Report November 30, 2018

An Oral History of PEPFAR: How a "Dream Big" Partnership is Saving the Lives of Millions

Posted on: December 1, 2018 / Updated: December 14, 2018

PEPFAR: An Oral History

How a “Dream Big” Global Health Partnership is Saving the Lives of Millions

In 2001, the HIV/AIDS crisis in Africa had reached new heights. Death tolls were in the tens of millions. Hospitals were overwhelmed. And the infection rates continued to rise. The United States faced a choice: respond to a call for help or watch a generation of lives be lost.

Photos, clockwise from upper left: Peter Mugyeni created a clinic in rural Uganda that became a model for healthcare delivery for PEPFAR (Marco Longari/AFP/Getty Images); the White House decorated with a red ribbon to commemorate World AIDS Day in 2008; Secretary of State Condoleezza Rice greets the crowd as she arrives at the State House in Dar se Salaam, Tanzania on February 17, 2008 (Jim Watson/AFP/Getty Images); President Bush gives remarks at The AIDS Support Organization Center in Entebbe, Uganda on July 11, 2003.

Fifteen years after the passage of the United States President’s Emergency Plan for AIDS Relief, what was once a death sentence is no longer one in Africa and other developing regions. Thanks to the generosity of the American people’s investments in PEPFAR, along with the political will of national leaders and commitment of engaged stakeholders, people with HIV/AIDS are able to live long and hopeful lives. Incredible gains have been made in the fight against HIV/AIDS. Recent estimates place the number of lives saved so far at 17 million.

But challenges remain. 1.8 million people worldwide were newly infected with HIV in 2017; new HIV infections are increasing in young populations; and people living with HIV remain vulnerable to other life-threatening diseases including cervical cancer and tuberculosis¹.

When we look back to the situation in the early 2000s — when saying that an entire generation of lives could be lost was no exaggeration — we realize how far we’ve come. And as importantly, that we need to keep going. In this oral history, compiled from multiple first-person accounts*, we take a look back at the decisions facing U.S. leaders — and how those decisions saved millions of lives.

Accounts include memoirs, speeches, Congressional records, documentaries, conference speaking opportunities, written articles, and government updates from more than 40 speakers. Some quotes are adjusted slightly for clarity and abridged for brevity. Speakers are attributed by their title or role in the global AIDS response.

Posted on: December 1, 2018 / Updated: December 14, 2018

Part I: 2000-2007

2000-2001

A Generation in Peril

In the early 2000s, an estimated 36 million people were living with HIV/AIDS and nearly 22 million lives had been claimed.² Without proper access to treatment and resources, AIDS was a death sentence. And while those drugs were available in developed countries, few in Africa had any hope of receiving treatment.

George W. Bush
U.S. President (2001-2009)

“Condi Rice and I spent long hours discussing foreign policy on the back porch of the Governor’s Mansion. One day our conversation turned to Africa. Condi had strong feelings on the subject. She felt Africa had great potential, but had too often been neglected. We agreed that Africa would be a serious part of my foreign policy.”

Condoleezza Rice
U.S. National Security Advisor (2001-2005)

U.S. Secretary of State (2005-2009)
Full bio

“At one of my first meetings with then Governor Bush in 1999, we agreed that our agenda in Africa would go nowhere if we did not address the scourge of AIDS… there were estimates of up to 100 million deaths over the next twenty years if something was not done to arrest the plague.”

Festus Mogae
President of Botswana (1998-2008)

“We really are in a national crisis. We are threatened with extinction. People are dying in chillingly high numbers. We are losing the best of young people. It is a crisis of the first magnitude.”

Mark Dybul
PEPFAR Architect

A principal architect of PEPFAR while with the U.S. National Institute of Allergy and Infectious Diseases
U.S. Global AIDS Coordinator (2006-2009)
Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria (2012-2017)
Full bio

“At one point, 75 percent of pregnant women had HIV in Botswana. Most diseases kill the very old and the very young. But this disease was killing the most productive and reproductive parts of society. So not only were many households run by orphans, but entire villages were run by orphans, because everyone [else] was dead.”

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“You’d go to towns, and you’d see grandparents and grandchildren. And the entire intervening generation was gone. Like a neutron bomb that destroyed a generation… we were facing a cresting wave of death.”

