New Directions in Global Health Seminar – Selibe Phikwe

As Prepared For Delivery | March 16, 2015 | Gaborone

Good morning.

It is a pleasure to be here. Thank you for hosting our U.S. Mission Team in Selibe-Phikwe for this important seminar.

As you know, I’ve been serving as Ambassador to Botswana for approximately two months now, but I have made it a point to get out of the Embassy and to meet many people and see many parts of the country. My very first visit after presenting my credentials was to Tebelopele Voluntary Testing and Counseling center in Gaborone. It was there that I conducted a very public HIV Test with the media present because I wanted to show people that global health is one my Mission’s top priorities, and specifically in helping Botswana to change the course of the HIV/AIDS epidemic.

We want to convince people to test for HIV, as it’s the only way we are going to get a handle on this problem. Thus, I wanted to show good faith and lead by example. Talking about health and the path to an AIDS-free generation may THE most important thing I do in my role as anAmbassador. That’s also why I am here this morning.

For the first time since the beginning of the AIDS epidemic, Botswana has an historic opportunity to lay the groundwork to achieve epidemic control. We have the tools necessary to do this – including proven interventions like HIV treatment and Safe Male Circumcision. But now we need something else: We need the will to focus. By strategically focusing on the right things, in the right places, at the right time, we can achieve our ultimate goal of an AIDS free generation.

I believe with every fiber of my being that we can do this.

Ladies and gentlemen, I want to welcome you to the program we call “New Directions in Global Health: Sustainability and Progress in Achieving an AIDS-free Generation.”  This two-day seminar is organized by an interagency team from the U.S. government in partnership with your District Multi-Sectoral AIDS Committee.  We have also partnered with the Media Institute of Southern Africa, or MISA, in order to bring our friends from the media aboard as partners.

The aim of this program is to create a dialogue with district stakeholders outside of Gaborone and with the media, on the successes and best practices of U.S. government-funded health initiatives, programs and research here in Botswana. We also aim to persuade key policy makers at the district level to increase their commitment and coordination in the response to HIV and other global health issues. It should be an interesting and productive two days of discussions.

The world’s attention is focused on the very issues that you are discussing here today: responses to Gender Based Violence;services for Key Populations; studies on Combination Prevention; and new policies and support for Prevention of Mother-to-Child Transmission. Our friends from the media will have no trouble finding something relevant and timely to report on this week.

My government’s global AIDS program known as PEPFAR, or the U.S. President’s Emergency Plan for AIDS Relief, has been working in partnership with Botswana for 12 years. While the Government of Botswana has made the lion’s share of the total investment, the American investment in this joint effort has so far totaled more than $700 million U.S. dollars. That is more than 6 billion pula. Together, we have accomplished a lot.

What has changed over the last decade?

  • New HIV infections have dropped 71 percent since 2001;
  • The mother-to-child transmission rate has dropped from a peak of around 40 percent to nearly 2 percent – better than most Western countries;
  • Botswana’s provision of free antiretroviral treatment to its citizens has become a model for the rest of Africa, and frankly for the world; and,
  • Today, Botswana is one of a few countries where the HIV epidemic has passed the “tipping point” – the point where for every one new person on treatment, there is less than one person newly infected.

What these figures tell us is that we have begun to change the course of the epidemic. But we are not done. Every single day in Botswana, 45 people become infected with HIV.  That’s about 16,000 new infections every year. If we become complacent, if we lose focus in our efforts to control the HIV epidemic, the tremendous gains we have achieved will unravel.

So how do we plan to maintain these positive shifts? Like I said earlier, it will require delivering the right things in the right places at the right time. We must continue to invest in evidence-based, high-impact interventions – and advocate for effective health policies – if we are to realize the goal of zero new infections in Botswana.

What are the right things?  The New Directions program today and tomorrow is packed with discussions on the evidence-based interventions I am talking about. Ensuring access to HIV treatment is one of the right things. This is incredibly important in our path towards controlling this epidemic.

My government is engaged right now with the Government of Botswana to consider changing its treatment policy and adopting a CD4 500 cutoff for initiation of HIV treatment. As most everyone here knows, the current CD4 count cutoff is at 350 in Botswana. But the World Health Organization has recommended that countries move to CD4 500 in order to get more people on treatment faster – and save more lives.

