Dr. Angeli Achrekar is Principal Deputy U.S. Global AIDS Coordinator to the U.S. President’s Emergency Plan for AIDS Relief. She is the second in command to the U.S. Global AIDS Coordinator and supports the daily oversight, coordination, leadership, management, and implementation of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to ensure that all its activities and resources, including its annual budget of approximately $6 billion in over 50 countries, is as impactful, effective, and efficient as possible. Dr. Achrekar is a dedicated public servant with extensive experience in HIV/AIDS, women and girls’ health, and global public health development. In 2011, she joined the U.S. Department of State and helped lead the conceptualization and development of Saving Mothers, Giving Life, a public-private partnership that impacts maternal and neonatal health and HIV services. In early 2023, she will leave PEPFAR to become the UNAIDS Deputy Executive Director for the Programme Branch, based in Geneva, Switzerland.

Staff from the FDA’s Office of Global Policy and Strategy’s Communications Team spoke with Dr. Achrekar on November 28, ahead of the World AIDS Day 2022 commemoration on December 1.

Dr. Achrekar, you have a unique vantage point as someone who has been with the PEPFAR program from its earliest days. How has the program and its mission evolved during this period?

Thanks so much for inviting me to join this interview and to be with you for World AIDS Day. As you noted, it's really been a remarkable thing to be part of PEPFAR for so long. You know, the program will soon be approaching its 20th anniversary. I'll never forget President George W. Bush announcing PEPFAR in his State of the Union address in January 2003. I was in Uganda at the time, and I was watching live from my hotel room - it must have been 3 a.m. in the morning so I could catch the State of the Union. It was the most miraculous announcement ever – [involving] real resources, a real focus intended for a real lifesaving impact. At that point, I could only dream of being part of PEPFAR. And I was privileged – I was really privileged – to start my journey with PEPFAR in 2003. And I've stuck with it since then.

PEPFAR has been the ultimate example, I would argue, of evolution, of innovation, of pushing the envelope, of iterating, of changing – really, to continuously improve the effectiveness and the efficiency of the program designed to bring life-saving services, HIV prevention and treatment services to those in need. Now what hasn't changed or evolved is PEPFAR’s mission, and that is the thing that has hooked me ever since. Our mission is truly a North Star, and it hasn't changed, it's why we're here – to end the HIV/AIDS epidemic as a public health threat by 2030. And that’s what's kept me going since.

You talk about the program evolving and innovating. Can you give us some examples of what you mean by that?

Sure. So, we are constantly looking for ways to ensure that HIV prevention and treatment services reach the most vulnerable populations. We have learned and adapted the programming over time to make it more client-centered, person-centered. We have evolved how we use data, and are so granular that we target our investments so that they have a greater impact. And we have learned over time what kinds of drug regimens work better for people living with HIV. Over the years, we have adapted to best meet the people we serve, where they're at, and with what they need.

PEPFAR has seen a leadership change with Dr. Nkengasong’s arrival in June. Have there been any changes in the program’s direction since then?

We've seen multiple leaders over the course of the program’s history and each leader who has come through – whether it was Ambassador [ Randall] Tobias at the very beginning, Ambassador [Mark] Dybul, Ambassador [Eric] Goosby, Ambassador [Deborah] Birx, and now Ambassador [John] Nkengasong – brought critical leadership that was necessary to evolve the program at that particular time. They've each left a really important mark on the program in terms of the progress that we had made under their respective leadership.

Ambassador Nkengasong joined us in June of this year, and there couldn't be a more perfect leader for PEPFAR at this stage of the program when countries have continued to make remarkable progress, and we need to ensure we work together to sustain the HIV impact and response by countries. We are still without a vaccine or a cure. Yet some of these countries are getting to a point of community viral suppression of nearly 90%. That is extraordinary. We are at a place where we need to ensure that the work that we have done over these past two decades is sustained as we move into the future. And so, one of the absolute critical changes in terms of the program’s direction from Ambassador Nkengasong is a new 5-year strategy that we will be releasing on World AIDS Day. This strategy is a clear and bold articulation of the strategic direction that we and the program will be taking as we move into the future to drive toward ending HIV/AIDS as a public health threat by 2030.

We’d like to hear about your own career at PEPFAR. You’ve held a wide range of leadership roles at PEPFAR over the years. What have been some of the greatest successes during your tenure? What lessons have you learned?

It has truly been a privilege of a lifetime to be part of what I would call this “PEPFAR movement” for the past 20 years that has swept across the globe, across all 55 countries in which we work, and transformed lives by the millions. This extraordinary movement involves eight different U.S. government agencies, including the FDA, multilateral partners, partner governments, and communities. PEPFAR is comprised of the most dedicated and passionate group of people I have ever known, and probably will ever know.

