WASHINGTON — Through his office window in what was then one of the few modern clinics in Africa dealing with HIV and AIDS, the man who now oversees the United States’ endangered global AIDS effort heard the sound of taxis pulling up all day long. .
When he turned his head to look out the window, Dr. John Nkengasong said, he knew what he would see: another desperate family with a dying loved one in their arms — a man or woman already in a coma, a thin child – and hoping to find help.
That was before the Bush administration began the US President’s Emergency Relief Plan for AIDS Relief, better known as PEPFAR, in 2004. There was virtually no affordable, effective treatment anywhere between South Africa and the Sahara, no rapid HIV testing or high-quality government laboratories. and few beds for AIDS patients.
Nkengasong has spent decades working in Africa on HIV and AIDS, a career intertwined with the U.S. program that has transformed care in some of the hardest-hit countries and saved an estimated 25 million lives since its introduction two decades ago. He spoke to The Associated Press amid a funding battle in Congress that is putting the future of the AIDS program in jeopardy.
Opponents say the HIV/AIDS funding could indirectly support abortion abroad, although the Biden administration and PEPFAR defenders say there is no evidence that is the case. After a handful of conservative lawmakers threatened for months to block funding unless restrictions were imposed, a compromise was reached in late March that extends funding for another year.
But proponents of the program warn that without the full five-year extension, its future remains in doubt as the political debate over abortion and reproductive rights only becomes more combative.
Before PEPFAR, the Nkengasong infectious disease clinic in Abidjan, Côte d’Ivoire, was unable to provide care to families in most cases. In their loved ones’ final hours, the families who came there often stayed outside in the parking lot.
They surrounded “a skeleton of a human being, with a hint of flesh over their body,” Nkengasong recalled. “They held their loved ones and gave them the best comfort they could.”
Soon the sound of wailing came through his windows. The cries signaled another death from HIV/AIDS, one of millions in Africa in the mid-2000s.
The scene would repeat itself “almost hour after hour,” Nkengasong said. Sometimes he got up and closed the curtains, which helped him keep out the misery of an epidemic that he could not then control.
Twenty years later, Nkengasong says, his trips to the region from his Washington office bring joyful encounters with men, women and children whose lives were saved by PEPFAR, seen as the largest government effort ever against a single disease.
In total, the U.S. program has spent more than $110 billion on HIV care and treatment, local medical systems and social programs aimed at combating infections. The US says it has saved 25 million lives in sub-Saharan Africa and other vulnerable areas, including 5.5 million children.
Born in Cameroon and graduated in Belgium, Nkengasong worked in Africa in the 1990s, when the AIDS epidemic raged virtually unchecked.
It created a “booming coffin industry,” he said. When he visited cities in Uganda, Rwanda, Kenya and elsewhere for his work in infectious diseases, he traveled through the streets lined with handmade coffins of all shapes and sizes.
Infectious disease clinic beds were full of “adults lying there looking like babies because of what HIV had done.” That ugly face,” Nkengasong recalled.
Because early retroviral drugs cost an average of $10,000 per patient per year, it was estimated that only 50,000 HIV-infected people in sub-Saharan Africa were receiving effective treatment in the mid-1990s. That matched what the World Health Organization said: 10 million people there are living with HIV and AIDS.
One day in the spring of 2002, while he was conducting tests in his laboratory, a large American delegation suddenly arrived at the clinic in Abidjan.
Health Secretary Tommy Thompson and other top U.S. health officials streamed into the facility, along with business representatives and members of faith-based organizations.
“I remember opening the door and the first person to come in was Dr. Fauci,” Nkengasong said. Anthony Fauci, a leading HIV researcher, was at the time a top official at the US National Institutes of Health and a leader in Nkengasong’s HIV and AIDS work. “And he said, ‘John, good to see you again.’ And I was so excited.”
Unbeknownst to Nkengasong and his colleagues, National Security Advisor Condoleeza Rice and other officials had privately made it clear to President George W. Bush that the U.S. could make a huge difference in the global HIV epidemic.
For the Bush administration, the epidemic provided an opportunity to do some good at a time when the US was waging war in Afghanistan and later in Iraq after the attacks of September 11, 2001.
Nine months after the Americans showed up in his lab, “we’re watching the news on CNN, it was the State of the Union address,” Nkengason recalled. “And President Bush announced the start of PEPFAR.”
That evening, the president pledged an initial $15 billion over the next five years to address the AIDS epidemic around the world.
Nkengason called it the “aha moment” for himself and others fighting AIDS in the world’s most vulnerable region.
Twenty years later, AIDS deaths worldwide have fallen by almost 70% from their peak in 2004. Sub-Saharan Africa remains the most vulnerable region, home to two-thirds of people living with HIV. But the PEPFAR program and others have strengthened health care systems to tackle infectious diseases, made treatments available to millions of people and expanded support for the most at-risk populations, including women.
On a trip back to Abidjan, Nkengasong met a healthy 17-year-old girl, one of millions spared from infection at birth thanks to medical treatment that prevented the transmission of HIV from their infected mothers.
Last summer he visited a clinic in Namibia where HIV-infected mothers had given birth to “super healthy” babies thanks to a treatment that saved them from infection.
“I picked up some babies and looked at them,” he said. He held them and wondered what would have happened to them without proper care.
“And they just give you that smile,” he said.