How HIV/AIDS Shapes U.S. Foreign AID

Max Essex and Michelle Gavin

On March 30th, Michelle Gavin, former U.S. Ambassador to Botswana (2011-14), spoke to a packed house at the Harvard T.H. Chan School of Public Health. Her topic was “What Botswana’s Fight Against HIV/AIDS Teaches Us About Foreign Assistance.”

Before becoming Ambassador, Gavin served for two years as a Special Assistant to President Obama and as the Senior Director for Africa at the National Security Council. In March, Gavin was chosen as Managing Director of The Africa Center in New York. She also serves on HAI’s International Advisory Council.

After working on emergencies in Sudan and Somalia for the National Security Council, “where everyday was an exercise in crisis management,” Gavin welcomed the opportunity to serve in Botswana and “to work with one of the world’s most compelling development success stories, though a country that also has the second highest HIV prevalence rate in the world.”

She listed Botswana’s well-functioning government, atmosphere of security, and small population as factors that make it a model for other African nations, as well as a testing ground for new programs. “These are the places where you’re going to figure out how you solve hard problems,” said Gavin. “If it doesn’t work in Botswana, what are the chances that it’s going to work in Congo or even Tanzania?”

Gavin addressed the issue of how funding for HIV/AIDS takes up an enormous portion of the U.S. budget for programs in Botswana and other countries. With the majority of assistance already targeted for HIV/AIDS, less funding is available for other priorities, such as diversifying Botswana’s economy beyond its current reliance on diamond mining. “PEPFAR is the monster that ate our foreign assistance budget,” said Gavin.

PEPFAR, the President’s Emergency Plan For AIDS Relief (PEPFAR), is the U.S. initiative that was announced in 2003 by President George W. Bush. The U.S. pledged $15 billion over five years to address the global HIV/AIDS epidemic, making it the largest public health initiative ever initiated by one country to address a single disease.

PEPFAR dramatically increased access to antiretroviral treatment, mostly in Africa, where AIDS hit hardest. The program has saved millions of lives, is widely considered a success, and has received strong bipartisan support. In 2008, Congress authorized another $48 billion for PEPFAR to be spent from 2009-2013. Funding continues for an evolving PEPFAR program. As of September 2014, PEPFAR was supporting life-saving antiretroviral treatment for 7.7 million men, women and children worldwide.

“You can’t launch a program that helps get people on treatment they need to avoid a fatal illness and then change your mind five years later,” said Gavin. “There is no way out of that spending.” A number of people in the audience, many of them directly involved in HIV/AIDS research, were nodding in agreement. With no promising HIV vaccine in the pipeline, people currently taking antiretroviral drugs are likely to be taking drugs for decades or longer. “Very rarely does anybody honestly say, we’ve essentially mortgaged our ability to make foreign assistance choices to PEPFAR for the foreseeable future,” said Gavin, “but that’s exactly what we’ve done.”

Though Gavin was candid in questioning the sustainability of PEPFAR, she also saw progress being made in HIV prevention efforts. Specifically, she mentioned the Botswana Combination Prevention Project (BCPP), a large clinical trial to test methods to significantly reduce new HIV infections at a community level. “How can you actually get out from under it? This was the most compelling answer I heard and I asked the question a lot,” said Gavin. The BCPP was launched in fall of 2013 when she was still ambassador. Dr. Max Essex, Chair of HAI, is the Principal Investigator of the trial.

“The politics really do matter in terms of outcomes on the ground,” said Gavin. “Anybody who tries to ignore them and wishes them away ends up being far less effective.”