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PEPFAR: The anti-AIDS program that changed the world now under threat

High angle photograph of Amanda McNulty, a NCHHSTP staff member, in a laboratory setting, holding an electrophoresis plate for DNA separation over the UVP imaging System, in an effort to examine HIV resistance to antiretroviral drugs, in people from PEPFAR (President's Emergency Plan for AIDS Relief) countries, 2007. Image courtesy CDC/Hsi Liu. (Photo by Smith Collection/Gado/Getty Images)
High angle photograph of Amanda McNulty, a NCHHSTP staff member, in a laboratory setting, holding an electrophoresis plate for DNA separation over the UVP imaging System, in an effort to examine HIV resistance to antiretroviral drugs, in people from PEPFAR (President's Emergency Plan for AIDS Relief) countries, 2007. Image courtesy CDC/Hsi Liu. (Photo by Smith Collection/Gado/Getty Images)

Twenty years ago, President George W. Bush launched a massive public health initiative – known as PEPFAR.

Some health workers in Africa say the results have been miraculous.

“PEPFAR is equal to the United States. People know you say PEPFAR, people know PEPFAR is USA,” Nkatha Njeru, CEO of the Africa Christian Health Associations Platform, says. “So it’s been a very good thing that the Americans have done.”

Now, a small group in Congress wants to kill the plan.

Today, On Point: Why one of the most successful public health programs is in peril.


Nkatha Njeru, CEO of the Africa Christian Health Associations Platform, an umbrella group which serves Christian Health Associations and Church Health Networks in Sub-Saharan Africa.

Shepherd Smith, co-founder of Children’s AIDS Fund International. Co-author of the forthcoming book “A Journey of Faith.”

Sarah Owermohle, Washington correspondent at the health and medical news website STAT.

Also Featured

Dr. Mark Dybul, U.S. Global AIDS Coordinator during the Bush Admin.


Part I

DEBORAH BECKER: One of the most successful public health programs in history is under threat. The program started 20 years ago and it’s saved millions of lives. It’s called PEPFAR, short for the President’s Emergency Plan for AIDS Relief. In his State of the Union address in 2003, then President George W. Bush explained why help was needed to stem the devastation from HIV and AIDS.

GEORGE W. BUSH: Today on the continent of Africa, nearly 30 million people have the AIDS virus, including 3 million children under the age of 15. There are whole countries in Africa where more than one third of the adult population carries the infection. More than 4 million require immediate drug treatment. Yet across that continent, only 50,000 AIDS victims, only 50,000, are receiving the medicine they need.

BECKER: Bush chose Dr. Mark Dybul to design and implement the program, and Dr. Dybul remembers that State of the Union address well.

DYBUL: And I remember thinking two things. One, this is one of the most extraordinary acts of mercy, which is what the president called it, one of the greatest things in the history of humankind.

And secondly, “Oh my God, now we actually have to get it done.”

BECKER: In the two decades since, PEPFAR has saved millions from disease, death, and orphanhood. Congress has reauthorized PEPFAR every five years since, and it’s always enjoyed broad bipartisan support. Not this year. It’s up for renewal in just two days.

And a former chief supporter, Republican New Jersey Congressman Chris Smith, says the Biden administration has turned the program into a slush fund for abortion programs in Africa.

CHRIS SMITH: In comes Joe Biden. He puts out brand new guidance to all of the recipients of PEPFAR, 6.7 billion, and says, “You have to now try to change the laws in the countries you’re operating under for sexual and reproductive health and rights.” Which means on the LGBTQ agenda and on the abortion agenda. And they’re not trying to protect life. Believe me.

BECKER: But many dispute those claims, including former President Bush himself, who is urging Congress to reauthorize PEPFAR. I’m Deobrah Becker, in for Meghna Chakrabarti, and this is On Point. This hour, the PEPFAR program, the new pushback, and what happens if it goes away.

Joining me from Nairobi, Kenya is Nkatha Njeru. From 2002 to 2008, she ran an HIV clinic at Nazareth Hospital, near Nairobi. Since then, she’s been CEO of the Africa Christian Health Associations Platform.

That’s an umbrella group serving Christian health associations and church health networks in Sub-Saharan Africa. Nkatha, thanks for being on Point.

NKATHA NJERU: Thank you for having me.

BECKER: And joining us from Washington is Shepherd Smith. He’s co-founder of Children’s AIDS Fund International. He’s an evangelical Christian who says he’s opposed to abortion in most circumstances, and he’s worked on this issue for decades.

Shepherd, welcome.

SHEPHERD SMITH: Thank you for having me.

BECKER: So I want to start with reminding folks of what it was like 20 years ago and why PEPFAR was so needed. So let’s start with the intent of the program. And I think perhaps the best person to explain this is former President George W. Bush. Here’s a little bit more from that State of the Union address and his vision for what PEPFAR was going to be.

BUSH: This comprehensive plan will prevent 7 million new AIDS infections, treat at least 2 million people with life extending drugs, and provide humane care for millions of people suffering from AIDS and for children orphaned by AIDS.

