Just 15 years ago, in a historic act of global humanitarian leadership, President George W. Bush proposed in his 2003 State of the Union address the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR). Later that year, Congress passed the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act of 2003, which launched PEPFAR as a comprehensive response to the global AIDS crisis. It would go on to save millions of lives (and counting).
Initiated as an emergency response to the global AIDS crisis, PEPFAR’s renewal every five years since 2003 has tracked the evolution of an unprecedented, multifaceted attack on a single disease. Along the way, it has provided a model of sustainable, evidence-based action against other preventable illnesses and deaths.
Spurred by climbing HIV incidence and deaths, fractured families, and decimated communities around the world, PEPFAR’s evolving mission was sparked by a simple vision: that even in the absence of a cure or a vaccine for HIV infection, accelerated access to services could reverse the trajectory of the epidemic in resource-limited countries.
PEPFAR’s mission has slowly been validated, largely by doing the right thing — providing access to treatment for people who need it. That may seem obvious, but over the years since PEPFAR began, we’ve continued to learn the overwhelming benefits of following the best medical practices.
In 2011, I presented preliminary results from HPTN 052, a clinical trial conducted among nearly 1,800 “sero-discordant” heterosexual couples — one partner was infected with HIV, the other was not. HPTN 052 showed that consistent treatment with antiretroviral medications brought a 96 percent reduction in the risk of HIV transmission to the partner without HIV. Final results from that trial, and from others that followed, definitively demonstrated that treatment that durably reduces the amount of HIV in an individual’s body to an undetectable level lowers to virtually zero the risk of transmitting it to someone else.
In the meantime, results from the Strategic Timing of AntiRetroviral Treatment (START) study, which explored the possible benefits of starting antiretroviral treatment as soon as possible after infection with HIV, showed that this strategy reduced the risks of serious illness by more than half. START reinforced the impetus for ensuring that immediate treatment be accessible for all people diagnosed with HIV.
During the 15 years of PEPFAR’s existence, discoveries of new medicines and new modes of delivery have simplified treatment and lowered the cost of supplying it. Today, people living with HIV can suppress the virus to undetectable levels with uninterrupted access to HIV treatment. Where available and affordable, that can mean taking just one pill a day.
Those key findings — the importance of viral suppression and early access to medication — have informed PEPFAR’s goals, and the plan has set an example for later responses to disease. Today, PEPFAR-supported treatment has prevented mother-to-child transmission of HIV among more than 2 million babies who would otherwise have been infected. It has also made anti-HIV treatment accessible for more than 14 million men and women in PEPFAR-supported countries.
Population-based surveys across 10 countries in Africa have shown that the number of people newly infected with HIV has fallen in direct proportion to the increased rollout of antiretroviral treatment.
As a treatment program, PEPFAR is a success. But it is much more than that. Following science, PEPFAR now provides proven HIV prevention interventions, including circumcision and the use of antiretroviral medicines for pre-exposure prophylaxis (PrEP).
Through all of this, PEPFAR has maximized all possible efficiencies. It can no longer scale up treatment without cutting other key endeavors. The spread and toll of HIV remains a crisis and the need to confront it is urgent. After a decade of flat funding, 15 million people living with HIV worldwide today do not have access to treatment. That’s a problem on two levels. Early and reliable treatment protects individuals living with HIV and also prevents their transmitting the virus to others. It can also help prevent infection with tuberculosis, a curable disease that is the leading killer of people with HIV.
The House of Representatives approved the PEPFAR reauthorization on Nov. 13. I hope the Senate will swiftly follow suit. Earlier this year, the Senate proposed a $50 million increase for PEPFAR, while the House proposed an additional $41 million for USAID’s TB program. For this year’s reauthorization, increasing funding for the program will be critical.
We know what to do: Diagnosing and treating everyone with HIV leads to normal life spans and stops the spread of the virus. On its own, that won’t be enough to end the threat of HIV. The quests for a vaccine and a cure continue. But the course is clear, and staying the course is imperative, with PEPFAR as a bridge to a world in which HIV no longer presents a public health threat to any population in any country.
Myron S. Cohen, M.D., is the architect and principal investigator of the multinational HPTN 052 trial and a professor of medicine, microbiology and immunology, and epidemiology at the University of North Carolina at Chapel Hill. He serves on advisory boards for Merck and Gilead related to the prevention of HIV infection.
