Could new abortion rules in the US affect the world’s biggest state HIV fund?

• In June, the US government swore in the first African head of its Aids fund, Pepfar. 
• John Nkengasong is a virologist from Cameroon with US citizenship. His appointment comes at a challenging time when the Covid pandemic has overshadowed HIV and current Pepfar legislation is ending in 2023. 
• Nkengasong would have to deal with the potential impact of the US Supreme Court’s recent ruling that nullified the constitutional right to abortion in America, as Pepfar has to follow US laws.

In June, the US government took an unprecedented step. The first African head of the President’s Emergency Plan for Aids Relief, Pepfar, was sworn in. 

John Nkengasong, a virologist from Cameroon and the former head of the Africa Centres for Disease Control & Prevention, is now the head of the world’s largest government fund to fight HIV. The scientist is, of course, also a US citizen — a requirement for most federal US government positions — and it’s not his first time working for an American government agency. Nkengasong worked for the US Centers for Disease Control & Prevention (CDC) from the mid-1990s until the mid-2000s in Washington, DC and Abidjan in Ivory Coast.

Pepfar has invested more than $100bn in fighting HIV in more than 50 countries and was created in 2003 during the administration of former president George W Bush. In 2021, the fund spent R7.5bn in SA; the programme is the largest contributor to the Global Fund to Fight Aids, Tuberculosis & Malaria.

But Nkengasong’s appointment comes at a challenging time when the “ongoing Covid-19 pandemic has overshadowed HIV” and current Pepfar legislation is ending in 2023, according to the Pepfar Extension Act of 2018.

Pepfar has also not been run without contention.

The fund was initially controversial because of Bush’s Republican government’s strong support for conservative, non-evidence-based approaches to curb the pandemic, such as provisions that prevented organisations from receiving funding if they supported the decriminalisation of sex work and favouring projects and governments that supported abstinence from sex before marriage as opposed to condom use.

But Pepfar’s policies have since evolved and today the fund is widely credited with having played a meaningful role in making antiretroviral treatment available in Africa and a consequent decline in HIV-related deaths.

Because the programme also invests in the upskilling of health workers and improvement of health systems, its impact stretches far beyond HIV: studies have found that, compared with countries that don’t receive Pepfar funding, between 2004 and 2018, Pepfar-supported countries showed significant drops in deaths among children under five, pregnant people and those who give birth.

Such countries also showed a decline in general mortality rates (so also deaths not specifically related to HIV) and increases in the proportion of children getting vaccinated against childhood diseases.

Pepfar, however, becomes controversial each time there’s a Republican administration, as the party doesn’t endorse self-initiated abortion and then implements a regulation commonly referred to as the “gag rule”, which requires funded organisations to disassociate themselves from pregnancy terminations.

President Joe Biden’s Democratic government revoked the rule in January 2021, but the US Supreme Court’s overturning of the Roe v Wade ruling in June, which guaranteed Americans’ constitutional right to abortion, now complicates matters, as Pepfar has to follow US laws, Nkengasong told Bhekisisa’s Mia Malan in an interview for the centre’s television programme, Health Beat. 

Malan also asked Nkengasong how he’ll address inequality, one of the biggest contributors to the spread of HIV, what lessons the US can learn from Africa and if Pepfar will intervene to make HIV prevention injections available on the continent as soon as possible.  

American secretary of state Antony Blinken recently visited SA and said the US will treat African countries as equal partners. What lessons can the US learn from Africa?

There’s a lot that the US can learn from Africa, including in the field of HIV and Aids. For example, Botswana, has just announced that they have exceeded the 95-95-95 targets. These targets mean [by 2025] 95% of the population infected with HIV need to know their status, 95% of those who have been diagnosed need to be on treatment, and 95% of those on treatment should have a viral load [the amount of HIV in someone’s blood] below detection level.

That’s a unique situation, especially when you know where Botswana was a few years ago, looking at the burden of the disease. Colleagues in the US, where I’m based, should be able to go to Botswana to learn how they got there. Also, the Omicron variant was identified by researchers in SA [and Botswana]. That’s a lesson for the world, not just the US, to learn how Africans worked together in a network to identify the emergence of such a new variant.

Before joining Pepfar, you were the head of the Africa Centres for Disease Control (CDC). How will you apply the lessons that you learnt during that time, especially with regards to Covid-19, to your new position?

There are so many parallels: know the pathogens, which in this case are HIV and [SARS-CoV-2]. [With] Covid, we still continue to learn the variants and HIV has many genetic subtypes. Having the right policies is also very important. We saw in the Covid response how good politics can enhance a country’s ability to fight the pandemic and how bad politics can lead to [an insufficient] response.

Which African country used “good politics” to respond to Covid-19?

At a regional level, President Cyril Ramaphosa was the chair of the AU when Covid just hit the continent and I was the director of the Africa CDC. In my 32 years of working in global health, he has, in my view, been the most effective political leader with regards to guiding the continental response. He convened his peers — heads of states — nearly every month to discuss the pandemic. President Ramaphosa was the one who set up the African Vaccine Acquisition Task Force. The task force promoted vaccine acquisition on the continent and resulted in 400-million doses of vaccines being  acquired in Africa at a time when there were absolutely no vaccines for the continent. He also set up the Africa Medical Supplies Platform, which is a platform like amazon.com, where you can click on products to put them into your basket, pay and go. That’s how we unlocked the challenges that we had early on. That’s good politics.

