TRANSCRIPT: Briefing on the 15th Anniversary of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)

Africa Regional Media Hub

Press Briefing on the 15th Anniversary of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) with U.S. Global AIDS Coordinator and U.S. Special Representative for Global Health Diplomacy Ambassador Deborah L. Birx via Teleconference,

Washington, D.C.

May 29, 2018

OPERATOR: Ladies and gentlemen, thank you for standing by. Welcome to the PEPFAR Update conference call. At this time, all participants are in a listen only mode. Later we will conduct a question and answer session; instructions will be given at that time. If you should require assistance during the call, please press * then 0. As a reminder, this conference is being recorded. I would now like to turn the conference over to your host, Brian Neubert. Please go ahead.

MODERATOR: Good afternoon to everyone from the U.S. Department of State’s Africa Regional Media Hub. I’d like to welcome our participants dialing in from across the continent and thank all of you for joining the discussion. Today, we are very pleased to be joined by Ambassador Deborah L. Birx. She is the U.S. Global AIDS Coordinator and Special Representative for Global Health Diplomacy at the Department of State. Ambassador Birx will discuss the 15th anniversary of PEPFAR and its life-saving impact on the African continent. Ambassador Birx is speaking to us from Washington, D.C.

We will begin today’s call with opening remarks from Ambassador Birx and then turn to your questions. We will get as many of your questions included in the time that we have, which should be between 30 and 45 minutes. At any time during the call, if you’d like to ask a question, you can join the question queue by pressing *1 on your phone. If you’d like to join the conversation on Twitter, please use the hashtag #AFHubPress and you can also follow us @PEPFAR and @africamediahub.

Again, today’s call is on the record, and without further delay let me turn it over to Ambassador Birx.

AMB. BIRX: Thank you so much and it’s good to be talking to all of you this afternoon from Africa. I think you know that 15 years ago, PEPFAR—in fact, just this last Sunday—was signed into law by President George Bush. It’s really remarkable; we went from a presidential announcement and a State of the Union at the end of January to passing of this legislation in less than four months, and I think it showed how compelled both the president and Congress were to answer the issues that had arisen in sub-Saharan Africa from the HIV/AIDS pandemic.

In those days, mothers, fathers, teachers, children, doctors, nurses, were all succumbing to the disease. In fact, those of us who worked on the continent at that time attended many more funerals than we attended weddings, and our own staff was dying from this deadly disease. I think at that time less than 50,000 individuals were on any kind of treatment in sub-Saharan Africa. And since that time, we’ve come a long way together, and I say “together” because it’s been a critical engagement with the host country governments and the communities and civil society in each country to make the progress that we’ve made, with over 14 million men, women, and children now on treatment—a long way from the “just fifty thousand”. In fact, we doubled that number in just a little more than four years. We did all of that in a flat budget, showing that although resources are critical, ensuring that every resource is optimally spent has really been a hallmark of our program in the last few years, and I think we are absolutely committed to not only continuing to save more lives, but, in moving us forward, to ending AIDS as a public health threat.

So through our 15 years, PEPFAR has had incredible support, and what we would call bipartisan support, from both Republicans, Democrats, and Independents, along with three presidential administrations and eight Congresses, and we always are deeply grateful for the continuation of support. Under President Donald Trump, with his ongoing bipartisan support of Congress—and certainly we must recognize the generosity of the American people—PEPFAR continues to expand its remarkable impact. But we’re very much drive by a focus on accountability, transparency, and ensuring that our investments are cost-effective, because we realize every day that these are hard-earned American taxpayer dollars, and we’re deeply committed to using them wisely to save more lives.

Also, since its inception, we’ve prevented infection of over 2.2 million babies, who’ve now been born HIV-free to HIV-positive mothers, and this is a huge accomplishment across sub-Saharan Africa, and you can see many countries are showing a dramatic 80-90% decline in the number of babies born with HIV. At the same time, we continue to support orphans and vulnerable children; really, over 6.4 million of those orphans and vulnerable children, but changing the focus of that program to really ensure that children can thrive and remain HIV-free.