Anti-retroviral treatment acts as a prevention measure and moving to 500 would actually cut the number of new infections in Botswana by 22%. Most other countries in Sub-Saharan Africa have already adopted this recommendation. My government through PEPFAR is willing to help Botswana make this transition and adopt this important initiative, which may cost more initially, but will in the long run save Botswana’s health costs through fewer infections and a healthier population. We can’t afford not to do this.

Option B+ is another one of the right things. My government has pledged $7.5 million in funding to support the Government of Botswana’s recent decision to adopt and implement Option B+. Members of my PEPFAR team are already working with officials from the Ministry of Health on this project. For those unfamiliar with Option B+, this is a program that provides lifelong treatment to HIV-positive pregnant women regardless of their CD4 count. Why is this important? Lifelong treatment helps prevent infant infections, it saves mothers’ lives, it reduces the numbers of orphans, and it is cost-effective.

Another key policy change, we believe, would be to empower mothers by promoting and supporting breastfeeding. Currently, the government of Botswana purchases and provides formula free of charge to all HIV-positive mothers. If Botswana were to adopt the 2010 WHO recommendations related to infant feeding and promoted breastfeeding over formula feeding for HIV-infected mothers on antiretroviral treatment, we could improve health outcomes.

What else are the right things?  Science tells us combination prevention is important, and we are studying the best ways to execute this. The United States, the Botswana Ministry of Health and Harvard University are working on a four-year project called the Botswana Combination Prevention Project, also known by its Setswana name Ya Tsie (YAT-SEE-YEA). We hope to determine whether coordinated and strengthened prevention methods – including HIV testing and counseling, antiretroviral treatment, Safe Male Circumcision, and PMTCT – when scaled-up together at the community level, can prevent the spread of the virus better than methods offered individually.

So far, we have already learned some valuable lessons from the first year of this study. We were able to pilot Option B+ prior to the national rollout, and demonstrate the willingness of HIV-positive pregnant in Botswana to continue anti-retroviral therapy for life when recommended. We also learned that using door-to-door, home-based and community HIV testing campaigns can help to successfully identify community members with HIV who were unaware of their status, and to link them to immediate treatment which they otherwise would not have benefited from.

We need to continue this kind of research that advances high-impact detection and prevention of HIV, but we also need to begin applying now the lessons we have already learned.

Over the past 10 years, PEPFAR has moved from an emergency response program to one of sustainability and shared responsibility. We have an obligation to Americans and Batswana alike to ensure every dollar spent on the HIV response in Botswana is maximized and used to accelerate HIV epidemic control.

With that in mind, we plan to focus greater attention and resources on drivers of the epidemic that, if left unaddressed, will make it impossible to achieve an AIDS-free generation. I cannot emphasize enough the need for a focused effort on vulnerable populations, especially young women, who are at a vastly higher risk of acquiring HIV compared to young men. Gender-based violence is one reason for this. Studies have shown that women who experience GBV are 50% more likely to be infected with HIV than women in non-violent relationships.

Prevalence is also extremely high among female sex workers. A 2012 survey in Botswana found HIV prevalence among sex workers to be above 60 percent, which makes them the sub-group most affected by HIV in Botswana. Today, we know if any one of our populations is left behind, all of us are left behind and we will not ultimately control the epidemic.

Scale up of effective HIV prevention activities for key populations – and this includes sex workers and men who have sex with men – needs to take place in parallel with efforts to tackle the underlying social drivers of the epidemic, including stigma, legal barriers and social and gender norms. I know that these are uncomfortable topics for some people, but they are also important public health issues, and you cannot isolate them from the broader HIV public health challenge.

We have witnessed across the globe that political environments contributing to stigma and discrimination against key populations impede access to life-saving services such as health care. This has to change. Through the courage of civil society organizations, such as LEGBIBO, it will.

So those are the right things – the evidence-based, high-impact interventions. The right place means we have to focus more geographically as well as on the most vulnerable populations, and the right time is now to ensure implementation of new policies and international guidelines, and to prevent new infections in the most vulnerable and high prevalence areas.

Change must come. But I promise you this: PEPFAR and the American people remain committed to our shared vision for an AIDS-free generation. Why? Because it matters. I look forward to working with you all and with our government counterparts here in Botswana to achieve this.

I hope the ideas I have shared this morning will help fuel your exchanges today and tomorrow. I am calling on my PEPFAR team to lead discussions that will help the residents of the Selibe-Phikwe District think about the best ways to implement these programs. I encourage everyone to participate actively and to take advantage of our presenters by asking lots of questions.

I thank you for your time.