PEPFAR's Dr Deborah Birx urges sharper focus to halt HIV globally

January / February 2016 | Volume 15, Issue 1

Dr Deborah Birx speaks at a podium at NIH
Photo by Ernie Branson/NIH

To successfully vanquish HIV/AIDS globally requires urgent
focus on high-risk populations, such as young women in
sub-Saharan Africa, PEPFAR's Dr. Deborah Birx told NIH.

​​By Cathy Kristiansen

To protect and extend the significant progress made against the HIV/AIDS epidemic globally, policymakers and funders must target specific high-risk populations, especially young women in sub-Saharan Africa, according to U.S. Global AIDS Coordinator, Dr. Deborah Birx, who oversees the President's Emergency Plan for AIDS Relief (PEPFAR).

"You can't talk about a sustained response when you have an ever-growing epidemic," said Birx, who is also Ambassador-at-large and Special Representative for Global Health Diplomacy. "HIV is not everywhere and our investment needs to track where the disease is.

Birx made her comments during an NIH lecture honoring Dr. Joseph J. Kinyoun, who founded the one-room lab in 1887 that has evolved into 27 Institutes and Centers now comprising the agency. The annual event is hosted by the National Institute of Allergy and Infectious Diseases (NIAID).

Urgent measures must be taken or there will be 28 million more people infected with HIV by 2030, according to a recent UNAIDS forecast, Birx warned. "We don't have a choice; we risk losing our $65 billion investment if we don't figure out how to control infections."

PEPFAR, with a $6.8 billion annual budget covering 31 countries, has played a key role in controlling HIV since 2003. But with stagnant funding, more efficient use of resources is required, Birx said. "Funding has plateaued and the real challenge is how do we apply the tools that have been given to us through the scientific method and how do we do that in a budget-neutral environment." It's important, she suggested, to focus on the "right things, right places, right now."

This means urgently directing resources to areas with the highest burden and scaling up interventions in a strategic and targeted way, along with collecting data to evaluate if efforts are working as intended, she said. "We're spending our time focusing, focusing, focusing on the results we're expecting to achieve and ensuring that all of our results predict those outcomes and are in alignment."

New HIV infections in sub-Saharan Africa,
by age and sex, 2013

Bar chart: number of new HIV infections subSaharan Africa by age, sex Source UNAIDS The Gap Report http://bit.ly/1PNWVfD p32

Description: Bar chart shows the number of new HIV infections in
sub-Saharan Africa by age and sex, according to UNAIDS 2013 estimates:
Less than 15 years: about 100,000 males, about 100,000 females
15 to 24 years: about 150,000 males, about 300,000 females
25 to 49 years: about 350,000 males, about 350,000 females
50+ years: about 50,000 males, about 50,000 females

Source: UNAIDS "The Gap Report," page 32

Nearly three-quarters of existing and new HIV infections are in sub-Saharan Africa, Birx noted. With this in mind, PEPFAR's 2017 targets in Africa include extending antiretroviral therapy to nearly 13 million more men, women and children, encouraging 13 million more male medical circumcisions and slashing new HIV infections in young women by 40 percent - which Birx said is the minimum needed to prevent the epidemic from outstripping the resources available to contain it.

She discussed the particular problem posed by new infections in young women, whose incidence of HIV is persistently high. A key reason is the age group has expanded by an astounding 30-40 percent in this region of Africa since the HIV/AIDS epidemic began, due in part to success at protecting children under five years, who are now reaching adulthood, she said. There are now 10 million girls and women, aged between 10 and 29 years, up from 7 million in 1985.

New infections are also fueled by a sense among uninfected women that they are not at risk, as well as cultural norms whereby younger women feel coerced - or are raped - by infected older men, become HIV-positive and in turn spread the virus to male peers.

To take on this population in force, a trio of funders in 2014 launched a program called DREAMS, or Determined, Resilient, Empowered, AIDS-free, Mentored and Safe women. The $280 million initiative is funded by PEPFAR, the Bill and Melinda Gates Foundation and the Nike Foundation. Related efforts aim to strengthen families, extend the years girls remain in school, provide youth-friendly sexual and reproductive health care, and mobilize communities to help change behavioral expectations.

Birx noted previous targeted interventions have had success against HIV, such as those aggressively treating infected pregnant women and their newborns with antiretroviral therapy. Health systems strengthening is also critical, she said.

Policymakers must remain vigilant for resurging HIV in populations where it is seemingly under control, she warned. For instance, Uganda, which had been a success until 2010, saw new infections soar to an historic high. Stakeholders set out "to analyze everything we were doing, because obviously it wasn't working," Birx recalls. They instituted new approaches, such as testing and immediately treating all pregnant and breastfeeding women no matter how low their HIV levels and encouraging male circumcision. "Uganda has gone from the highest burden of new infections to the potential to have control of the epidemic in less than five years," Birx observed. "This is what we believe is possible if we bring the same approach" to other countries.

The NIH has played a leadership role in producing research to battle the HIV/AIDS epidemic and it is "enormously important" to continue moving basic science discoveries through the required rigorous steps to ultimately benefit human health, Birx said. No stranger to NIH, where she received training early in her career, Birx has collaborated with scientists on a number of HIV/AIDS clinical trials. These discoveries give her hope for the future, she concluded. "But now we need really a call to action to ensure that we move these policies into a new place so we can bring the end of AIDS, together, in the next five or 10 years."

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