We’ve also, in addition to all the investment that we’ve had in health systems and human resources and laboratory systems and electronic medical records, we’ve also increased our investment in prevention. I think many of you know that Africa is undergoing an incredible demographic youth bulge, with about twice as many 15-24 year olds on the continent as there was at the beginning of the epidemic. Because of that, we’ve really strengthened our prevention activities, ensuring that boys and young men are circumcised, because that decreases their risk of STIs, but most importantly, HIV, by more than 60%, and we believe that to be lifelong. We additionally increased our investment to prevent infections in young women, particularly the 15-24 year olds. That’s a public-private partnership that’s been extraordinarily important to us. And just over the last two years in the majority of the districts, over two thirds of the districts, where this program is focused, across 10 countries, we’ve seen a 25-40% decline in new HIV diagnoses among adolescent girls and young women.

We continue to focus the program to utilize the power of the partnerships, including the foreign governments, the private sector, but also multilateral institutions and, critically, civil society and faith-based organizations, but importantly, working directly with the people living with HIV/AIDS that continue to make the program more important at the community level. So more people are diagnosed and more people can receive life-saving treatment, as well as increasing our prevention.

So as we celebrate this 15 years of saving lives and seizing this historic opportunity for the first time in modern history to control a pandemic without a vaccine or a cure, we’re laying the groundwork for eventually eliminating HIV, as we develop a vaccine and a cure, and I think you know NIH, our National Institutes of Health, work very hard on developing a cure and a vaccine.

So PEPFAR, 15 years ago, was born out of the belief that we could make the impossible possible, and I think we’re seeing today that’s becoming a real reality in Africa and around the world. I’m going to stop there and be brief because I want to get to your questions, so thank you.

MODERATOR: Thank you very much, Ambassador Birx. We’ll now turn to questions. Again, in order to join the question queue, press *1 on your phone. For those of you listening on a speakerphone, you might have to pick up the handset in order for that to work. And I know that we have listening parties around the continent at U.S. embassies.

Let’s turn first to Addis Ababa. If you could introduce yourself and your outlet and ask your question.

OPERATOR: Addis Ababa, your line is open. Please go ahead.

MODERATOR: Okay, it seems as though we’re having difficulty opening that line. Let’s turn to Kevin Kelley, Greg, and we’ll try to get Addis next. Thank you.

OPERATOR: Kevin Kelley, your line is open. Please go ahead.

QUESTION: Yeah, hi, thanks for doing this today. I’m Kevin Kelley, I write for the Nation Media Group in Kenya. I’m based in New York, which is where I’m calling from. So yeah, PEPFAR has made some really impressive achievements in the last 15 years. I’m wondering, though, to what extent your work involves capacity-building in Africa and if you could speak specifically to Kenya or East Africa that would be great. I mean, this is a U.S.-led initiative, obviously, but is it sustainable on that basis, and what are you doing to make it an African-owned effort? Thanks.

AMB. BIRX: Great, thank you for that question, because it’s really very important to us. So over the history of PEPFAR we’ve invested billions in what we call “above-site”—those infrastructures, laboratories, clinics, building clinics, building district hospitals, renovating regional hospitals, but critically, creating an integrated lab system, and I think a way to ensure that that becomes wholly African and African-sustainable is, I think you know, we also created ASLM, the African Society for Laboratory Medicine, recognizing the importance of the laboratory, not only for PEPFAR, but for diagnosis of other diseases in the future, including the other infectious diseases, speaking of malaria, but also important for NTDs and critically important for the Global Health Security Agenda that we all share together.

And so that infrastructure, as well as the human capacity, has been built, but also African-specific components through the African Society of Laboratory Medicine, but also through the African CDC. The individual who is responsible, with us, to really design and work with countries to create the lab strategy, John Nkengasong, is currently the head of the African CDC, so knows very well the importance of this sustainability.

But I think you asked a very important question about the health infrastructure and what we are doing to continue to support that, and in some places I can say we’ve been incredibly successful. I think the work that we’ve done and the [UNCLEAR] infrastructure and the human capacity, both training and employing more than 250,000 new healthcare workers just on the continent alone—that work has been really essential, and we invest about $750 million a year, about 20% of our budget into sub-Saharan Africa, goes solely into these sustainable infrastructures.