One of the greatest successes during my tenure was probably also one of the greatest challenges, and that’s how we confronted the COVID-19 pandemic. We had to make sure that countries could both protect and accelerate their gains in HIV during the pandemic. We achieved that by innovating and adapting and changing. The lesson I learned may sound very sort of basic – it was the power of teamwork, the power of flexibility, the power of passion to serve people, and the power of all of us coming together with the mission in mind and just adapting and changing the program so that we can best meet the needs of the people we serve.

Given the challenges of COVID-19, making it very difficult for face-to-face meetings, how were you able to deliver services?

We had to completely change the way that we thought about service delivery. From the early days of COVID-19 – before vaccine, before testing was accessible, we did two things: We started to issue guidance twice a week based on what we were learning in real time. Certain countries were locking down, or we were intentionally preventing people from coming into the health clinics because we didn't want them to get infected with COVID. So, we found ways to bring antiretrovirals into the communities closer to where people were so that they didn't have to come into the facility. For example, since schools had closed, we used schools or other community locations as makeshift pharmacies. The second thing we did is use virtual communications more effectively. Across the globe we convened with all of our member countries on a weekly basis to share what was happening, how we could improve, and how we could change the program. We also used telemedicine in the countries themselves, to work more effectively.

Let’s switch now to the FDA. The FDA's primary contribution to PEPFAR is to approve antiretroviral drugs for the program. I don't have an exact count, but we certainly know that the FDA has approved or tentatively approved more than 200 ARV drugs since PEPFAR was established. How important is that aspect of the program? And in addition to approving ARV drugs, how else can the FDA support PEPFAR'S mission moving forward?

Thanks so much for that question. Where would we be without the approval of the actual ARVs themselves? Nowhere. So, FDA's primary contribution to PEPFAR’s success is absolutely critical, it's absolutely fundamental. We could not have done this – and we cannot do this – without the FDA. To your second question, there continue to be new innovations that are always emerging. We're seeing pre-exposure prophylaxis and various long-acting solutions coming out to prevent HIV infections. These are really important to the work that we do. Whether it's injectables or the vaginal ring, or whether one of these days, it's an HIV vaccine, these are going to be really important innovations that we will need to continue to support and bring to scale and will need FDA's approval. I think the other thing that I would just note is that a really important part of sustaining the HIV response is ensuring that we are supporting national, regional, and local capacity for manufacturing HIV diagnostics and antiretrovirals. That is something that we really need to be focusing on that is critical to sustaining the HIV impact and the response for the future. This is something that I think is really important for us to collaborate on with the FDA and local and regional entities to see what’s possible.

How well developed is this manufacturing capacity?

If you look regionally, it probably varies. Most of the work that we do is in Africa, given the burden of disease there, and I think manufacturing capacity is developing there but we need to do more work together to help develop it. I think some of the challenges that we all face are some of the policy barriers that exist at the local level or with pre-qualifications. And so, how do we work together better to create an enabling environment that helps promote local manufacturing? This is going to be one of the most important things that we do for the future, if we're really talking about sustaining the HIV response.

Why is it so important to develop local or regional manufacturing?

This relates a bit to COVID-19 and what we learned in COVID. You know the reality is, the response to HIV and AIDS is always going to happen in an environment where there are other emerging health threats. That is the reality. We're still in a state where COVID is everywhere. Ebola is occurring in Uganda, and there is monkeypox. So, we are always in this state of having to finish the job for HIV and AIDS, yet there are emerging health threats that are everywhere and that will continue. In the world in which we live, that will constantly be impacted by various health threats, having the capacity, the local capacity to manufacture ARV drugs on the continent, to leverage health systems for HIV and other health threats, or to deliver services is important. If we're thinking about sustainability, we have to think about what kind of local capacity or national capacity is required to do so.

We've been talking a lot about COVID. Certainly, the pandemic has dominated global health discourse for nearly three years. How can nations restore public and political awareness of the silent pandemic of HIV AIDS?

You know, that is a really important question. In the very early days, before and shortly after PEPFAR, it was a different reality. For example, there were coffins being carried everywhere you went. Mothers, fathers, teachers were dying, and children were orphaned. 

The success of PEPFAR and the success of the global HIV response has been that we don’t see that anymore. People living with HIV are taking their ARVs and they have suppressed their viral load - so they’re living long, healthy lives. Also, the population, the cohort of people living with HIV, is aging. So, the political leadership that is required, it's harder to find but it is essential.

And so, a critical focus of where we are now and where Ambassador Nkengasong is leading the program, is to reinvigorate political leadership in response to HIV. I think that is absolutely critical because we haven't finished the fight, and HIV is still a health and security threat. This situation is further compounded with these other emerging health threats, which makes it even harder for us to finish the fight on HIV and AIDS. And so political leadership is among one of the most critical things that we have to do to reenergize as we approach the third decade of PEPFAR.