George W. Bush
U.S. President (2001-2009)

“The statistics were horrifying. Some ten million people in sub-Saharan Africa had died. In some countries, one out of every four adults carried HIV… the United Nations projected that AIDS could be the worst epidemic since the bubonic plague of the Middle Ages.”

A mother in Uganda reads a memory book with her children on August 6, 2000. The mother, living with AIDS, created the book for her children. (Louise Gubb/CORBIS SABA/Corbis via Getty Images)

Children orphaned by the AIDS epidemic in Malawi sit in the Tithanizane Orphan Care Center in Ndirane township in Malawi, August 13, 2001. The center acts as a pre-school for 209 orphans that lived within a 1/2 kilometer radius of the town. (Alexander Joe/AFP/Getty Images)

2001-2002

First Steps

On May 11, 2001, President Bush announced action to fight the devastation across the globe by making the first contribution to the Global Fund to Fight AIDS, Malaria, and Tuberculosis. Joined by Nigerian President Olusegun Obasanjo and U.N. Secretary General Kofi Annan, he noted that “the sheer number of those infected and dying is almost beyond comprehension.” AIDS alone had left more than 11 million orphans in sub-Sahara Africa, and in several African countries, as many as half of the 15-year-olds could die of AIDS.

“We have the power to help.”

George W. Bush
U.S. President (2001-2009)

“We have the power to help. The United States is committed to working with other nations to reduce suffering and to spare lives. And working together is the key…Our high-level task force chaired by Secretaries (Colin) Powell and (Tommy) Thompson has developed a proposal that we have shared with U.N. officials, developing nations and our G-8 partners. We will need ideas from all sources. We must all show leadership and all share responsibility.

“For our part, I am today committing the United States of America to support a new worldwide fund with a founding contribution of $200 million. This is in addition to the billions we spend on research and to the $760 million we’re spending this year to help the international effort to fight AIDS. This $200 million will go exclusively to a global fund, with more to follow as we learn where our support can be most effective.”

Kofi Annan
U.N. Secretary General (1997-2006)

“To defeat this epidemic that haunts humanity and to give hope to the millions infected with the virus, we need a response that matches the challenge. We should now build on the remarkable progress over the last year in galvanizing global awareness of the threat of HIV/AIDS.”

Olusegun Obasanjo
President of Nigeria (1999-2007)

“Today, Mr. President, you have begun to concreteize that hope for Africa, and particularly for millions of Africans infected and affected by HIV/AIDS.”

President Bush welcomes Nigerian President Olusegun Obasanjo and U.N. Secretary General Kofi Annan into the Oval office on Friday, May 11, 2001. (Eric Draper / White House)

A year later, President Bush escalated the fight on HIV/AIDS. On June 19, 2002, he announced a new Mother and Child HIV Prevention Initiative, under The Global Fund to Fight AIDS, Tuberculosis, and Malaria that was intended to treat HIV-infected women with an antiretroviral drug to block transmission of the virus from pregnant or nursing mother to child. By building the healthcare delivery capacity, this new effort was expected to greatly expand the reach of care. As importantly, the administration set a concrete benchmark — as it would do with future investments.

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-present)

“President Bush sent (Secretary of Health and Human Services) Tommy Thompson and I, together with a group, on a fact-finding mission to various African countries to scope out what was going on down there. When we came back, he asked me to put together a mother-to-child transmission initiative, because it was just then that Nevirapine was shown in a single dose to mother followed by a single dose to baby right after birth had a major impact on blocking transmission from mother to child.

“I made a proposal to the President… that a $500 million investment in mother to child transmission would be a very important contribution.”

George W. Bush
U.S. President (2001-2009)

“The wasted human lives… are a call to action for every person on the planet and for every government. So, today, my administration is announcing another important new initiative in the fight against HIV/AIDS.

“Our initiative will focus on 12 countries in Africa and others in the Caribbean where the problem is most severe and where our help can make the greatest amount of difference. We’ll pursue medical strategies that have a proven track record. We’ll define specific goals. We will demand effective management. When the lives of babies and mothers are at stake, the only measure of compassion is real results.”