But critical to that is really the supply chain, and so where I think we’ve made great progress at the clinical level and with the human capacity and at the laboratory level and that human capacity, I haven’t seen the same improvements across the board in the supply chain, despite nearly $3 billion of direct above-site investment into the supply chain. And so I think that really raises a new question, which is whether we’re building, together with countries and communities, a supply chain for the 21st century or we’re using a 20thcentury model that may not apply anymore. And so we’re going back very carefully to look at the issues around the supply chain and really figure out how we can bring private sector and public-private partnership supply resolution to these critical issues, to ensure that life-saving medications get to everybody at all times. We are committed to that; we haven’t had stock-outs in the PEPFAR sites. We’ve had times when we’ve gone to two weeks of drug supply because of low stock, so that’s really an opportunity for us to all do better, and if a country wants to move forward with an NTD agenda, a robust supply chain at all levels will be critical.

QUESTION: Can I ask a follow-up?

MODERATOR: Go ahead, Kevin.

QUESTION: Can I ask a follow-up question? Yeah, so thanks, that’s really helpful. But what do you mean by “supply chain problems”, “supply chain 20th century model, not a 21st century model”? Can you be specific about that?

AMB. BIRX: I think we’ve contemplated a lot on the physical infrastructure and the human capacity, but have not got really IT solutions, to really understand what’s at each of the sites. So I know we’ve done a great job at training people, forecasting, developing warehouses, creating central supply stocks that are highly regulated, overseen, and have great oversight at the country level by, often, host governments. But the issue is, when it gets transported out to the remote sites, what exactly is there? How are we tracking that? How are we constantly observing for stocks? And so I think when you go to any CVS in the United States, you can see sometimes there are slots where—or if you go to a hotel in the United States and you take out a beverage, you know, it signals that that beverage has been taken out. Mostly because they want to charge you, but in our case we’d really like to know what is being utilized, when it’s being utilized, and that will help us know precisely when things need to be refilled at that site, and what other medications could be refilled simultaneously to make that supply chain across all the medical supplies and not just HIV.

And I think we’ve taken a very horizontal approach, and we probably haven’t gotten that message out well enough, but I really appreciate the question. Our investments into the health systems in sub-Saharan Africa have been solely in a horizontal way, that help the entire system, not just the HIV component.

MODERATOR: Thank you. We’ll turn to the next question. If you could introduce yourself and your outlet before you ask your question.

OPERATOR: Nick Turse, your line is open. Please go ahead.

QUESTION: This is Nick Turse from The Intercept. Thank you for taking the time to talk, Ambassador Birx. I appreciate it. President Trump proposed cutting PEPFAR funding in fiscal 2018 and 2019, and his budget proposals would cut more than $1 billion from global HIV funding. The ONE Campaign says that this would lead to roughly 300,000 deaths, and I hope that you could comment on the administration’s repeated attempts to cut the program, the reasons behind it, and whether you agree that the cuts would end up costing lives.

AMB. BIRX: So let me be very clear about the resource agenda, because that is why I opened with how we have tripled the number of circumcisions and doubled the number of people on treatment and launched these new prevention programs in a flat budget. I think what we always have to understand is, are we looking at every single dollar and ensuring it’s invested optimally? And I think that’s a challenge that President Trump has put out in the foreign assistance arena, to say, “What kind of business data and business models are you using to ensure that every dollar of our American people’s taxpayer dollars are invested for the optimal impact?”

I think we’ve been very careful to ensure that we have outcomes and impact, and so we would be able to tell you in the future whether there have been any issues as raised by ONE, but I don’t have, currently, the evidence base—I actually have the opposite evidence base—that we’ve been able to continue to expand our work. And really, too, I want to give credit where credit is due. This is due to host country governments and communities and partners looking at every single dollar.

So will there reach a point where we won’t have those same levels of increasing the efficiencies and effectiveness of the program? That could happen, and we’re to watch for that all of the time. But I think we have to ask ourselves, “Are we, every day, optimizing our foreign assistance budget for maximum outcomes and impact?” And I think that’s what President Trump has said to all of us. “Look at what you need and make sure that your program is optimized to have the greatest impact and outcomes.”

