A Q&A with Robert Greenwald on ‘getting to zero’ and the success of PEPFAR, 15 years later

Harvard Law Clinical Professor Robert Greenwald discusses the challenges of ending the HIV epidemic in the United States and globally—and the outlook for the future

“Getting to zero”—what Harvard Professors Ingrid Katz and Ashish Jha describe as “end[ing] transmission of [HIV] and control[ing] the epidemic in the United States within the next 10 years”­—will take a suite of tools to achieve, according Robert Greenwald, a clinical professor at Harvard Law School and the faculty director of the Law School’s Center for Health Law and Policy Innovation (CHLPI). Greenwald has been a leader in the field of health law for more than 25 years and is currently serving as co-chair of the Federal Chronic Illness & Disability Partnership and the HIV Health Care Access Working Group.

On October 7, the Harvard Global Health Institute, the Harvard University Center for AIDS Research, the Center for Health Law Policy and Innovation at Harvard Law School, and the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School hosted “15 Years of PEPFAR,” a full-day conference looking back on the uncertain early days of the epidemic, the successes of President George W. Bush’s President’s Emergency Fund for Aids Relief, and opportunities for the future.

Kaitlyn Dowling, communications associate at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics, sat down with Greenwald to discuss PEPFAR’s impact at home in the United States, policy barriers to “getting to zero,” and ways to address the epidemic head-on. The following interview has been edited for length and clarity.


Kaitlyn Dowling: Your work focuses on domestic HIV care and prevention efforts. How do you see your work relating to what’s happening globally with such efforts?

Robert Greenwald: The U.S. and global efforts to end the HIV epidemic face many of the same challenges. To start, I think we all recognize the critical role that biomedical treatments play in any getting to zero plan. Successfully engaging all people living with HIV in antiretroviral therapy is a significant first step, as treatment leads to viral suppression which promotes individual health and eliminates the risk of transmitting HIV. We also recognize the critical role that Pre Exposure Prophylaxis (or PrEP) plays in preventing HIV transmission.

Yet, biomedical interventions alone will not get us to zero. A successful ending the epidemic plan must also address the political, economic and social conditions that often drive the HIV pandemic. While both the U.S. and PEPFAR countries are confronting similar issues, the specific challenges often vary by country and region.

Dowling: Since the beginning of the epidemic in the early eighties, many norms have shifted within American government, in particular the problem of partisan gridlock in Congress. How has that impacted your work and the work of other activists, policy makers, and public health officials?

Greenwald: Partisan gridlock certainly has an impact on the role that Congress plays in ending the epidemic. Thankfully, our current Congress appears, to some extent, to continue bipartisan support for both domestic and global HIV funding. On the other hand, the expectation that Congress will pass any meaningful, substantive legislation is low.

Domestically, gridlock is good news for people living with HIV, at least as compared to before the 2018 mid-term elections in the U.S. Then, Republicans controlled both the legislative and the executive branches of government, and their health law and policy agenda was largely focused on repealing the Affordable Care (ACA) and restructuring our health and public health systems.

If this agenda had succeeded, over 20 million people would have lost their health insurance coverage and we would have returned to a time when many people living with HIV were excluded from public and private health insurance systems.

Thankfully that didn’t happen, and as a result of the ACA’s Medicaid expansion and other reforms, the rates of uninsured people living with HIV has declined by over 50% in most of the states that expanded Medicaid. That’s a tremendous gain in health care coverage, and as a result we’ve seen the U.S. go from about 25% of people living with HIV virally suppressed to about 54% in 2019. So, I’ll take gridlock over the prior political landscape.

Dowling: What are your thoughts on President Trump’s Ending the Epidemic program?

Greenwald: I agree with the Trump Administration that an important focus of the plan must be on improving access to biomedical interventions. I also agree that Phase One of the plan should focus on geographic hotspots, the 48 counties with the highest number of new diagnoses. Additionally, it is important that the Administration recognizes the rural epidemic in the Southeast, U.S., where health inequities are greatest and outcomes are far below the national average, by including seven states in the Southeast as geographic hotspots.