Mark Dybul
PEPFAR Architect

“The world was moving, but moving slowly. People weren’t thinking big. They were thinking a little here, a little there… no one was thinking billions… that we have to really get after this thing. We were thinking $500 million was a lot of money. But the President was thinking something much bigger.”

Joshua Bolten
White House Deputy Chief of Staff for Policy (2001-2003)

Director of the Office of Management and Budget(2003-2006)
White House Chief of Staff (2006-2009) Full bio

“President Bush thought the mother-to-child transmission program was a great start, but he wanted to do more to address the problem of AIDS in Africa. His exact words were, ‘Think big.'”

Video: Anthony Fauci recalls the early days of PEPFAR and the Global Fund to Fight AIDS, Tuberculosis, and Malaria in this video by HIV.gov.

President George W. Bush announces a new Mother and Child HIV Prevention Initiative in the Rose Garden on June 19, 2002. Standing by the President from left to right, are Secretary of Treasury Paul O’Neill, Secretary of Health and Human Services Tommy Thompson, and Secretary of State Colin Powell. (White House)

The HIV/AIDS pandemic continued to worsen. By the end of 2002, more than 40 million people were living with HIV and the death toll was rising, leaving more than 14 million children orphaned³. Hospitals throughout sub-Saharan Africa were overwhelmed by the number of people needing help. In the worst-affected countries, life expectancy decreased by 20 years.

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“The mother to child transmission announcement had a strange effect. It was a great program, but it revealed how pitiful what we were doing was. The scale of the need, compared to what we were doing… it was just not sufficient.”

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-present)

“President Bush told me, ‘Make it something much bigger, I want a game changer for Africa. I want you to go and get multiple models and come back and work with the staff to see what we can do to really turn things around in Africa. I want it to be feasible, I want it to be implementable, and I want it to be accountable. I don’t want to just give money to foreign countries and say go do it.'”

Joshua Bolten
White House Deputy Chief of Staff for Policy (2001-2003)

Director of the Office of Management and Budget(2003-2006)
White House Chief of Staff (2006-2009) Full bio

“He wanted to do something game-changing. Something that, instead of at the margins assuaging everybody’s conscience, might actually change the trajectory of this disease which, from the reports we were getting, was headed to destroy a whole continent.”

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“The President wanted measurable outputs, which translated into numerical goals. Which was just completely unknown in foreign assistance. It was a revolution in the way foreign assistance was done.”

To commemorate the 15th anniversary of PEPFAR, Mark Dybul and Michael Gerson recall their experiences in its development with Barbara Bush and Agnes Binagwaho at The Lazarus Effect at Engage at the Bush Center, Presented by Highland Capital Management, on May 9, 2018.

Up to this point, Anthony Fauci and Mark Dybul had worked on clinical trials in Africa to research the feasibility of various approaches of delivering antiretroviral care. Modeled after a clinic in Uganda’s capital created by Peter Mugyenyi and a program in rural Uganda from the AIDS Support Organization, Dybul and Fauci formed the early versions of what would eventually become the foundation of PEPFAR.

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-present)

“Peter Mugyenyi had a model that had a central core of treatment, with clinics, and it became less sophisticated care as you went out farther and farther from the center. But everything was linked together.”

Mark Dybul
PEPFAR Architect

“[The trials] showed me that it was possible to treat AIDS both in clinic and through rural outreach.”

Peter Mugyenyi, pictured above in 2005 in Kampala, earlier created a clinic in rural Uganda that became a model for healthcare delivery for PEPFAR. (Marco Longari/AFP/Getty Images)

Planning in earnest for an approach that leveraged new developments in antiretrovirals that could prolong the life of AIDS patients began in August of 2002, with Fauci and Dybul making regular visits to the White House to work through details. In November, Joshua Bolten asked Fauci and Dybul to provide a panel of experts that had real-world experience in delivering the drugs in developing nations.

This meeting — whose topic was intended to be a surprise to its guests, though Fauci secretly gave them warning — would serve as a final litmus test before White House officials made their recommendations to the President.

Anthony Fauci
PEPFAR Architect and Director of National Institute of Allergy and Infectious Diseases (1984-present)

“They wanted validation of this plan from people who are implementing treatment and care in the developing world. They want to know whether I am giving them a completely unrealistic pie-in-the-sky fantasy.”