I think, really, we should be asking that of all of our global health programs, all of our Feed the Future programs, all of our Power Africa programs. Every day we should be looking at performance and how to improve performance, because our mission—we know our missions are critical, that’s why we have money in foreign assistance. But I think we also have to really ensure that we have optimized our dollars to be utilized effectively.

MODERATOR: Thanks, Ambassador Birx. We have Addis Ababa embassy back on the line. Go ahead and introduce yourself and ask your question, please. Let us know what your outlet is.

OPERATOR: Addis Ababa, your line is open. Please go ahead.

QUESTION: [UNCLEAR] Could you tell us, [UNCLEAR] Africa, so [UNCLEAR]

MODERATOR: Addis Ababa, I’m sorry, we can’t understand you at all.

QUESTION: [UNCLEAR]

MODERATOR: No, I’m sorry, we can’t—try picking up the handset; otherwise we’ll have to go to another line. I’m sorry, we can’t make it out at all.

AMB. BIRX: I think I understood enough of his question to answer it, if that’s okay.

MODERATOR: Terrific. Yes, please, Ambassador. Go ahead.

AMB. BIRX: I think he’s asking about the high-burden countries and how we’re balancing investments in the high-burden countries versus countries like Ethiopia. I think that’s a really critical question, because Ethiopia is in a critical situation right now. That’s important for all of us, and I want to really emphasize that. Because of the work we have done in Ethiopia, together with the governments and communities, the investments that we’ve made in community health workers and infrastructure, the number of health centers we’ve built across Ethiopia, both the Global Fund and PEPFAR, we’ve seen remarkable progress in Ethiopia. And so Ethiopia is approaching the situation where we call it that they are “controlling their pandemic.” What do I mean by that? It means that the number of people infected with HIV is beginning to shrink, because of both their prevention and treatment work that we’ve done together with our Global Fund and PEPFAR investments.

Ethiopia had one of the largest investments, between PEPFAR and Global Fund, and I just want to emphasize, again: those dollars were put to highly effective work in Ethiopia. And so today, we’re asking the team and the country and the government and communities to really come up with a long-term plan about what kind of investments do we need to make—this gets back to the first question—what are the long-term investments that PEPFAR and Global Fund need to make together to ensure that the epidemic remains controlled and continues to shrink? I think that’s a really critical question.

Ethiopia is poised to answer that for us in sub-Saharan Africa, and so their investments will be utilized in a different way. Other countries that have high burden, with our restoration of our 18 budget by our Congress, all of our investments were maintained at their high level in all of the countries with high burden of disease. And the Ethiopia question is a different question, and is really not a resource question. It’s really, “What do the next 10 years look like as we develop control of this pandemic?” And I think Ethiopia is in a unique position to answer that.

MODERATOR: Thank you. We have a listening party at the U.S. embassy in Lesotho. Go ahead and introduce yourself and your outlet and ask your question. Thank you.

QUESTION: Thank you very much. My name is Lerato from Lesotho. I have two questions, and my first question to the Ambassador is, since the beginning of PEPFAR in sub-Saharan Africa, where can you say we are in ending HIV and AIDS as a health pandemic? That’s number one. Number two, stigma is one of the major challenges in our African countries. How is PEPFAR dealing with that African challenge? And my last question is, in how many countries has PEPFAR introduced the Self-HIV Testing? And how effective is it thus far? Thank you.

AMB. BIRX: Wow, great question, showing you have a lot of awareness of our program, so thank you and thank you for keeping appraised of where the HIV/AIDS epidemic is. So that’s really a key question, and so, you know, we have UNAIDS that’s been doing really effective modeling, country-by-country, and we really felt like we needed to validate that model, country-by-country, and really show where we are precisely in the epidemic. And so in Lesotho, I think you know, we completed a community-level survey in Lesotho about a year and a half ago, maybe a year ago. We’ve done that now in 11 countries and we’ll be releasing four more countries’ results this July. Those surveys have really been critical for us because they show very clearly what we have done together and how we’ve made progress together.

And so if you look at women over 25, almost all of those women know their status and are on treatment and are what we call “virally suppressed.” That means that for their own health, they no longer have high viral loads that contribute to their disease, but equally importantly, they don’t transmit the virus to others, whether during pregnancy or to their partners. This is what’s allowing us to decrease the epidemic across the continent.

