‘Not Out of the Woods’
Ambassador Nkengasong Discusses Global HIV/AIDS Response
Photo: Chia-Chi Charlie Chang
Dr. John Nkengasong issued a dire warning in his David E. Barmes Global Health Lecture in June, held at the Natcher Conference Center. Nkengasong, senior bureau official for global health security and diplomacy at the U.S. Department of State, gave a talk titled, “Global HIV/AIDS Response: Then, Now, Future.” The lecture preceded a Q&A facilitated by NIH Director Dr. Monica Bertagnolli.
“What keeps you up at night?” Bertagnolli asked.
“The threat of financial challenges,” Nkengasong answered without hesitating. “I fear that HIV fatigue can kick in, complacency can kick in and, if it does, the gains we’ve made may be quickly eroded.”
As an example, Nkengasong recalled the malaria eradication program, initiated by the World Health Organization in 1955. The effort achieved some success though not as much as initially hoped. A turning point arrived in 1969.
“The countries that had made gains saw a resurgence of malaria and global interest faded,” he recounted. Financial support dwindled soon after, he told Bertagnolli.
First Barmes Lecture Since Pandemic
Photo: Chia-Chi Charlie Chang
When he took the stage, Nkengasong, who is U.S. Global AIDS Coordinator—a role that includes leading the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)—noted key moments in his career. He joined the HIV struggle in 1988 and also helped with the western Africa Ebola epidemic and the Covid-19 pandemic response efforts. Each crisis required a focus on the five Ps, he said: knowing the pathogen, the population, the policies, the politics and the partnerships.
In 2012, most PEPFAR-supported African countries reported less than 60% of people living with HIV on ART (antiretroviral treatment); a decade later, many countries are above 80% coverage. AIDS-related deaths have declined 68% since their peak in 2004, while new infections are down 42%. PEPFAR has saved 25 million lives and 5.5 million babies have been born free of HIV.
Overall, the rate of new infections has plummeted, but “we’re not out of the woods,” warned Nkengasong.
PEPFAR’s strategy to accomplish its 2030 goal of decreasing HIV infections by 90% compared to 2010 focuses on the three 95s: 95% of people who are infected know their status; 95% of people with HIV are in treatment; and 95% of those in treatment have viral suppression. When the 95s are achieved, Nkengasong said, the new infection rate dips below the HIV-related death rate and the epidemic comes under control.
“I believe in that metric strongly,” he emphasized.“It gives us a north star.”
Current & Future Challenges
Photo: Chia-Chi Charlie Chang
PEPFAR’s progress, though widespread, is uneven across the globe.
“We have a series of countries—Kyrgyz Republic, Tajikistan, Papua New Guinea and the Philippines—that we characterize as ‘epidemics of concern,’ countries where we see incidence increasing,” Nkengasong said.
In all regions, key drivers of transmission include the undiagnosed, those diagnosed but never treated and those who interrupt treatment. Studies have begun to show viral resistance to medications, which is exacerbated when people “cycle in and out of treatment.” Meanwhile, the 15- to 24-year-old age group accounts for 27% of new infections globally.
“We have to pay attention and use all kinds of behavioral science, interventions and approaches to try to bring [people] to care and make sure they stay in care,” said Nkengasong. Data, he pointed out, must be used in a more granular fashion to identify and close gaps.
Photo: Chia-Chi Charlie Chang
Nkengasong envisions a future when the HIV/AIDS response transitions from an infectious disease crisis to a disease management strategy.
“We’ve put a lot of emphasis on PrEP [pre-exposure prophylaxis],” said Nkengasong. PEPFAR has introduced long-acting PrEP in four countries (Malawi, Zambia, Zimbabwe and Ukraine), and by year’s end, 12 countries will be receiving supplies.
Though he remains hopeful about priority setting, Nkengasong said HIV gets pushed to the background whenever other emerging diseases, such as Covid-19 or mpox, arise.
Meanwhile, the HIV response is at a crossroads.
“We need to think about financing—we need to finish the fight,” Nkengasong concluded. “If PEPFAR was to stop today, you’d have an almost 400% increase in death rates.”
Watch the archived videocast at https://videocast.nih.gov/watch=54646.