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Open Mike

Michael J. Klag

Michael J. Klag

A Moral Imperative

In the small shack perched on a hill in Rakai, Uganda, about 20 people waiting to see the HIV outreach team broke into passionate applause after we walked in the door. Health Advisory Board member Tom DeRosa, Bloomberg School development director Sally O'Brien and I were initially perplexed. Why are you clapping for us? we wondered.

Because you are Americans, because you are from Johns Hopkins, and because we are grateful for the medicines that are keeping us alive, they told us.

Without free antiretroviral medications (ARVs), the people who were so generous with their applause would be dead and they know it. Most of them have seen friends and family members—including their own children—die from HIV. In fact, before ARVs became available, whole villages in Uganda withered from the loss of life; many are now abandoned. More than 25 million people in Africa alone are infected with HIV. As I found in our recent trip to Africa, the epidemic's toll defies comprehension.

And yet there is hope. The Rakai Health Sciences Program, a joint effort of faculty from the Bloomberg School and Makerere University, has made important discoveries in how HIV is transmitted. In 2004, the Rakai Program began offering ARV treatment to the community, using funds from a U.S. government program called PEPFAR, the President's Emergency Plan for AIDS Relief. PEPFAR is the reason the people in the Rakai clinic are alive today. Each day's supply of pills is a day of life preserved.

In the public health community, PEPFAR is not perceived as unambiguously good. Many have decried the PEPFAR requirement that only brand name ARVs, not less expensive generics, be purchased. (Fortunately, that policy has changed recently.) Public health advocates—myself included—find other restrictions irrational. One example is using funds to promote abstinence at the expense of successful, evidence-based, prevention methods like condom distribution.

Certainly PEPFAR should be improved and expanded, but above all else it must be continued. The program is funded only through fiscal year 2008. Because many Americans do not recognize the impact that PEPFAR is having on people's lives, I am genuinely concerned that it will not be renewed. If Americans had the good fortune, as I have, to meet with HIV-positive Africans who have been saved from a certain death, who are now healthy and productive, they would understand the moral imperative of maintaining this program. To stop would literally consign millions to death.

Of course, we cannot and should not give up on prevention. Development of a vaccine remains elusive. Thus, behavioral interventions and other efforts must be pursued with redoubled vigor and creativity. We have to shut down the HIV pipeline that so predictably leads people from infection, to plunging CD4 counts, to full-blown AIDS and death—or a lifelong dependency on expensive medications.

So until a cure becomes available, we have to keep people already infected with HIV alive. PEPFAR and similar programs like the UN's Global Fund to Fight AIDS, Tuberculosis and Malaria are our best shots at doing that. Controversy surrounds many U.S. policies in the world today, but PEPFAR is one program that we have gotten mostly right. Whatever our politics, we have to send a message that what President Bush has done with PEPFAR is a really good thing. And it cannot stop.

I returned from my three weeks in Africa with a sense of the enormity of the public health problems but with an even stronger sense of hope and accomplishment. Our faculty and staff, in cooperation with their colleagues in Africa, are unraveling the mechanisms of transmission of disease from animals to people, developing new ways to prevent and treat disease and delivering life-saving interventions. More than once, as in that shack in Uganda, I felt overwhelming pride to be part of our School and, like those patients, grateful for the dedication and ingenuity of our faculty.

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