So if you look at Lesotho’s numbers, your incidence has decreased by almost 50% just in the last few years. That’s remarkable. That’s what we need to do, and that’s why we’re very persistent about maintaining the pressure. There’s country after country that look in the same way as Lesotho, including Swaziland, Namibia, Botswana, Malawi, and there are other countries where we know the burden of disease is quite large, like South Africa, where we’re working together to actually realize the President’s vision of getting two million additional South Africans on treatment in the next two years. That’s what it will take to really decrease what we call the “community viral load,” the transmission at the community level.

But thank you for raising the issue of stigma. So for years we talked about it, but we didn’t measure it. And so we’ve been working very closely with NIH and what we call the “Office of AIDS Research” to create a stigma index with the UNAIDS group and then utilize that to collect the data, country by country, community by community, to really measure where we are and do more things to show whether we’re having an impact. We were doing a lot of things, but as you clearly pointed out, stigma in general is still very high across the continent, and remains incredibly high. So that’s critically important, that self-testing, and who’s doing self-testing.

We’ve asked all of the countries in sub-Saharan Africa to begin self-testing. Why? Because when I talked about those community-level surveys, although we found huge impact among women, because women have access to treatment and diagnosis when they become pregnant, if you look at men, we were finding men very late. We were only finding men when they presented as inpatients or outpatients with TB or opportunistic infections, because they didn’t see themselves during the time of the six to seven years where you’re well with HIV; they didn’t really see the immune destruction that was occurring, and so didn’t come to the clinic. And the surveys really pointed out that we’re missing well children and well men.

And so I think it’s our task together to figure out how to get well children and well men, who are no longer under five, to interact with the healthcare delivery system, community by community. And Lesotho has come up with some very innovative ideas of creating these “men’s corners” so when men come into the healthcare delivery centers, they see other men in the waiting room in a special area, and they see male doctors and male nurses. Part of that is ensuring that men who still don’t believe they need to come to the clinic have access to testing outside of the clinic, and that’s when self-testing becomes really important. But self-testing is only important if we can then get the person to come to the clinic so that they can get treatment to save their lives and to decrease transmission in the community.

MODERATOR: Thank you, Ambassador Birx. We’ll turn to embassy Accra in Ghana. If you could introduce yourself and your outlet and ask one question, in the interest of time.

QUESTION: Thank you very much. My name is Linda Asante-Agyei. I work for the Ghana News Agency. First of all, I have to commend PEPFAR for saving lives through the generosity of the Americans. I want to find out, after 15 years of PEPFAR, what should we expect in the next 15 years, and what is PEPFAR also doing to empower Africans to own this global initiative that you have started? Thank you very much.

AMB. BIRX: I think that’s the really critical question; that’s why I spent a little bit of time answering the Ethiopia question, because we believe over the next three years, a whole series of countries in sub-Saharan Africa will make the progress equivalent to Ethiopia, and really figuring out, with governments, and with communities—and I keep emphasizing communities because we’re only as successful as the community’s ability and willingness to access the healthcare delivery system and to become diagnosed and on treatment. And so over the next three years we think we’ll have a whole series of countries that have made this kind of progress, which is really remarkable. I mean, we’re talking about in less than two decades going from really no opportunities for treatment or prevention on the continent to a place where we’re talking about where the epidemic is being controlled and what it looks like in the out years.

And so we’re very excited about this opportunity, but I also talked about the youth bulge, and so it really comes down to how, as a global community, are we going to ensure young people see themselves in the healthcare delivery clinics and see themselves going to the clinic to maintain and have good, healthy, and thriving lives? And what do I mean by that? This is outside of coming to the health clinic when you are desperately ill or when you’re injured. This is coming to the health clinic for this critical preventive information, where you can be tested for a serious of diseases; for the ones that you don’t have, counseled on how to prevent those diseases in the future, and those that you do have, whether it’s hypertension or HIV or malaria, that you get treatment at that moment in time and see yourself as preventing the consequences of progression of disease, whether it’s HIV or hypertension that could lead to stroke, or cardiovascular disease.

