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The 20th anniversary of the US President’s Emergency Plan for AIDS Relief, or PEPFAR

The US says it saved 25 million lives -- and most people don't know it

Originally Published: 25 FEB 23 08:08 ET

(CNN) — Former President George W. Bush made a rare appearance in Washington, DC, on Friday — gathering some big names from his administration, a key political opponent in former House Speaker Nancy Pelosi and even Microsoft co-founder Bill Gates — to help protect his signature foreign policy achievement.

The US government says it literally saved 25 million lives, but Bush is afraid most Americans don’t know that fact.

This year marks the 20th anniversary of the US President’s Emergency Plan for AIDS Relief, or PEPFAR, which the rock star Bono, in a video message beamed into the event, called a “genius plan, pretty crappy acronym.”

Pelosi sat a row behind Dr. Anthony Fauci, who worked on the federal response to AIDS, and just in front of Ukraine’s ambassador to the US — in addition to funding Ukraine’s effort to repel Russia’s invasion, the US also helps fund Ukraine’s effort to control AIDS. They’re all hoping the US reups on PEPFAR, which costs a relative pittance in US government tax dollar terms — $7 billion in 2022 and more than $110 billion total over 20 years — but has saved so many people.

Two of those 25 million lives appeared at the event

Tatu Msangi found out she was HIV positive in 2004, after she was already pregnant with her daughter, Faith.

“Seventeen years later, my daughter, Faith, stands alongside me as a representative of the 5.5 million babies born HIV free as a result of years of the PEPFAR program,” Msangi said.

It’s not exactly clear that PEPFAR or its funding are in any danger, and I could not find any top Republicans who are actively lobbying against it.

But with the new GOP majority in the House talking about spending cuts and the current White House frustrating the former president by hoping to roll the program into a new bureau where the sole focus would not be AIDS in Africa, Bush went on stage with former Secretary of State Condoleezza Rice and the former president of Tanzania, Jakaya Kikwete, to educate people.

“I’m here to remind people that American taxpayers’ money is making a huge difference, a measurable difference in saving lives, 25 million people. Yet most people in America have no clue what we’re talking about,” Bush said during the event, sponsored by his namesake presidential center at the United States Institute of Peace building in Washington.

A message to current American leaders

When Rice asked him if he had a message about American leadership, “because there are a lot of people in our country who think we should mind our own business,” Bush had a clear message that the US must continue spending money outside its borders.

“I think we’re a big enough nation to do more than one thing,” he said. “To continue to fight against AIDS in the continent of Africa and to support the Ukrainian freedom fighters does not constrain our capacity to help our own citizens. I don’t understand why there’s any resistance to a program like PEPFAR unless we’ve lost our compassion.”

The chairman of the House Foreign Affairs Committee, Rep. Michael McCaul of Texas, is a major backer of the program.

“I still remember when I met Botswanan President Masisi in 2019, and he told me the U.S. global health investments in Africa — specifically PEPFAR — has saved a generation of people from extinction in his country,” McCaul said in a statement when asked about Bush’s comments.

I’ve been considering a newsletter focused on PEPFAR since President Joe Biden invited Bono to his State of the Union address and held PEPFAR up as an example of what can be done when lawmakers with different viewpoints work together.

When people came together in the early ’00s

That Bono, lead singer of the rock band U2, worked back in 2003 during the Iraq War with Bush, the Republican president, and Pelosi, then new to her role as Democratic leader, and with conservative and liberal lawmakers, feels bizarre today, when the political leaders are barely speaking.

That said, I think we forget how toxic the political environment was during the Iraq War years.

I talked to Tom Hart, president of the ONE Campaign, for his perspective on how the program worked, how much it’s cost the US and how they found a way, as he put it, to get “the chairman of the pro-life caucus working with the Congressional Black Caucus,” and LGBT activists alongside evangelical pastors. The ONE Campaign was co-founded by Bono and aims “to end extreme poverty and preventable disease by 2030,” according to its website.

Excerpts of that conversation are below.

What is PEPFAR?

WOLF: For starters, how exactly does PEPFAR work?

HART: PEPFAR, the President’s Emergency Plan for AIDS Relief, is the US bilateral program to provide care treatment and prevention for people suffering from HIV. Caring for those impacted and their families and orphans — preventative measures like condoms and education and training and treatment.

That last bit, treatment, was what was revolutionary, frankly, at the time. Twenty years ago, there was not any strategy or a conception that you could provide wide-scale treatment in sub-Saharan Africa or other resource-poor settings.

