In June, we reported that PEPFAR, the $7 billion U.S. global-AIDS relief program started by President George W. Bush in 2003, had been leaderless for more than a year. This left global AIDS advocates worried that the program was losing momentum and focus, especially amid the new global pandemic of COVID-19.
It had been last headed by the highly regarded Deborah Birx, M.D., who took it over in 2014 but left in early 2020 to be part of then-President Trump’s COVID response team. Notoriously, she stood by quietly alongside Trump while he said inane things, such as that injecting bleach could kill COVID. Then, her career tarnished and she retired from government service once the Biden administration came in.
For more than 18 months, Angeli Achrekar, Dr.P.H., has been PEPFAR interim director. Observant advocates said that the program seemed to be running OK but, without a real successor to Birx, it faced a wobbly future.
On Sept. 27, President Biden allayed those fears when he nominated John Nkengasong, Ph.D., M.Sc., to the role. Nkengasong, 57, is a Cameroon-born virologist who is the director of the Ethiopia-based Africa Centers for Disease Control and Prevention (CDC), which is part of the African Union. Before that, Nkengasong was at the U.S. CDC, as chief of the international laboratory branch in HIV/AIDS and TB, then as acting deputy director at the CDC’s Center for Global Health.
But wait, there’s more. Nkengasong, a U.S. citizen, was co-chair of PEPFAR’s Laboratory Technical Working Group and is a board member for the International AIDS Vaccine Initiative (IAVI) in New York. He has multiple science, medicine, and management degrees from universities in Cameroon, Antwerp, and Brussels, as well as Harvard’s Kennedy School. And he has authored or co-authored over 250 peer-reviewed papers in professional journals and book chapters.
Highly Respected by Advocates
Advocates for global AIDS seemed to react with delight to the news. “I’ve known John for almost 18 years, and he’s terrific,” said Mitch Warren, the head of AVAC, a nonprofit that promotes HIV treatment and prevention methods worldwide. “He’s always been approachable and engaging, irrespective of his position; he has always shown a willingness, ability, and patience to sit and explain virology of the virus or the politics of global health to the uninitiated.”
Warren called his nomination “a bold and exciting appointment—for U.S. leadership, for the global AIDS response, and for the larger fight for global health equity. John is a superb scientist and a consummate leader, including during our collaborations on HIV vaccine research and advocacy. His work as a virologist and in establishing the African Society for Laboratory Medicine provided a critical foundation for PEPFAR’s early successes in the AIDS response and subsequently for the rapid COVID response of the Africa CDC under his leadership.”
Warren said that, as head of the Africa CDC, Nkengasong had handled COVID superbly, “guided by science, political will, community engagement, and a commitment to equity. In many ways,” continued Warren, “the COVID response built on the lessons of the AIDS response, and no one embodies that better than John, but AIDS is far from over. It’s a huge leap forward for the U.S. government to name someone from the region where much of the PEPFAR work actually is. It shows a commitment to truly listening to and learning from the people PEPFAR is meant to serve.”
In some ways, the nomination is surprising because previous shortlists for the role floated by media outlets included only U.S.-born, white candidates, such as former secretary of state John Kerry’s daughter, Vanessa Kerry, M.D., or the respected global health pioneer Paul Farmer, M.D., Ph.D.
But advocates say that the choice of Nkengasong is inspired.
“It’s an exciting prospect to have for the first time a PEPFAR leader who is African,” said Katie Lapides Coester, public policy adviser at the Elizabeth Glaser Pediatric AIDS Foundation and a member of the U.S. Global AIDS Policy Partnership, which is convening a working group to support Nkengasong’s nomination before the Senate. (Most advocates believe that even in an evenly divided Senate, Nkengasong’s confirmation will not be problematic, as PEPFAR has always been among the few government programs that traditionally enjoy bipartisan support.)
“He has a great understanding of the workings of the U.S. government,” said Coester, “but also such strong ties to the countries where PEPFAR does the majority of its work.”
And Mark Harrington, co-founder and director of the HIV policy and advocacy think tank Treatment Action Group, said of Nkengasong, “I’ve known his name a long time—he’s been around forever and has a very distinguished career and great scientific acumen. And because he’s been at the African CDC, it’s likely he has access to heads of state.” That, said Harrington, is key for a PEPFAR head, “because sometimes they need to meet behind closed doors with [country leaders] to tell them to improve [their country’s] HIV surveillance” or other aspects of fighting the epidemic.
Nkengasong’s likely filling of the seat that Birx left empty “should be good morale for the PEPFAR staff,” added Harrington. “The program’s been on cruise control for over a year, and it’s very hard to feel you know where you’re going under an acting director.”
The Task Ahead
Advocates say that once Nkengasong is presumably installed, his overarching priority must be making sure that PEPFAR’s goal of aiding in effectively ending the global AIDS epidemic by 2030—via continued scale-up of both treatment and prevention tools, such as the HIV prevention pill, PrEP—is not sidetracked by the admittedly huge crisis of containing COVID.
“First, he has to assess the damage and delays [to PEPFAR progress] by COVID,” said Harrington. “He has to figure out which places have been able to continue running HIV services amid COVID and then share those places’ methods with [lagging] places. Some places in South Africa have been able to continue people on HIV treatment during COVID, but there have been lots of delays with [getting treatment to] newly diagnosed people. We need to get a clear sense of how to intervene, given that COVID vaccine rates in these countries are still low.” (Well below 10% in most African countries, in fact.)
Continued Harrington: “We just can’t go back to the smooth running of [PEPFAR] programs until COVID is far more under control in developing countries, so there’s no way PEPFAR can avoid [taking part in] COVID testing and vaccination. It’s no good running a good HIV program if all your patients are going to get, transmit, and get sick and die from COVID.”
Warren echoed that. “The task ahead for John [Nkengasong] and PEPFAR is huge,” he said. “To maintain the urgency and impact in ending the AIDS pandemic, to respond to COVID, and to build sustainable health infrastructure for the long term. But John brings the passion, vision, and experiences that make it possible.”