These are the kinds of challenges that we have in front of us, and our success will be determined on whether we can create awareness in the community that the health centers are there not only for illness, but there for their long-term health. If we can do that over the next three or four years, I am confident that 15 years from now we will be talking about an epidemic with a much smaller footprint in sub-Saharan Africa, and I hope, frankly, a vaccine and a cure so that we can be talking about elimination and eradication of HIV. That would be within less than 50 years from the origin of finding this virus to the actual ability to eliminate with a vaccine and a cure.

So you can know, I’m very optimistic. I’ve worked in this field for 30 plus years. I believe we have the tools to guarantee a different future for the world and to envision a world without HIV/AIDS. But it will take all of us during these next two or three years to really realize that vision.

MODERATOR: Thanks again, Ambassador Birx, and thank you to all of our participants. We do have several of you in the question queue. We’re doing our best to get to as many questions as possible in the time that we have. Again, to join the question queue, you press *1 on your phone.

We’re going to turn now to the U.S. embassy in Lilongwe, Malawi; if you could introduce yourself and ask your question. Go ahead.

QUESTION: Thank you so much. My name is Miriam [UNCLEAR], I work for Malawi Broadcasting Corporation. I have two questions. One of them is, much as we know that PEPFAR has managed to ensure that no baby is born with the virus, I just want to understand what PEPFAR is doing for those children that got the virus, maybe in the 1990s, and are now young adults, who are continuing to spread the virus and are not adhering to drugs? Is there any particular effort being made by PEPFAR to show that these youngsters are taken on board?

And the second one is, what is the cutoff point for PEPFAR? Is PEPFAR going to be there for good? Thank you so much.

AMB. BIRX: So those are great questions. Let me address a couple of issues that I think are difficult for all of us to talk about. Over the last five or six years, we’ve demonstrated very clearly that both young girls and young boys are undergoing forced, coerced, frankly rape, at young ages, particularly between nine and 15, really putting these young children not only at risk for HIV but for pregnancies, dropping out of school, and not having a robust future that we all want for them.

And so I think together, at the community level, we really need to address the sources of these ongoing practices that allow young boys and young girls to have that level of sexual violence and violation at young ages. And so there is work that we need to do together there. We’ve spent a lot of time now gathering the information, and now is the moment where we really need to change the course of history for these young boys and young girls. And so we’ve really increased our investment, and that’s why I mentioned the Orphans and Vulnerable Children program, really to increase our investment in ensuring that there’s community protection for young boys and young girls and so that they can grow up and thrive and be HIV-free and attend school.

I think you know in Malawi we have a large DREAMS program where we’re really focused on keeping girls in school and ensuring that they have the same opportunities as others around them, and that’s been a really important part of our DREAMS program, which stands for Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe young women.

If we’ve done our job correctly and these next two or three years we really figure out how to bring and keep children and young adults who perceive themselves as well—and remember, the first six or seven years of this infection in your body, you don’t have symptoms per se, symptoms that would take you to the health center—and so we really have to figure out, just like if you had hypertension, you may not have symptoms. Your first presentation may be after all the damage is done by having a stroke. So I think together we really need to figure out what wellness and what the community and public health system at each of these community levels need to look like to prevent disease in the future.

If we figure that out in the next two or three years, we have an opportunity with the new research going on, with a vaccine and a cure, to 15 years from now talk about PEPFAR not having substantial resources on the continent, not because we walked away but because the disease is no longer a significant problem for sub-Saharan Africa, and sub-Saharan Africa can afford the longitudinal investments to maintain control of this epidemic.

We will protect our investment; so in other words, we will not stand by in any case in the future if the epidemic begins to expand, and that’s why Ethiopia is critically important to us, to really understand what kind of systems—we talked about the healthcare delivery system, we talked about the laboratory system—but what kind of epidemiologic surveillance systems do you need in place to really monitor this epidemic closely enough that you can be alerted the minute that the epidemic begins to expand? Because unlike Ebola, where people get very sick very quickly with the disease, we know that with HIV, again, you’re asymptomatic. You don’t have symptoms for a significant number of years. And so this is a unique challenge for us that we look forward to really addressing country by country.