With that said, I have concerns that there is insufficient funding for the plan to succeed, that the plan is substantively too limited, and that there are serious disconnects between the Administration’s ending the HIV epidemic plan and its broader health policy agenda.

The Administration is promoting new regulations that would undermine our public and private health insurance systems and reverse the gains we have made in recent years, by supporting the sale of Association Health Plans and other forms of “junk insurance” that were largely prohibited under the ACA. These plans operate outside of mandates that prohibit insurers from denying health insurance based upon pre-existing conditions, or from ignoring the coverage of essential health benefits and consumer protections. In addition, the Administration’s attacks on immigrant communities, transgender and gender non-binary people, and women seeking sexual and reproductive health care services have been relentless.

These policies, and many others proposed by the Administration, clearly undermine access to effective HIV care and prevention services. Despite biomedical advances, we will not end the HIV epidemic in the US, and elsewhere, until we end policies that threaten the health and well-being of all people living with HIV.

Dowling: You’ve describe several of the challenges that the U.S. faces in getting to zero. Have there been any successful efforts to address these challenges?

Greenwald: There are many examples of successful efforts to address the challenges we face in current health and public health law and policy. I will focus on some of the litigation successes, but it is important to note that community mobilization and advocacy have also been successful in protecting and promoting sound health and public health.

As to litigation, a federal district court judge has struck down the Trump Administration’s approval of Medicaid work requirements in the first three cases to challenge them in our courts, finding that the Administration’s approval of such requirements reflected an arbitrary and capricious disregard for the primary purpose of the Medicaid program, which is to provide medical assistance to state residents.

Earlier this year, a federal district court judge invalidated the Trump Administration rule that encouraged insurers to offer Association Health Plans, a major form of “junk insurance” that I had mentioned earlier, saying the rule relied on a tortured reading of what the ACA allowed.

Most recently, at the intersection of the opioid, HIV and HCV epidemics, a federal district court judge in Pennsylvania ruled that safe injection sites do not violate the Controlled Substances Act, allowing for the development of public health programs that can dramatically reduce opioid related deaths and the transmission of infectious diseases.

These are just a few examples of how litigation has worked to defend against efforts that undermine ending the HIV epidemic goals.

Dowling: We’ve talked a lot about challenges to “getting to zero” in the United States, but where do you see hope for the future? Where do you think we’ll see successes?

Greenwald: I think we are at a crossroad in deciding the future direction of this country. I’m not sure what will happen in upcoming elections, but I believe that they will determine whether we have federal officials who support strong national standards in sound health and public health law and policy. In this past decade, we have made some great progress. We’ve seen this country make strides in moving away from disability-based health care financing and delivery systems toward systems that are focused on prevention, early intervention and value. I would like to think that we will move forward in a positive way and build on these successes, so that we have systems in place that truly respect the health, well-being and dignity of all people living in the United States.


VIDEO: Panel discussion on lessons learned from PEPFAR and “getting to zero”

In May 2003, the U.S. Congress passed bipartisan legislation authorizing a bold new plan to combat a fast-spreading, deadly epidemic. In the 15+ years since, the President’s Emergency Fund for Aids Relief—widely referred to as PEPFAR—has become the largest global health program focused on a single disease in history. Investing over $80 billion in HIV/AIDS treatment, prevention and research, PEPFAR has saved millions of lives and put 14 million people on treatment.

On October 7, 2019, the Harvard Global Health Institute co-hosted a one-day symposium exploring how this visionary program transformed not just the worldwide HIV/AIDS response but global health delivery more broadly.

In the video below, Clinical Professor Robert Greenwald joins a panel of experts in exploring lessons learned in the time since the fund was established, and what the future holds with respect to controlling the HIV epidemic in the U.S. (Photo by Lisa Abitbol)