I ask the Congress to commit $15 billion over the next 5 years, including nearly $10 billion in new money. To turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.

BECKER: I want to ask you, Nkatha, you have a history of working in health care even before PEPFAR. I wonder, can you tell us about what it was like before this program was put in place and how AIDS and HIV care in Africa has changed since?

NJERU: Thanks. I’m very nostalgic about what was and what has been since PEPFAR. I remember working in conditions where we knew there was HIV and AIDS. And we could test people and know that they were HIV positive. But we did not have much to offer. So we would tell someone that you have tested HIV positive and talk about, counsel them and make sure they have the right mind to go on with their life.

Talk about their nutrition. And then we would tell them that you can access treatment, but it’s going to cost about $100 a month at the time, just before PEPFAR. And then we had women who tested HIV positive. We would advise them not to get pregnant because if they were pregnant, their children would be born HIV positive.

BECKER: And we should say

NJERU: That was before.

BECKER: We should say, was it difficult, I would assume for many people to afford the $100 a month for treatment?

NJERU: Definitely. Definitely. With many people living below $1 a day, $100 was out of question. And so people didn’t even want to test because they couldn’t afford the treatment.

BECKER: They wouldn’t test because they couldn’t do anything about it anyway.

NJERU: Yes. Yeah.

BECKER: And so did you see a lot of destruction?

NJERU: Yes, there was a lot of death. There was a lot of stigma. I remember a woman whose family had abandoned her in the house, and they had a plate that they would put food on the door, and they had a basin that she would use as her toilet, and they would come and look every day to see if she had died.

But this was just a few months after PEPFAR and we were going around villages and trying to get people to get tested and get treated. And exactly one month after we put her on treatment, she was back on her feet and she’s alive today.

BECKER: Yeah. So you’ve seen remarkable changes, then, since PEPFAR.

So then it allowed people to get treatment for free instead of paying $100 a month and it allowed women to get treatment, especially pregnant women. Is that right?

NJERU: Yes, that’s right.

BECKER: Would you call. I’ve heard many folks say it’s one of the most successful public health programs in history. Would you agree?

What, why?

NJERU: Tremendous success. Having provided access to treatment, both financially and also because now we were able to get treatment to everybody through the various, for health facilities that were able to offer treatment. We were also able to get a lot of advancement in healthcare because with PEPFAR came advancement in technology.

We were able to collect data on our patients. We were able to train health workers to diagnose as well as treat people and HIV really is, you have a collection of other things that come with the immune syndrome. Because you need to be able to treat all the opportunistic infection. So there was advancement because health workers were trained on how to treat a lot of the different opportunistic infections and then there was availability and there was choice.

And hope for families, because if a woman had never had a child live beyond 2 years, because a lot of the children who were born HIV positive without any intervention would die before they got to 2 years, if at all they survived, then a woman is able to hold her child and at two years you graduate.

We say we graduate them out. Because at two years you test a child as having tested HIV negative, having been born of an HIV positive mother, then they’re definitely HIV negative. The joy of those women was something to me. So there was a lot of hope. PEPFAR came with tremendous hope.

BECKER: Shepherd Smith, I’m wondering what you think of what you just heard from Nkatha. And your work really before PEPFAR and what you think, why you think it’s been so successful.

SMITH: I want to reiterate what Nkatha said in respect to the conditions prior to PEPFAR and what President Bush pointed out.

We first went to Africa, we started in this issue in 1985. We went to Africa in about 1995 and saw a great need there. And in the villages, the people, the only people really making money were the coffin makers. And they were seen virtually in any country along the sides of the roads. It was a very desperate situation for the African communities.

And we had the good fortune of traveling with Secretary Thompson in March of 2002 to assess what sort of health facilities were in Africa that could treat large numbers of people. And what we saw was that there were a few bright spots in government facilities, but the facilities that offered the most were faith-based clinics and hospitals.

And so PEPFAR was partly designed to get resources directly to these facilities, which was really brilliant. Because it allowed the program to expand quickly and reach a lot of people. It really was miraculous how many people were able to access treatment and have their lives turned around.

People would come in with what was called then, slim disease, because people with AIDS, their bodies would just wither. And after treatment, it wasn’t long at all that when they came back, they were healthy. It was really what’s known as a Lazarus effect, but it was just incredibly gratifying to be a part of this program to save so many lives.

And globally, this is the largest health effort in history by any country and to consider that we have saved over 20 million lives and probably 5 million children or so. It is a very much life affirming and lifesaving program.

BECKER: Okay. PEPFAR is up for reauthorization. In fact, reauthorization is supposed to be done by the end of this month, which is in two days.

Yet there are some political forces in Congress who might hold that up. We’re going to talk about that when we come back. I’m Deborah Becker. This is On Point.

This article was originally published on WBUR.org.

Copyright 2023 NPR. To see more, visit https://www.npr.org.