MODERATOR: Thank you again. We have time for maybe just a couple more questions. One that came in by email I’ll ask on behalf of Health-e News. Ambassador Birx, if you could comment on the funding outlook specific to the PEPFAR program in South Africa, please.

AMB. BIRX: Thank you for that question. South Africa is one of our primary investment countries. We’ve invested a lot in South Africa, but let me also be very clear; we invest about a half a billion dollars a year in South Africa, and have over the last 14-15 years. So there’s a substantial investment there, well over $5 billion.

But I think that’s really not the question. I think the question should be, “What does it take, between the government, the Global Fund, and PEPFAR, to get control of this epidemic in South Africa?” And so the government has invested and still invests; about 80% of the resources dedicated to HIV/AIDS come from the government of South Africa, and they’ve been working very closely with us as well as with the private sector and with private institutions to really realize the vision that President Ramaphosa has of really getting control of this pandemic.

And what would that take? I think he’s absolutely right. It’s going to take getting another two million people in South Africa on treatment within the next 24 months. That is a huge number, we understand. That is increasing the total number of people on treatment in South Africa by at least another 30%. And so our investment in South Africa is actually increasing, because the government’s commitment to addressing this epidemic, as their individual investment in addressing this epidemic, has been remarkable. And so we are supporting them in this, and they have remarkable political will right now to change the course of this pandemic.

I think, in addition to the dollars, the most important thing that gets us to success is political will from the highest level in the country. And I think the president talking about this, the Minister of Health talking about this, and making the discussion of HIV/AIDS a critical component of their agenda will ensure that together we can get to a very different place in South Africa.

Then we need to look at what the long-term investment strategy looks like for South Africa, and we’re not there yet. But we hopefully will be there to have that discussion two or three years from now. But we’re in a two-year surge plan for South Africa.

MODERATOR: And for the next question we will turn again to the U.S. embassy in Addis Ababa, Ethiopia. If our journalist colleague could get close to the phone, please, and try to speak slowly and clearly, we’ll take your question. Introduce yourself and your outlet. Thank you.

QUESTION: [UNCLEAR] My first question is this: I want to know if it was [UNCLEAR] Ethiopia for the last 15 years [UNCLEAR] Africa? Thank you very much.

AMB. BIRX: I’m not sure I got that question and the intent of the question. If you could type it, it sounds like the email questions are quite effective. I don’t know if that’s possible.

MODERATOR: Okay, let me try to follow up on that, and in the meantime if we could turn to our embassy again in Lilongwe, Malawi. Go ahead and introduce yourself and your outlet.

QUESTION: Thank you very much, Ambassador. My name is [UNCLEAR] from Nation Publications Limited. The PEPFAR story, Malawi, the success one, what I wanted to find out is the issue of men who have sex with men as a risk population in terms of HIV transmission. Taking from other countries, what is working to target these groups which are culturally sensitive? I also want to find out, what are some of the gaps in the HIV response here in Malawi, taking from the survey interventions that you have in this country? Thank you.

AMB. BIRX: Great questions. So I think we’re actually learning from the sex worker and MSM programs in Malawi and across the continent what’s working. It’s different, and I want to be very clear. Each of our risk groups have very different needs and very different—we talk about a “cascade”—both a prevention and clinical cascade. And we have detailed information down to the site level, and each community and each risk group has a different gap in their cascade.

In young women and young men, our biggest gap is them knowing that they’re HIV-positive, because knowing your HIV status is critical for us to get important prevention information to you and doing the right thing for preventing new infections, as well as getting you on treatment if you’re HIV-positive. So the surveys—and Malawi has one of these surveys that has been completed—we know precisely what our gaps are.

Amongst female sex workers: ensuring that they can remain on treatment, as they’re often very mobile around countries. And so that’s been our key gap among our sex worker population.

Our key gap across many of the areas in sub-Saharan Africa with men who have sex with men is them knowing their status, because there is still and remains—when we talk about stigma, the highest stigma on the continent is men who have sex with men and men who have sex with men that are HIV-positive. And so this really keeps people from accessing the health prevention messages, as well as the health treatment components that each of these communities need. I think as we develop more and more information across the continent, one of our biggest gaps is among men who have sex with men knowing their status. When they know their status, when they’ve been able to access the healthcare delivery system, when they are not turned away, when they are not arrested, they actually get treatment and stay on treatment like anyone else in our systems.