It was quite radical, frankly, to develop a plan to simplify drug regimens and get them widely distributed, as President Bush described, by motorcycle and bicycle if necessary. How it happened is a longer story, but that is what the crux of the program was, and it has been wildly successful over the years.

It has exceeded its goals many, many times over and been endorsed by every president since and funded by every Congress since then — a really transformative program in terms of the lives that it saved, now 25 million lives over 20 years.

How can we guess it has saved 25 million lives?

WOLF: I have heard that figure a lot, and it’s amazing. I haven’t seen where that figure came from. How did we calculate that it saved 25 million lives?

HART: PEPFAR has done an extraordinary job of keeping track of the data. The health workers are issued these small iPads, and they keep track of every drug and every dose that is delivered.

They diagnose those who need to be put on treatment, put them on treatment and then will follow up. … And so that number comes from PEPFAR itself, having looked at all the interventions that they’ve put in and ascribe a value to their contribution to the lives saved over that time.

New goal: Eradicating AIDS as a threat by 2030

WOLF: The State Department’s plan for PEPFAR is to eradicate AIDS as a global health threat by 2030. What exactly does that mean?

HART: It means that we’ve got to get many more people tested and on the treatment regimen. It has a lot to do with prevention, particularly the hardest hit and marginalized populations like young women.

One of the largest groups of people who are contracting the disease now are our younger women and LGBTQ and other marginalized people. So it’s going to be very, very difficult and take a concerted effort to deliver prevention and treatment services to those who remain.

The 2030 goal is one that everyone shares. Although the pandemic did set back efforts, but it did not reverse it. PEPFAR continued to deliver services, both prevention and treatment services across Africa, even during the pandemic. And interestingly, some of the infrastructure, the lab services and health care training and other medical investments through PEPFAR over the last 20 years were used in some of the Covid response.

WOLF: Is there a threshold by which we know we’ve succeeded in doing that?

HART: What’s amazing about these medicines is that people will live with HIV. So it will still be among us.

But it will be at a level that is controlled within each individual — and then that the spread has been reduced to a level that it will be able to be managed as a public health issue. There is not, at the moment, that goal to eradicate it completely, like smallpox or the work that’s going on with polio.

Why does PEPFAR need to be reauthorized?

WOLF: I read a Kaiser Family Foundation synopsis of the program that much of the structure of PEPFAR will continue regardless of whether it is reauthorized by Congress. Is it a problem if it’s not reauthorized?

HART: I think it is a problem. For a couple of reasons.

One, Kaiser is absolutely right. Federal programs can continue even if the date on the authorization legislation expires. That is true for many federal programs, not just this one.

But it is a problem in that it is on a political level very important to maintain the bipartisan support and just the overall knowledge of Congress for this incredible life-saving program that Congresses before them have endorsed and funded.

We really embrace the reauthorization process, and the education that it provides is something that every member of Congress, and more importantly, their constituents, should be incredibly proud of.

Most American citizens don’t realize that they’ve saved 25 million lives around the world and the families and communities and goodwill that has come from that. It’s just an extraordinary success story.

So the reason to do it is both political, and the second reason is that there may be rule changes in the House. This is something that we’re still sorting out.

There have been some conversations that unauthorized programs would not be funded. There are many, many programs that are unauthorized at the moment. We want to make sure that there is no reason not to fully endorse and fund this important program.

This is true bipartisanship. How did it happen?

WOLF: This is an example of true bipartisanship and bringing people together from all different sides. Tell me a little bit about how that process occurred 20 years ago.

HART: It was the convergence of a bunch of different things that happened, one of which is building on the debt relief campaign in ’98, ’99 and the coming of the millennium in 2000.

You had to bring together politically left and politically right, people of faith, humanitarian organizations and others around debt cancellation. It created an interesting coalition of people. Strange bedfellows.

I’m talking about relieving the debts of the poorest countries. Rooted in the biblical notion that every 50 years should be a year of jubilee, when land is allowed to lie fallow, slaves were freed and debts were forgiven.

And this curious coalition of people who came together, and politicians who came together on debt cancellation work, first of all realized that any of the savings from debt relief were going to be completely swallowed up by the catastrophe that was the HIV/AIDS pandemic.

The working alliances of politicians and activists on the right and left were maintained and expanded around HIV. We had the chairman of the pro-life caucus working with the Congressional Black Caucus. We had LGBT activists and evangelical pastors.

