Opinion : The Principles of PEPFAR's Public Health Approach - by Deborah Birx

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April 16, 2014

The Principles of PEPFAR's Public Health Approach

by Deborah Birx

The U.S. global AIDS coordinator on disagreeing with foreign government policies.

Deborah Birx, MD
Deborah Birx, MD
Since its creation in 2003, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has been fundamentally about saving lives. When PEPFAR began, in much of the world, particularly in Sub-Saharan Africa, lives were being lost to HIV/AIDS at a truly terrifying rate. Individuals, families, communities – and in some cases the very foundation of societies – were being threatened under an unfathomable strain of the dead and dying.

Thankfully, just over a decade later, the situation has been transformed in dozens of countries. In large part because of a bipartisan commitment to PEPFAR across U.S. Administrations, more than 6.7 million people are now receiving lifesaving HIV treatment, the rate of new HIV infections has declined dramatically, and the vision of achieving an AIDS-free generation is no longer a distant dream. But, there is still much work to be done.

We have delivered results by following sound science, focusing on impact, targeting efforts where the virus is most prevalent, and grounding our work in approaches that protect the human rights of all people. PEPFAR is a public health program, and the principles of good public health demand that we strive to reach all affected populations with core HIV services even – and, I would argue, especially – when facing difficult cultural contexts, severe stigma and discrimination, or challenging security environments. These principles have underpinned PEPFAR from the outset, and we will never waver from them.

In some cases, this means that PEPFAR must operate in contexts where certain individuals or groups are subjected to violence or legal sanction – often just because of who they are as human beings. From a public health and human rights perspective, all forms of discrimination, harassment, and abuse – including on the basis of sexual orientation or gender identity – are unacceptable and run counter to all that we know works in effectively addressing HIV/AIDS from our nearly 35 years of experience in combating the epidemic.

No matter how challenging the conditions, PEPFAR has never been deterred from continuing to do all we can to support comprehensive, non-discriminatory HIV services for all individuals, and we will not back down now. As public health practitioners, our core ethical responsibility is to the people whom we serve – whether they live in Kampala, Cape Town, or the Caribbean – and this holds true even when we may disagree with host government policies that are at odds with sound science or good public health.

PEPFAR has never shied away from voicing its concern with host governments or other partners when such policies are instituted. And we will continue to champion sound science and respect for basic human rights at every opportunity. But I want to be quite clear: PEPFAR will not take actions that harm the very individuals for whom we have a responsibility to serve – such as curtailing their access to core HIV services solely because the political, cultural, or security space in which we operate gets rough. For it is in these critical moments that these individuals need us most. PEPFAR will stand with them in solidarity by doing everything within our power to sustain their access to HIV prevention, treatment, and care. This is what it means to practice good public health.

I also want to make clear that PEPFAR will not transition responsibility for its assistance to host governments without a well-defined and mutually-negotiated plan in place regardless of the context. In recent years, a number of host governments have assumed even greater responsibility for managing, overseeing, and financing their HIV/AIDS responses – developments that we enthusiastically welcome. As we move forward, PEPFAR is deeply committed to working hand-in-hand with all our partner countries to support their gradual assumption of greater responsibility for their national responses. But we also know that this will not happen overnight, and that the pace with which each of these partnerships evolves over time will appropriately vary from nation-to-nation.

PEPFAR is one of the greatest expressions of American compassion, ingenuity, and shared humanity in our nation’s rich history. As we march on together toward achieving an AIDS-free generation, PEPFAR will remain committed to our foundational principles of sound science, focusing on impact, good public health, and a rights-based approach. They are why PEPFAR has been so successful, and we will stay steadfast to them – and to the people whom we serve – even when times get tough.

Deborah Birx, MD, is the U.S. global AIDS coordinator. This statement was originally published on PEPFAR.gov and crossposted to AIDS.gov.

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