And then you asked about drivers of the epidemic. We believe that most of the new infections in sub-Saharan Africa are coming from these undiagnosed young people, particularly between 15 and 30 years old, because they’re well, they’re healthy, they don’t believe that they have HIV infections, and so they aren’t diagnosed. And because of that, they’re spreading the virus among themselves and across communities. And so it’s really a challenge to all of us to really figure out how to ensure that everyone feels welcome within the healthcare delivery system.

We opened this call talking about how much the United States has invested in physical infrastructure across the continent; how much we’ve invested in laboratories and in supply chain and in human capacity. Well, we’ve done all that and we know precisely what our gap is, but unless we figure out how to bring people who perceive themselves as well into the healthcare delivery system, we will not be successful in HIV—and frankly no country will be successful in preventing the consequences of non-communicable diseases, either, because those all start—most of them—in their twenties and thirties, and what you’re seeing at 50 is the damage done.

So collectively, we have to figure this out, and it’s a very important question for all of us.

MODERATOR: Okay, we’re just about out of time. Let me see, if we go back to Addis, if we could open that line and perhaps the Information Officer, if you could maybe ask that first question on behalf of the journalist. The line is not very clear. We’ll see if you can get that one question in before we conclude.

QUESTION: Yes, hello?

MODERATOR: Go ahead. Please speak slowly.

QUESTION: Okay, slowly. [UNCLEAR] My first question was, is there any special attention for refugees in Ethiopia by PEPFAR? Thank you. Is there special attention to the refugees [UNCLEAR] here in Ethiopia? [UNCLEAR] if you can hear me.

MODERATOR: Thank you. Ambassador Birx, did you get that?

AMB. BIRX: [UNCLEAR] Yeah, I think he’s asking about refugees. So there are important programs across PEPFAR specifically addressing the needs of migratory populations and displaced persons, as well as refugees. And so we have very specific programs that we developed over the last 15 years, both for natural disasters that occur, for famines that occur, for conflicts that occur. Each of those situations is different, and each of them requires a different structure and investment, and so we’re working very closely with the refugee and migration programs, both at USAID and the State Department, to ensure that there’s access to testing and treatments in each of these areas of refugees. Right now we’re working in northern Uganda with Southern Sudan refugees that are of special attention for us in northern Uganda, but also in displaced areas within South Sudan, and the same way in Ethiopia.

Let me make it clear, though, that there are areas where HIV is very low. What we mean is very low prevalence; HIV is less than 1%. In those cases, then, the decision that has to be made across the board about what kind of interventions are most important for the refugees. Are they having more respiratory diseases or diarrhea or are immunizations the need? So you really have to know the epidemiology of your diseases in that area to really have appropriate outcomes and impact for refugees, but thank you for raising that.

MODERATOR: Thanks, Ambassador Birx. We are, in fact, out of time. Do you want to offer any final words before we conclude today?

AMB. BIRX: No, we really appreciate the engagement and keeping HIV/AIDS on the front page. We know, as people are doing better and less people are dying, the awareness of HIV and the importance of HIV. And remember, HIV loves it when people get complacent, because it can spread widely, rapidly, among populations, without awareness. And so it’s really important, until we get to the point of eliminating and eradicating HIV, that we continue to make the knowledge and awareness of HIV and the important impact on people’s lives, always at the front page.

So thank you for your continued interest in this. We’re very excited about celebrating 15 years, but we know that the next two to three years will determine the future of the HIV/AIDS epidemic on the continent, and so we are being more and more diligent and we appreciate if you stay diligent with us.

MODERATOR: Thank you, Ambassador Birx. That concludes today’s call. I want to thank all of you for joining us. Again, this was Ambassador Deborah L. Birx; she is the U.S. Global AIDS Coordinator and Special Representative for Global Health Diplomacy at the Department of State. If you have any questions about today’s call or you’d like any follow-up, you can contact the Africa Regional Media Hub at afmediahub@state.gov. Thank you again.