In his early days as an AIDS specialist, U.S. Ambassador Eric Goosby, MD, watched as 500 of his patients died of a disease that he and his colleagues could do nothing to stop.
"None of us were prepared for the amount of death that confronted us," he said of that time in the late 1980s and early 90s at San Francisco General Hospital. The clinicians also suffered at the overwhelming burden of loss, developing symptoms of PTSD and gathering for weekly sessions to talk about their departed patients and what they meant to them.
That experience essentially defined his work today as the top U.S. official for global AIDS programs, Goosby said in a talk last Thursday at Stanford School of Medicine. He told the audience:
It was the central motivator - the fact that I had been in front of so many people who didn't get the benefit of antiretroviral therapy. I felt driven - and still do - because of those early losses to make sure people who would benefit from these drugs get in front of them.
Goosby today is director of the President's Emergency Fund for AIDS Relief (PEPFAR), which celebrates its 10th anniversary of providing vitally needed assistance to developing countries affected by HIV/AIDS. He also serves as the U.S. liaison with the multi-national Global Fund to Fight AIDS, Tuberculosis and Malaria and most recently became director of the new Office of Global Health Diplomacy at the Department of State. He visited Stanford at the invitation of Michele Barry, MD, director of the university’s Center for Innovation in Global Health.
When PEPFAR began in 2003, there were only 50,000 people in sub-Saharan Africa, the region hardest hit by HIV/AIDS, who were on life-saving antiretroviral (ARV) therapy, which was first marketed in United States in 1997. In those days, there were two, three or four people sharing beds in African hospitals, where ailing people lined the hallways. Death was so prevalent that there was a shortage of wood to build coffins, he said. But death rates have declined significantly with the growing availability of precious medications. Now there are some 5.1 million people on ARV's, in large part because of PEPFAR's support, he said.
In addition to direct aid for therapy, a significant portion of PEPFAR's funding - or $1.3 billion - goes to the Global Fund, and that "buys a lot of lives," Goosby said.
Since the global economic downturn of 2008, the PEPFAR budget, like most U.S. government programs, has been strained, remaining flat after years of significant increases. Goosby said the program has been able to continue to provide treatment by switching from brand-name drugs to generics, which are less costly; streamlining distribution systems; reducing some staff; and using less costly transport methods, such as trains and trucks, to distribute supplies.
"This is a very important program, but it has had to get smarter about how it uses its money," he said.
He says the program today is focused on prevention, targeting people in high-risk groups and encouraging them to be tested and know their HIV status. In 2012 alone, he said, the program helped pay for testing of some 46 million people. It identified and provided preventive treatment to 750,000 pregnant women who were HIV-positive, thus allowing approximately 230,000 infants to be born HIV-free, he said. It has also promoted male circumcision, helping finance some 2 million circumcisions in the last two years, as studies have shown that it reduces the risk of viral transmission by as much as 60 percent.
The program also encourages people who are found to be HIV-positive to get into treatment early, before they develop serious opportunistic infections, as a landmark study published in 2011 found that effective treatment drives down circulating virus in the body to the point where the risk of sexual transmission is reduced 96 percent.
The result of these and other programs has been a decline in AIDS incidence in recent years in 14 countries. "The high-impact prevention interventions are the way to go," Goosby said.
Goosby said he spends a lot of time on Capitol Hill with members of Congress, as there is much education to be done, particularly among the newly elected who don't understand why U.S. tax dollars are being used to fight a disease in Africa. He tells them, “We are one of the richest countries on the planet, and with that wealth comes responsibility.”
The program is among the few that enjoys bipartisan support, he noted, so he remains optimistic about the prospects for reauthorization when it comes up for review in Congress this summer.