We now live in an era where there are simultaneous pandemics, as we’ve seen with HIV and Covid. Other pandemics set back efforts to fight HIV. How will that influence your Pepfar strategy?

We saw how disruptive the Covid pandemic was to our ability to offer services to HIV patients, including enrolling new patients and even dispensing medication to patients who were already on treatment. We also know that Covid infection in HIV patients with lower CD4 counts [a high CD count is associated with a strong immune system and a low CD4 count with a weak system] makes it difficult for them to fight the virus. That means we have to look at HIV programming [within the context of] how we [can] strengthen health systems that can protect the HIV gains by warding off [new] outbreaks early enough — so that new outbreaks don’t disrupt HIV service delivery. That is one of the cornerstones of my reimagining of Pepfar: how do we strengthen health systems that can fight HIV [and] position them in such a way that they can very quickly be used to respond to new disease outbreaks i.e, monkeypox or Covid-19.

The latest UNAids report pointed to the many ways that inequality fuels the spread of HIV. How will you, as the African head of Pepfar, address inequality on the continent?

Each time we fail to address inequalities the virus wins.

We need policies that will  result in better outcomes. HIV/Aids is a generational disease, the burden of the disease is in young people. We have to position young people in a way that will lead to the reduction of inequality [among them].

We have a unique opportunity to address inequalities by ensuring that the Global Fund [to fight Aids, Tuberculosis & Malaria] is replenished at $18bn [by] September. That will give us the resources to continue to address some of the inequalities.

What can African leaders do to show more political commitment to fight HIV?

Many countries in Africa are already showing strong political commitment and political will. SA contributes about 77% of the resources that are required to fight HIV/Aids in the country. Botswana contributes in excess of 80% of such resources. Is that the trend across the board in Africa? No. We want to see those countries that have not leveraged their own domestic resources, step up to the plate and say: “This is about our people and [though] we can do this in partnership with Pepfar and the Global Fund, we have to increase our own resource envelope.”

A two-monthly HIV prevention injection, cabotegravir, has been developed and is working even better than the daily HIV prevention pill. But Africa can’t afford it. Following pressure from activists, ViiV Healthcare, the company that makes the injection, has said they will sell it at a lower price to African countries until a generic version of the injection becomes available. But we still don’t know at which price. What can Pepfar do to get pharmaceutical companies to put people ahead of profits?

Pepfar cannot do it alone, so it means we have to rely on the power of partnerships [and] of collaboration. For the new long-acting pre-exposure prophylaxis (PrEP), Pepfar is already in discussion with multiple groups with whom we’re going to sit around the table and look at ways to shape the market. This is not the first time we are dealing with a drug that comes on the market at an unaffordable price. When antiretrovirals [used to treat HIV] were first introduced in 1996, it cost $10,000 [about R163,000 at today’s exchange rate] to treat one patient for a year. But look at where we are today! [SA’s health department pays about R888 for a year’s treatment per patient]. I’m optimistic that if we bring the right partners together, we can sit down with ViiV Healthcare to look at ways that we can bring the prices down as it looks like that long-acting injectable PrEP could be a game-changer.

How long do you think those negotiations will take?

It’s quite urgent. We are not talking years, it should be a question of months. We should aggressively work on it as a priority so that in months, not years, we can begin to roll out the injection in Africa.

Reproductive rights, such as access to contraception and safe abortion, are connected to women’s vulnerability to contracting HIV. But abortion is a controversial issue in the US because of the overturning of the Roe v Wade ruling. How do you see those rights playing out in the Pepfar programme?

Pepfar is governed by the laws of the US. We have to follow the rules and regulations we are governed by. We will be looking at [reproductive rights] closely in partnership with the countries we work in. If there are things that we cannot do with Pepfar programming [such as funding abortion services], then countries can also lead in that direction or look for additional partners who can leverage the limits and work with us to complete the areas that Pepfar cannot provide funding for.

The recent changes in the US are very new. We at Pepfar are still discussing these and we still need to ask questions for clarity where the need exists.

The Covid pandemic showed us how research conducted by African countries wasn’t always taken as seriously as studies from the Global North. Do Western countries take HIV research from Africa seriously enough?

Based on my own experience as someone of African origin, my answer is yes, colleagues in advanced countries do respect scientists from Africa. Is there room for improvement? Yes. But room for improvement should go both ways.

African scientists should also promote their own findings or create platforms to promote their findings. For example, we should have African respected journals where you can publish high-quality data from the continent. We should also have conferences on the continent where African scientists can share such information. When I was at the US CDC I addressed some of these gaps. I created the African Society For Lab Medicine in March 2011 and it became the premier platform for sharing laboratory knowledge and science. We don’t need permission from anybody to do that.

I also [helped to] create The Journal of Public Health in Africa and the African Journal of Laboratory Medicine, top-notch journals where Africans can publish their findings and disseminate it across the continent. My advice to African scientists is: count on your own strength, count on your networking. Create platforms that can promote your science and learn from each other. If you do that, countries  in Europe, Asia and the US will be eager to come and learn from Africa.

Should more international conferences be held in Africa to avoid excluding voices from the developing world like we saw at the 2022 Aids conference in Canada?

Absolutely, but Africa should also create its own international conferences. Nonetheless, Aids conferences for which Africans can’t get visas are simply inappropriate. It’s not in the spirit of fighting HIV together.

On a personal note, you’re now based in Washington, DC. What will you miss about living in Africa?

The warmness, not just in temperature, but warmness of the heart. People are willing to share whatever they have. The culture is just so rich.

Watch the full interview with John Nkengasong

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter​