Science

New head of U.S. aid program for HIV/AIDS vows to refocus attention on the other, ‘silent’ pandemic

On 13 June, John Nkengasong, 58, was appointed the first African-born head of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), a program that helps more than 50 countries respond to their HIV/AIDS epidemics. Nkengasong, who grew up in Cameroon and became a U.S. citizen in 2007, previously ran the Africa Centres for Disease Control and Prevention (Africa CDC).

PEPFAR is credited with helping save more than 20 million lives since its inception in 2003. It had a $10.7 billion budget in 2021, more than half of it spent on HIV treatment and care. The agency has relied on an acting director since Deborah Birx left in February 2020 to join then-President Donald Trump’s White House Coronavirus Task Force.

After earning a bachelor’s degree at the University of Yaoundé, Nkengasong did an internship as a lab technician at a medical school that in 1987 hosted a conference on sexually transmitted diseases. One of the attendees was Peter Piot, an epidemiologist at the Prince Leopold Institute of Tropical Medicine in Antwerp, Belgium, who was eager to expand collaborations with Cameroonian researchers to study an unusual HIV variant in that country. Piot later invited Nkengasong to Antwerp, where Nkengasong earned two master’s degrees and a Ph.D. Piot went on to become the head of the Joint United Nations Programme on HIV/AIDS and later ran the London School of Hygiene & Tropical Medicine.

“If I turned out to be bad today, you can blame it on Peter Piot,” Nkengasong says.

Between 1996 and 2002, Nkengasong worked at Projet RETRO-CI in Côte d’Ivoire, a field station of the U.S. Centers for Disease Control and Prevention (CDC) that was then one of the largest HIV/AIDS research projects in Africa. (Science ran a short profile of Nkengasong in 2000.) He moved to Atlanta to work at the U.S. CDC, then returned to Africa in 2017 to become the first director of Africa CDC, created to improve coordination between public health responses on the continent.

Nkengasong, who was named U.S. ambassador-at-large as well as PEPFAR head, will unveil his plans at the International AIDS Conference in Montreal, where he will speak during the 29 July opening ceremony and in four other sessions. This interview has been edited for brevity and clarity.

Q: How did you get this job?

A: In July 2021, I came home from work around 9 p.m., sat down with my wife for dinner, picked up my phone, and saw an email from the White House saying they wanted to consider me for this position. My first reaction was: How do I even think about this? I was leading the COVID response on the continent and reporting almost every month to 18 heads of states. What was I going to do? Say, hey, look, I am being considered for this job and might leave? My mind and my heart were racing.But I said: This is something to be considered, because I needed to also think about impacting the HIV epidemic in Africa.

Q: You have been on the job for just over 2 weeks. What’s your focus right now?

A: Listening. I’m contacting others around the Washington, D.C., area who have a huge stake in PEPFAR, engaging with the Department of Health and Human Services leadership, including people like Dr. Anthony Fauci [the head of the National Institute of Allergy and Infectious Diseases] to get insights and input about how we reimagine PEPFAR and the HIV/AIDS response. I’m talking to my own staff here, meeting with ambassadors and Secretary of State Antony Blinken.

Q: Has COVID-19 harmed PEPFAR’s efforts?

A: Absolutely. If you look at countries with high burdens of HIV, like South Africa, the service delivery very early on dropped by 40% because of COVID. Luckily, that was a dip and they’ve actually gained back momentum, but in many countries, COVID clearly impacted testing, the ability to retain people in care, and delivery of services. We have to remind ourselves always that when another infection occurs, it will continue to challenge our HIV response.

COVID has dominated the past 2.5 years, and we have a responsibility to bring back the political awareness about HIV/AIDS. When you talk of a pandemic, the first thing that the leadership in PEPFAR partner countries thinks about now is COVID. They forget that there’s a silent pandemic going on of HIV/AIDS. … If we take our eyes off that ball, the gains that we’ve made over the last 20 years can be eroded very, very quickly.

Q: What’s your big picture vision for PEPFAR?

A: HIV has defined global health for the past 30 years or so—bringing global health to the fore. This is the time to really look at the interface between HIV and health security.

Q: What do you mean by that?

A: Global health security is about developing policies that will govern all of us so that we can share information and collaborate, because when a disease strikes anywhere, the disease strikes everywhere. PEPFAR over the years has put an infrastructure in place, training over 300,000 health care workers and setting up more than 3000 laboratories across partner countries. Massive surveillance systems and networks are established there. You can use the same networks very effectively to rapidly squash any outbreaks. Pandemics don’t just occur. Pandemics occur because you fail to contain an outbreak.

Q: PEFPAR over the past decade has pushed for countries to “own” their epidemics and move away from assistance. Yet some countries remain heavily reliant on PEPFAR. How do you more aggressively help them become self-sustaining?

A: You’ve touched on a very key area of focus that I’m reviewing very carefully with different stakeholders. The moment is now to have a purposeful discussion with the countries and to define what sustainability looks like. PEPFAR will not always be there.

Q: Do you think you’ll have an advantage because of your relationship with African leaders?

A: I hope to use that very constructive relationship that I’ve developed with the highest leadership of the continent. Twenty years ago, they signed a declaration in Abuja, where they committed to bringing a certain percentage of their budgets to health. [At a 2001 health summit in Abuja, Nigeria, many African governments signed a declaration committing 15% of their annual budgets “to the improvement of the health sector.”]

Q: And it hasn’t happened.

A: It hasn’t happened. But that means it is easy to remind people about their commitments and to start a new discussion. I will be very eager to reengage and say, look, this declaration was very visionary, but let’s transform that vision into action because we have seen that these disease threats are a serious economic and developmental threat.

Q: At Africa CDC, you pushed for manufacturing of vaccines for COVID-19 and other diseases in Africa, which is another form of country ownership. Does that fit in with your vision for PEPFAR?

A: One of the things I would like to champion in PEPFAR is to build public-private partnerships to continue to advance certain manufacturing, like diagnostics. We conduct more than 100 million tests a year on the continent, but there’s not a single country that produces a simple rapid test. If we support a few countries to begin to produce an HIV rapid test, you can repurpose that platform when you have a new disease. The pipelines will be there already.

Q: Offering anti-HIV drugs to people at high risk of HIV infection as pre-exposure prophylaxis has proven extremely effective, and long-acting injections of PrEP are now available. But African countries in particular have been slow to adopt PrEP. Do you see that as an important aspect of the future of PEPFAR?

A: I see that as a critical part of the big picture. When I worked in Abidjan, Côte d’Ivoire, you could look across the fence at the infectious disease clinic and see AIDS patients lying there, just helpless. Now, because of the tremendous success of PEPFAR, the Global Fund, and others, people are very healthy. We’ve changed the landscape. In many pandemics, and with many diseases, when you get to that tail end, it gets harder to win the fight. We need to now begin to look at innovative ways of using new drugs.

Q: A large part of your portfolio is Africa. [Of the $100 billion PEPFAR has received to date, roughly 90% has gone to Africa countries.] Do you see it as challenging to work in other regions?

A: During my time at the U.S. CDC, I used to work in Southeast Asia, the Caribbean, and Central America. So at least I know those regions very, very well.

Q: Thank you for spending the time with ScienceInsider. I much appreciate it, ambassador.

A: It’s still a strange name to me. How did a technician become an ambassador? But “ambassador” comes with the job. I’m sure that with time I’ll get used to it.

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