Eric Goosby
CEO and Chief Medical Officer of Pangaea Global AIDS Foundation (2001-2009), who worked in Rwanda

U.S. Global AIDS Coordinator (2009-2013)
Full bio

“The discussion was real blood and guts. It was things like, ‘What do you confront most often, what did you put in place, why did you think you could do it, what kind of lab support did you need, how did you keep track of the patients, how many patients stopped taking medicine?”

Paul Farmer
Co-Founder of Partners in Health

“We don’t have doctors posted in villages now where people are treated and monitored. We have community health workers, and they deliver a higher standard of care from what I have seen in many U.S. settings. In fact, we have introduced this same model with community health workers in Boston, in the shadows of the teaching hospitals, and we can do it much more quickly and efficiently than they do it here.”

Peter Mugyenyi
Co-Founder, Joint Clinical Research Center in Uganda

“The carnage of AIDS in Africa constituted a moral imperative to act; that it was a catastrophe of astronomical proportions of people dying when they could have been saved, and the U.S. was in a position to stop it. AIDS could be treated in Africa and treated with as good an outcome as was achievable in the US.”

Paul Farmer with a patient in Haiti. (via Partners in Health)

The movie Bending the Arc takes an in-depth look at Partners in Health’s work in innovative methods of delivering high-quality health care in the fight against HIV/AIDS, following their PEPFAR-inspiring work in Haiti along with their later work in Rwanda. Watch the trailer

In early December, a small team made their recommendations to the President in the Oval Office. After discussion, the President told them he was ready to announce a plan at the State of the Union address in January. The advisory team had moved quickly in part because it had moved quietly, dodging the bureaucracy of the federal government.

Condoleezza Rice
U.S. National Security Advisor (2001-2005)

U.S. Secretary of State (2005-2009)
Full bio

“The President turned to each of us and asked whether he should proceed [with the plan, knowing that drugs could prolong life but a cure was not available]. When he turned to me, I said, ‘Mr. President, one of the saddest days of my life was when my mother died. But I have always been grateful that she survived her initial bout with cancer. She died when I was thirty, not fifteen. That meant she saw me grow up, graduate from college, and become a professor at Stanford. You may not be able to cure those mothers in Africa, but maybe they’ll live long enough to see their kids grow up. That will matter.”

Michael Gerson
White House Director of Speechwriting and Senior Policy Advisor (2001-2006)

“I remember thinking in the aftermath of that meeting, that from a historical perspective… there had been other meetings around tables of government leaders in Moscow, and Beijing, and Berlin in the 20th century, where plans had been made to murder millions of people. And I got to be in a meeting where the President of the United States made the decision to save millions of people.”

George W. Bush
U.S. President (2001-2009)

“I was confident I could explain how saving lives in Africa served our strategic and moral interests. Healthier societies would be less likely to breed terror or genocide. They would be more prosperous and better able to afford our goods and services. People uncertain of America’s motives would see our generosity and compassion. And I believed the American people would be more supportive if we could show that their tax dollars were saving lives.”

A family — both parents HIV-positive — visits Ugandan clinic run by the AIDS Support Organization (TASO) in 2000. TASO would later become a model for PEPFAR. (Louise Gubb/CORBIS SABA/Corbis via Getty Images)

2003

Making the Leap

In 2003, with Dr. Mugyenyi at the side of Mrs. Bush at the State of the Union, the President unveiled the President’s Emergency Plan for AIDS Relief (PEPFAR).

In his speech, the President requested $15 billion for combating global HIV/AIDS primarily in fifteen countries, twelve of them in Africa. The plan was designed to prevent seven million new HIV infections, treat at least two million people with life-extending antiretroviral drugs, and provide humane care for 10 million people suffering from AIDS and for children who had lost one or both parents to AIDS.

George W. Bush
U.S. President (2001-2009)

“Ladies and gentlemen, seldom has history offered a greater opportunity to do so much for so many. We have confronted, and will continue to confront, HIV/AIDS in our own country. And to meet a severe and urgent crisis abroad, tonight I propose the Emergency Plan for AIDS Relief, a work of mercy beyond all current international efforts to help the people of Africa. I ask the Congress to commit $15 billion over the next five years… to turn the tide against AIDS in the most afflicted nations of Africa and the Caribbean.”

