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U.S. Global AIDS Leader Has Tough Job Ahead

A raucous round of applause greeted Eric Goosby last night at his swearing-in ceremony as the new Global AIDS Coordinator and Ambassador-at-Large for the U.S. government. Secretary of State Hillary Clinton introduced her new employee, who she noted began working as an AIDS clinician near the start of the epidemic. Goosby went on to serve as director of HIV/AIDS policy at the Department of Health and Human Services during Bill Clinton’s presidency. Most recently he was head of the Pangaea Global AIDS Foundation, an offshoot of the San Francisco AIDS Foundation that helps people in poor countries. Goosby’s new job will be to run the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), a massive aid program launched in 2003 to deliver anti-HIV drugs and prevention services around the world.   

Goosby spoke with ScienceInsider a few hours before his swearing in. The following transcript is edited for brevity and clarity.

SI: Do you plan to do anything differently than your predecessor?

EG: We’ll continue largely on all fronts that Mark Dybul had started and Joe O’Neill and Ambassador Randall Tobias before him.  I don’t anticipate any changes in the focus or intensity of the commitment except for those that are generated by resource issues, which we’re all struggling with.

Our focus will turn from an emergency response to one that is very aggressively going to think strategically about how to embed these programs so they’re durable and sustained long after the PEPFAR resource begins to decline. We are serving our patient population well, but we have to think about the long-term configuration that will ensure that these drugs and services continue for the duration of the patient’s life. We’re looking at 25, 30-plus years for just the group we have now.

A central part of the stability is realized through strengthening the role that the partner governments play in managing and running these programs, beginning with their ability to have an oversight function that allows for continued transparency on the fiscal level. But they also have to begin taking the wheel and driving the programs, targeting prevention efforts to the demographics of their epidemics and monitoring efficacy outcomes that enable the policymakers to correct inefficiencies in real time, as opposed to 3 years after with an evaluation. 

SI: A key criticism of the past incarnation of PEPFAR is that it frequently didn’t target to the demographic of the epidemic. The federal government ban on needle exchange meant that money given to Vietnam couldn’t be used for that even though they have an epidemic driven by injection drug use. Other countries that had epidemics driven in part by sex workers were limited. I realize that Congress stipulates these things, but will that change with the new leadership?

EG: The simple answer is yes. Those have both been targeted and prioritized in this Administration and in our office already. We’re well down the road and working on moving away from any constraints put on an individual program to not engage with a population because they’re sex workers or involved in injection drug use. I have spent much of my life focused on matching demographics to responses. If you do not base responses to the demographics of your epidemic, you will not be successful at reaching the populations who are already infected. And you’ll especially be ineffective at reaching the higher risk populations that will become infected.

SI: How do you get around the needle-exchange ban?

EG: PEPFAR is not burdened by the needle-exchange ban. It is a domestic-based ban. Legislatively, we are not restricted. And we are in a dialog with the White House to try to rapidly change that position domestically, given that it already is open to our international activities.

SI: I had always been told it was an international ban. That’s inaccurate?

EG: That’s inaccurate.

SI: The Bush Administration has been praised for PEPFAR, maybe more so than for any other of the programs it launched. How do you view coming in to something that’s working?

EG: I’m grateful to PEPFAR for the work it has done, putting a finger in the dike, but we have by no means reached the threshold by which we can relax or view this as a job well done. The job that has been done is precariously positioned to not sustain itself. We need to make that the number one concern. We must expect our partner countries to integrate these services into their existing public systems—or we won’t have them. They’re too dependent on an NGO-based continuum of care, and those systems are fragile and dependent on ephemeral funding. They are not in and of the public systems that the majority of patients are accessing for their care. We can’t NGO this disease off the planet. That’s not to say NGOs don’t play a critical role in completing the continuum of care, but we must place them in the public sector to ensure their durability.

SI: One criticism of PEPFAR is that it has put so much money into U.S.-based NGOs that it hasn’t built enough local infrastructure in other countries. Do you see that changing?

EG: I think that is the change. We need to look at how to build country-based, country-run, country-owned delivery systems. We can’t just build islands of excellence with HIV care and not address the larger health needs of that same individual. That’s shortsighted. The president and Secretary Clinton have been very clear about wanting all the vertical programs—HIV, TB, malaria, immunization, maternal and child health—to now look at expanding the service constellation and bringing in those broader health needs of what is a complete overlap in populations. The discussion is mostly focused on using women as that access point to children, husbands, and partners.

SI: PEPFAR will have to struggle to keep supplying antiretrovirals (ARVs) to the people already on the drugs, especially given the likelihood that more and more will develop resistance and need more expensive treatments. Will you be able to expand the program?

EG: We are concerned about this, too. Our ability to keep up with this is going to be especially challenging in this economic downturn. We’d be foolish not to open up a strategy to try and bring in other bilateral and multilateral resources. We need to be smarter about how we think as funders. We can’t just go in with parallel systems of intervention. It is probably the biggest issue on my plate, thinking about how to deal with that expanding need, and how to continue the medical, clinical, and ethical commitment we’ve made to the patients already on drug. We’re looking for efficiencies by moving to a more country-based delivery system. We also need an aggressive new dialog with our global partners who have resources that can converge on this.

SI: Some have suggested that PEPFAR fold and give the money to the Global Fund to Fight AIDS, Tuberculosis and Malaria and get rid of the redundancy. What do you think of that idea?

EG: Right now, I would not be ready to turn over the resources from PEPFAR to the Global Fund, but I’d like to really move them together. The Global Fund has played a critical role, no doubt about it, the role in many countries. The Global Fund’s process is the right idea—it is more country-based—but the ability to support that country in its implementation challenges has been less than optimal. It’s the combination of a PEPFAR and a Global Fund strategy that really will win the day here.

SI: How many people are receiving ARVs through PEPFAR now, and what are your projections for the 5-year plan?

EG: We’re around 2.4 million now and climbing rapidly. We have no doubt that we will meet the 3 million goal very soon. We’re moving much more rapidly than we had anticipated, like two to three times as fast. There’s no question we’ll be increasing. The question really is can we match the resources in a timely fashion to the expanding need. That’s really what I spend most of my time thinking about.

SI: What is the estimated need?

EG: The legislation goal was 3 million, but that’s probably about 40% of what we know is the need already, so there are about 7 million people in need of antiretrovirals.

SI: What other issues are you facing?

EG: It’s a no brainer in terms of the science to use tenofovir instead of d4T [an ARV that has serious side effects]. The problem is the cost. The same with using the current policy of 200 CD4 cells to start treatment versus 350 CD4s as the cutoff. The science has been there for a long time. That’s why no else is doing 200. The United States has been at 350 forever. You could argue we should be in the 400 to 500 range. The science is clear. What isn’t clear is how we can pay for that. We need to be honest: We’re in the business of trying to find resources to cover that extraordinary expansion of need. And the elephant in the room again is the second-line treatment cost, going up three, four times the cost of first-line for the most part. That’s the final thing that keeps me up at night.