
15 Years of Progress – Stories from the Field
The Power of Partnerships: Global Elimination of Mother-to-Child HIV Transmission
The theme for PEPFAR’s 15th anniversary observance is “15 Years of Saving Lives Through American Generosity and Partnerships” because, since its inception, PEPFAR has put partnerships at the center of its work.
Community Adherence Clubs: Breaking Down Barriers to Treatment in Namibia
“Are you tired of waiting at the clinic just to collect your antiretroviral therapy (ART)? Would you rather come just once a year? Ask the nurse today about joining a community adherence club (CAC)!” announces Simataa, a registered nurse at a clinic in the Zambezi Region of northeast Namibia.
Reaching Boys and Men in Malawi: A Village Chief Inspires His Community to Fight HIV
One breezy morning, Bobby Nduwaluwa, 52, walked into the Malembo Health Centre in Lilongwe District in Malawi to undergo voluntary medical male circumcision (VMMC).
A Decade of PEPFAR Support, A Life Regained in Côte d’Ivoire
My name is Vei Jonas, and I am 63 years old. I have lived in Man (in western Côte d’Ivoire) since 2004. I have three daughters who range in age from 33 to 12 years old.
PEPFAR’s 15-Year History Informs Country Operational Planning
In 2003, when PEPFAR began its partnership with Rwanda, less than 1,000 people living with HIV had access to life-saving treatment. Fifteen years later, PEPFAR supports close to 95,000 HIV-positive people on treatment.
Namulindwa Rose: 15 Years of PEPFAR Care and Still Patient 0001
Rose learned she was HIV-positive after losing her husband to the same disease. At the time, she could only access HIV treatment from the local private clinic and the medicines were cost-prohibitive.
15 Years of Life – and 10 Healthy Children – Thanks to PEPFAR and CDC
Madina was a mother of four when she discovered her HIV-positive status in 2002. After PEPFAR launched in 2003, Madina was one of the first clients at the Reach Out Mbuya Parish HIV/AIDS Initiative. She eventually gave birth to six more HIV negative babies.
Fifteen years ago, when PEPFAR was created, only 50,000 people in Africa were on lifesaving HIV treatment. New results released in May 2018 showed that the program now supports over 14 million men, women, and children on treatment.
“Over the past 15 years, PEPFAR has transformed the impossible into the possible by rapidly accelerating access to lifesaving HIV prevention and treatment services,” said Ambassador Deborah L. Birx, M.D., U.S. Global AIDS Coordinator. “We have not only saved more than 14 million mothers, fathers, daughters, and sons, but also accelerated global progress toward ending AIDS as a public health threat.”
In the video above, meet one of PEPFAR’s first treatment recipients, John Robert Engole, from Uganda and hear his remarkable story of survival thanks to PEPFAR’s lifesaving programs.
CDC’s Division of Global HIV & TB offers the following resources demonstrating CDC’s impact and support of PEPFAR.
An overview of CDC’s global efforts and key initiatives helping provide HIV prevention, care, and treatment in over 50 countries
New data highlights CDC’s contributions, as part of the U.S. President’s Emergency Plan for AIDS Relief, toward global efforts to control the HIV and TB epidemics.
CDC’s impact and focus on accelerating HIV treatment and prevention worldwide using a precision public health approach
Shareable social media graphics that highlight the burden of TB, global progress to date, and CDC’s leadership to help end the epidemic