Peter Mugyenyi
Co-Founder, Joint Clinical Research Center in Uganda

“We will save the others. Help is coming.”

Jim Yong Kim
Co-founder, Partners in Health

“I was blindsided. I couldn’t believe it. I mean this was really an incredibly gutsy decision to make, and it was done, as far as we can tell, I’ve never spoken to him about this, it was done on the basis of compassion.”

Mrs. Laura Bush turns to Peter Mugyenyi of Uganda, whose work was instrumental in the development of PEPFAR, during President George W. Bush’s State of the Union address at the U.S. Capitol Tuesday, Jan. 28, 2003. (Susan Sterner / White House)

President Bush had announced his plan – but now had to make sure that the American taxpayers and their representatives would be on board as the bill went through the legislative process. Both houses of Congress recognized the urgency of the matter, and the bill received bipartisan support.

Henry Hyde
U.S. Representative (R-Illinois, 1975-2007) and Chairman of the House Foreign Affairs Committee (2001-2007)

“Today we have an opportunity to do something significant and of lasting importance. Today we have an obligation to do something reflecting our commitment. We have a privilege – the privilege of doing something truly compassionate. The HIV/AIDS pandemic is not only a humanitarian crisis. Increasingly, it’s a threat to the security of the developing world.”

Tom Lantos
U.S. Representative (D-California, 1981-2008)

“I rise in strong support of this grand humanitarian legislation and I urge all of my colleagues to make history today by securing its passage.”

Richard Lugar
U.S. Senator (R-Indiana, 1977-2013) and Chairman of the Senate Foreign Relations Committee (2003-2007)

“[HIV/AIDS] has imposed a crushing burden on the economies of numerous African nations; it has exacerbated undercurrents of political instability that weaken the fundamentals of responsible government; and it has destroyed millions of family units… The President has recognized the urgency of moving forward at this moment in history and has announced his support very solidly… We must join him in this effort.”

Joe Biden
U.S. Senator (D-Delaware, 1973-2009)

“HIV/AIDS is the worst epidemic that mankind has ever seen. It is a source of instability. It is highly damaging to economic development in some of the poorest countries of the world. It is a humanitarian disaster. It is, in short, a national security issue, and will be for the foreseeable future. It is right and proper that the Congress and the President work together to develop a comprehensive program of assistance. As the world’s leading economic power, we have a responsibility to lead the world in fighting this plague.”

Tom Daschle
U.S. Senator (D-South Dakota, 1987-2005) and Senate Minority Leader (2003-2005)

“This bill offers the beginning of real hope. This bill holds out the promise that some of those children will grow to be adults and perhaps have children on their own. I am convinced that, if we combine America’s resources and technology and the great compassion of the American people with the courage and hope shown by (South African) Mary and so many others, we will defeat this disease.

HIV/AIDS is the great humanitarian crisis of our time. But it is more than a humanitarian crisis. AIDS is a national security issue. It is a public health issue. It is an economic issue. And it is a moral issue. We have the tools to fight this disease. It is our duty and our obligation to use them.”

Bill Frist
U.S. Senator (R-Tennessee, 1995-2007) and Senate Majority Leader (2003-2007)

“History will judge whether a world led by America stood by and let transpire one of the greatest destructions of human life in recorded history — or performed one of its most heroic rescues. President Bush has opened the door to that latter possibility. We must pass this legislation now and get this program established without further delay. The President’s Global AIDS Initiative is a rare opportunity to enact legislation that will save hundreds of thousands – millions – of lives.

“This is our moment.”

Video: The 2003 State of the Union address delivered by President Bush.

President Bush discusses the HIV/AIDS Bill with, from left, Secretary of State Colin Powell, and Senators Joseph Biden, Bill Frist and Richard Lugar in the Oval office May 8, 2003. (Eric Draper / White House)

Senate Majority Leader Bill Frist speaks during a news conference on global AIDS suffering, May 15, 2003 on Capitol Hill in Washington, DC. (Alex Wong/Getty Images)