New Directions in Global Health Seminar

Ambassador Miller Giving A Speech

Good morning. Thank you for having me here this morning at this important event.

What a great day to be out here in Ghanzi.  As always, I enjoyed my drive up yesterday along the Trans-Kalahari Highway, getting to view the vast and beautiful desert landscape of this great country.  Ghanzi is a place like no other, so unique from the rest of the country in art, culture, and geography.

Ladies and gentlemen, I am happy to be here to open this important program called “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 also partnered with the Media Institute of Southern Africa in order to bring our friends from the media aboard.  It should be an interesting and productive two days of discussions.

This program is sponsored by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which is my country’s global health initiative to assist countries in responding effectively and sustainably to the HIV epidemic.  Over the last decade, PEPFAR has committed more than $750 million to Botswana in its response to HIV.  Together, with the Government of Botswana, civil society and other development partners, we have come a long way.  The results of our combined efforts have been remarkable, and I think you will see from the discussions over the next two days just how far we’ve come together.

Many of you sitting here today are familiar with the UNAIDS global 90-90-90 targets.  For those who aren’t, these are the UN targets that replaced the Millennium Development Goals at the end of 2015 to guide and accelerate progress through the year 2020.  The simplified “90-90-90” motto refers to the HIV testing, treatment and viral suppression targets – 90% of those infected with HIV should be aware of their status; 90% of those aware of their status should have received treatment; and, for 90% of those being treated, the drugs will have had the intended effect of suppressing the patient’s viral load.

If you are an avid reader like I am, you would have seen the article last week about Botswana’s progress towards the 90-90-90 targets.  This was based on the Lancet medical journal’s article on a clinical study called the Botswana Combination Prevention Program , or locally known as “Ya Tsie.”  This is a study sponsored by PEPFAR and run in partnership between CDC Botswana, the Botswana-Harvard Partnership and the Ministry of Health.

Out of the 3,500 individuals from 30 communities who tested HIV positive, the BCPP study reports that 83% of them knew their HIV status, 87% of them had initiated treatment, and 96% of those on ART had achieved viral suppression.  All of this looks pretty impressive.  But to be fair, we must caution against concluding that these numbers are representative of the entire country.  It was a relatively small sample size in just 30 communities.

Still, the results reported are encouraging.

Once again, Botswana stands out as a laudable example for other countries to follow – just as it did back in the early days of the AIDS epidemic when this country was one of the first to extend treatment to the entire country.  Now, Botswana could be among the first countries to actually control the HIV epidemic.  This is exciting.  We should collectively seize the opportunity to do so.

In December of last year during World AIDS Day, we announced PEPFAR’s new direction in evidence-based programming.  Our investments in Botswana have shifted to become more focused on the hardest-hit geographic areas and on the most impactful activities.  The overall aim of this new shift is working with partners to help Botswana achieve epidemic control by 2018.  In order to accomplish this, we need to focus on the right things, in the right places, and do them right now.

So what are the right things?  We believe that offering HIV treatment to anyone living with HIV is one of the right things.  I would like to commend the Government of Botswana for considering the adoption of the Test and Treat policy.  Moving towards earlier initiation of treatment is strongly supported by a recent international randomized clinical trial.  Treatment also acts as prevention by lowering the risk of transmission to uninfected sexual partners.  The World Health Organization and PEPFAR are encouraging all countries – including Botswana – to move to the new policy for all people living with HIV.

Reaching more people with HIV prevention, care and treatment services requires strengthened linkages between health facilities and community service providers.  Communities have an important role to play in the response to HIV, helping to reduce stigma and encouraging community members to get tested and adhere to treatment.  PEPFAR is now focused on strengthening this community-to-facility model by ensuring that people living with HIV are linked to treatment programs and other services, such as gender-based violence support and social services.

Other right things include ensuring life-long treatment for HIV-positive pregnant women, regardless of their viral load – a program that helps prevent new infections among children, saves mothers’ lives, reduces the number of orphans and is cost-effective.  Scaling-up Safe Male Circumcision, especially in 15-29 year olds, addressing TB/HIV co-infection and ensuring quality control and accredited laboratories are also the right things.

What do I mean when I say we must focus on the right places?  PEPFAR has shifted from working in all 24 health districts in Botswana to focusing on half of those districts with the greatest disease burden.  Focusing efforts in those places offers an opportunity to make the biggest impact in the shortest amount of time.

The right places also means targeting the right groups of people who stand to benefit the most.  Overcoming the barriers that prevent key populations – including female sex workers and men who have sex with men – from receiving treatment and care is critical to reaching epidemic control in Botswana.  We are encouraged by a recent Botswana High Court ruling to allow LGBTI advocacy groups to legally register and campaign for non-discrimination.

As I said earlier, Ghanzi is a unique community and we realize this is true even when it comes to health.  We know Ghanzi is not a high burden district in terms of HIV, but that the real need here is a continued and sustained response to the TB epidemic.  Ghanzi has the highest TB incidence in the country.  So while we have shifted completely out of many other districts, PEPFAR will remain in Ghanzi to support community TB care through partners like Kuru Health and BONEPWA.  You will hear more about these important partnerships over the next two days.

Globally, Botswana is among the top high TB/HIV burden countries and has been identified by the WHO as a priority country for the global TB/HIV response.  I would like to reiterate if the Government of Botswana decides to adopt the Test and Treat policy, it will not only ensure the best care for individuals living with HIV, but will also be a key strategy to curb the TB/HIV epidemic in Botswana by preventing active TB disease.

I guess you can tell by now, this all means big changes are coming. Indeed, they are already underway.  But I promise you this: PEPFAR and the American people remain committed to locking Botswana on the path to an AIDS-free generation.  I look forward to working with you all and with our government’s partners here in Botswana to achieve this.

I hope the ideas I have shared this morning will help fuel your exchanges today and tomorrow.  I encourage everyone to participate actively and to take advantage of our presenters by asking lots of questions.  Remember, we are getting closer and closer, we can see the goal ahead of us.  Now is the time to redouble our efforts and, together, run to and through the finish line.

Thank you. Ke a leboga!