July 2012—Hillary Rodham Clinton was sworn in as U.S. Secretary of State in January 2009. Since then, she has traveled more than 800,000 miles on diplomatic visits to 100 countries. As Secretary of State, she oversees the Office of the Global AIDS Coordinator and the President’s Emergency Plan for AIDS Relief (PEPFAR). The U.S. government’s largest global health program, PEPFAR was reauthorized in 2008 for $48 billion over five years. Secretary Clinton also oversees United States embassies in 162 countries, which implement a variety of diplomatic initiatives and other community-based HIV/AIDS programs.
TREAT Asia Report: You have been an outspoken advocate of women’s rights, including the right to sexual and reproductive health care. How will the needs of women living with HIV be supported as U.S. global health strategies evolve?
Secretary of State Hillary Clinton: First, I would like to thank amfAR for being such an important part of what we’ve been able to achieve through PEPFAR. We truly appreciate our partnership.
As you are aware, in low- and middle-income countries worldwide, HIV is the leading cause of death and disease in women of reproductive age. In Africa, 60 percent of those living with HIV are women, and in some of these countries, prevalence among young women aged 15-24 years is about three times higher than among men of the same age. So PEPFAR is putting women front and center in the response. We’re ensuring equitable access to services, addressing the tragedy of gender-based violence, keeping mothers alive through programs to prevent mother-to-child transmission of HIV, and making sure HIV programs are linked to our other women’s health programs under the Global Health Initiative. There’s a lot of work ahead because some of these issues go very deep, but we are working with countries to address them.
TA Report: PEPFAR is arguably the most popular and successful foreign policy initiative in recent years, yet the President’s fiscal year 2013 budget proposal calls for a nearly 12 percent reduction in funding for PEPFAR. How does the administration reconcile this with its ambitious commitment to achieving an “AIDS-free generation?”
Clinton: We define success in terms of results—saving lives is the most important metric. President Obama and I are committed to creating an AIDS-free generation, including reaching ambitious goals for treatment and prevention. PEPFAR has a history of success to draw on—this program has consistently met its goals, and I am confident it will continue to do so. But achieving an AIDS-free generation requires the shared responsibility of everyone—donor nations, partner countries, the Global Fund and the private sector.
TA Report: Programs like PEPFAR that deliver lifesaving antiretroviral treatment to millions of people in developing countries are heavily reliant on generic ARVs produced in India. How will the U.S. government’s trade policies ensure that affordable medicines remain accessible to those who need them?
Clinton: PEPFAR, the State Department, and our other interagency partners are working with the U.S. Trade Representative to increase access to medicines and ensure that public health concerns are part of the conversation. We’re very proud of the large reductions in per-patient costs PEPFAR has been able to achieve and we will continue to work to make medicines even more affordable.Secretary
TA Report: You made a historic commitment to the rights of LGBT people last year. As you know, gay men and other men who have sex with men are disproportionately affected by HIV in most parts of the world. How is the PEPFAR program expanding access to HIV services for MSM?
Clinton: This is a clear priority for PEPFAR because there is strong evidence of the higher risks faced by MSM. Last year, PEPFAR released guidance on providing services to MSM, explaining the evidence base and offering tools to help country programs respond. An important part of the effort is working with partner countries to help them see that a public health approach that makes HIV services available to marginalized groups, without the stigma or discrimination that can drive people underground, will advance the health of the nation as a whole. In addition to working with governments on a data-driven response that targets funding to key at-risk populations like MSM, PEPFAR is also working with community groups. By supporting efforts like the Purple Sky Network in Asia, PEPFAR has enabled MSM organizations to develop peer relationships and advocate on behalf of HIV and other health issues in their nations. So we’re taking a comprehensive approach that works with governments and communities to get the services to the people in need.
TA Report: Through PEPFAR, the U.S. has focused primarily on AIDS in Africa. How does Asia—with its concentrated HIV/AIDS epidemics, harder-to-reach populations, and PMTCT challenges—fit into U.S. global health strategy?
Clinton: Asia requires very different approaches than Africa—and indeed there is great variety even within Asia. I think our PEPFAR programs in the region reflect the unique circumstances. Many of the countries have significant resources of their own to devote to fighting AIDS, but what we can offer is the technical support to maximize the impact of what they are doing. Because the epidemics are concentrated among population groups that face stigma—such as persons who inject drugs, MSM, and sex workers—we work directly with those groups in ways that will not put them at risk.
TA Report: In December 2011, you became the first U.S. Secretary of State to visit Burma in more than 50 years. How might closer diplomatic ties between the two countries impact support for Burma’s HIV response?
Clinton: The changes to date are fragile, but very encouraging. Following my visit, in April of this year, Burma’s Minister of Health led a delegation that visited a number of U.S. officials, including our PEPFAR leadership at the State Department and our implementing agencies. It’s too soon to make any definitive statements as to increased cooperation on HIV, but the fact that our governments are now in dialogue is certainly promising.
Secretary Clinton visits Daw Aung San Suu Kyi at her house in Rangoon, Burma, on December 2, 2011.
TA Report: As you travel the world, are you seeing any notable shifts—either dispiriting or encouraging—in country responses to AIDS?
Clinton: Compared with where we were in the recent past, I’m very encouraged by the leadership we’re seeing from many of the hardest-hit countries. More and more, they understand the importance of this issue, and want to grow both their commitment and their capacity to step up. I think a key to this transformation is that they now see that it’s something they can be successful doing—the past decade has proven that. It’s always easier to enlist people in a fight they can win, and I am confident that we can win this fight against AIDS.
TA Report: What do you see as the major impediments to achieving an “AIDS-free generation?”
Clinton: Any sense of complacency would be tremendously misguided and harmful—there is still significant unmet need in the world, and for our part the United States is going to keep the pressure on. But as I have said, it’s a shared responsibility, and we need other donor and partner countries to step up and meet the challenge as we are doing. Budget constraints and competing demands are issues everywhere, and always will be. But the vision of an AIDS-free generation is so compelling, and the science is behind us. I believe we will all rise to meet the challenge.