People came together through various lenses and various interests through this.

There was bipartisan legislation before PEPFAR was announced. It was supported by (Sens.) John Kerry (of Massachusetts) and Bill Frist (of Tennessee), and in the House by Barbara Lee (of California) and Jim Kolbe (of Arizona), saying the United States needed a bolder response to the AIDS pandemic. Not anywhere close to what President Bush ended up announcing, but to encourage more to be done.

You mentioned the bipartisanship. It was a time where compromise was still valued, and those cross-party conversations were able to happen.

There were incredible disagreements around the treatment focus, incredible arguments around how do you do prevention. There was this famous debate over ABC: abstinence, being faithful and condoms. It turns out you need all three, but that was a really intense debate. There was a lot of effort to expand the remit beyond HIV, and include malaria and other health issues.

Lots of compromises, hard-fought but goodwill toward the broader goal of saving as many lives from HIV as possible.

Those compromises, rolling up the sleeves in the backroom, created alliances and indeed friendships that have lasted over many, many years.

And that’s one of the things that we try to remind new Congress’ new members and their constituencies: Compromise is necessary in order to make big things happen.

How to compromise

WOLF: One of those compromises of the original law was that a third of prevention funding had to go to abstinence-only education, which in my ears today seems kind of crazy. I’m sure to a lot of people it seemed kind of crazy back then. But in compromise, you have to give something up.

HART: That’s just it. Is it a perfect piece of legislation? Is it perfect public health policy? No.

But the larger good that came from those compromises, and those disagreements, having both sides come together and 20 years later, and $110 billion approved just wouldn’t have happened unless both sides were at the table, arguing about their own values and what worked and what didn’t work.

Keeping the big picture in mind and making sacrifices for things that you thought were the most important things for the greater good was what was necessary. We’ve lost sight of that now. It’s become even more difficult.

Squaring Bush and the Iraq War v. Bush and PEPFAR

WOLF: At the same time, you refer to that as a time when compromise was still valued. I’m thinking back to 2003. Kerry and Bush were about to have an incredibly contentious presidential campaign. The larger story at the time was about the Iraq War. Bush was reviled by a large portion of the international community for that. I don’t want to lose sight of that. How does PEPFAR, which everybody can agree was an accomplishment, change Bush’s legacy in terms of the war?

HART: I will quote my co-founder here, Bono, who says, “You don’t have to agree on everything if the one thing you can agree on is important enough.” Even though said by an Irish rock star, those are probably wise words for politics.

Absolutely, we knew the divisions around the Iraq War, and obviously the ONE Campaign did not weigh in on that. But many Democrats were fiercely opposed.

Barbara Lee, I think, was the only person to vote against military intervention in Afghanistan after 9/11 and yet was the chief advocate on the Democratic side for a global response and worked with the Republicans very effectively to move this legislation forward.

If politics is the art of the possible that is, you have to be able to say I vigorously don’t agree with you on this. But if we can agree on that, we can make a big change. And that’s what happened with HIV.

If you’re an advocate like Bono or the ONE Campaign or many others, do you wonder, am I giving cover to someone you don’t agree with on a whole host of things. But the opportunity to do something great — and I think history has shown that PEPFAR is one of President Bush’s great legacies. I’m just grateful that folks were able to understand where they disagreed and yet charted a path where they could agree.

Foreign aid in a time of $31 trillion national debt

WOLF: The domestic political conversation is increasingly about the US debt, which is more than $31 trillion now. Republicans are insistent there will be some spending cuts, and I think we can all agree that’s probably going to happen. When you’re in a Republican member of Congress’ office arguing for international aid, how do you make that argument when there’s so much focus on the debt here at home?

HART: Great question. Polling over 20 years has consistently told us that the American public thinks we spend around 20% of the budget on foreign aid. It’s less than 1%.

So the magnitude of what foreign aid occupies in terms of the budget versus the impact that it has globally is one of the first things that we talk about.

The second is that it is far cheaper to prevent catastrophe and conflict. The United States is very good about responding to catastrophe and conflict. But if we can prevent it beforehand, whether it’s a health disaster or even the instability that is caused from severe economic strain.

The foreign aid that the United States provides, which is very targeted, is measured and the results are carefully tracked — we have seen that it has demonstrable impact across the world for just pennies of our federal budget, and we believe an excellent investment in the way the United States both presents itself in the world and serves our interests.

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