How A Rock Star, A Physician-Legislator, And An Evangelical Senator Bonded To Help End The Global AIDS Pandemic: A Backstory

Three weeks ago, Bono came through Nashville on his book tour for “Surrender: 40 Songs, One Story.” Following his 2-hour solo performance at the historic Ryman Auditorium, the original home of the Grand Ole Opry, we visited backstage, recalling the exactly two decades since we worked together in Washington and in Africa building support for global HIV/AIDs relief, and what a year later became known as PEPFAR.

Bono: “Remember the night you brought our esteemed friend Senator (Jesse) Helms and Dorothy (his wife) to the U2 concert?” Afterwards Helms never said much about the music and the performance. What impressed him most, he told Bono and me after the show, were the vast audience’s “synchronized arms swaying high in the air, just like fields of golden corn waving in the wind.”

The thousands of swaying arms, moving in unison, in some ways symbolized the work we did together twenty years ago to help build the groundswell of bipartisan, popular support for what was once a polarizing issue: ending the AIDS pandemic in Africa.

How a Rockstar and a Tennessee Senator Came Together

In 1998 before I was Senate Majority Leader, and before Bono’s name became synonymous with addressing the AIDS pandemic and the RED campaign, he visited my Senate office to lobby me, and then collaborate with me, on the Heavily Indebted Poor Country (HIPC) initiative to provide debt relief to the world’s poorest nations, in exchange for the nations investing in clean water and public health initiatives at home.

This early, successful collaboration led us to many later conversations, including in 2002 discussing how to change conservative and evangelical hearts and minds to see the moral imperative of addressing AIDS globally.

I suggested to Bono at the time, “to move policy into legislation, you have to capture the views of mainstream, Middle America. If you as a rock star, who speaks so effectively to hearts of millions around the world through music, can do that, then you will demonstrate that we can move the U.S. Congress to support legislation to address global HIV/AIDS in a big way,” which at that time was killing 3 million people a year globally.

Bono took those words to heart – and months later on World AIDS Day (December 1, 2002) he embarked on his “Heart of America Tour.” Different than his dazzling rock concerts, Bono personally spent eight days on the ground directly engaging people on their home turf with his message of how America can lead the world in reversing the relentless, global scourge of HIV/AIDS. He made stops in Nebraska, Iowa, Illinois, Indiana, Ohio, and Kentucky, culminating on December 8,^{2002 with a final event in Nashville, Tennessee. I joined him as he spent two hours raising awareness about AIDS, played a few songs, and visibly moved the audience. Earlier on his tour at a stop at the University of Iowa, he had shared, “I’m told you can grow anything here. We’re here to grow a movement.”}

And that’s exactly what Bono’s deep-seated, unwavering commitment to this cause did. Unlike many celebrities who give lip service to important causes, Bono immersed himself in the movement. He devoted immense amounts of his own personal time and star-power capital to move the needle. His commitment was one of faith, of spirit, and of action. We in 2001 had quietly traveled together through rural Uganda to see the families affected by HIV, tour the medical clinics, and observe the new wells being dug with our nation’s early investments. We saw firsthand where more resources and more infrastructure could make a pivotal difference. But in addition to moving the American people – the taxpayers who would be funding the initiative – we also had to move the conservative politicians, who historically viewed the issues very differently.

Moving Middle America on HIV/AIDS

Because HIV/AIDS at the time was heavily stigmatized, and the groups most vulnerable to it, gay men and intravenous drug users, were discriminated against, the “Religious Right” was not sympathetic to the cause. But cracks began to emerge as iconic public figures like Arthur Ashe – who contracted HIV via a blood transfusion – and Magic Johnson – who became infected from heterosexual partners – demonstrated this was not a disease to which whole sectors of the population were immune.

It also led to the orphaning of more than 10 million children in Africa. It was this figure that Bono and I shared with North Carolina Republican Senator Jesse Helms in his office. Jesse was the iconic, conservative conscious for the Senate GOP, as well as the highest-ranking Republican on the Senate Foreign Relations Committee. He had previously taken a stance that HIV was morally wrong, but then, with Bono and me sitting across from Jesse’s imposing desk, the U2 front man said to him, “This is not a conservative or liberal issue, but it’s an issue impacting children. There are 10 million orphans created by this disease. We can prevent 10 million more children from losing their parents, and from contracting the disease themselves.” Jesse listened; for years he had been an advocate for children globally. I shared with him that a single dose of a new medicine could stop the transmission of HIV from mother-to-child. He listened even more.

This was the beginning of Jesse’s sincere and dramatic change of heart, which opened the door to broad Congressional support for the 2003 enactment of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the largest commitment by any nation to address a single disease in history. Through PEPFAR, the U.S. government has invested over $100 billion in the global HIV/AIDS response, and now 20 years later, more than 21 million people are alive today because of that legislation.

The President’s Landmark Call to Action – And the Work Behind the Scenes

Undoubtedly, President George W. Bush’s unprecedented announcement and commitment to addressing AIDS in Africa, boldly shared in his 2003 State of the Union address, was what turned the tide on this viral pandemic that had killed millions, hollowed out societies, and destabilized nations. He was the lynchpin; the visionary leader who believed we could do what no nation had done before, and made it happen.

But behind the scenes, there were so many that laid the groundwork that made PEPFAR possible. Bono and Jesse Helms were the odd couple of AIDS relief who made this broadly bipartisan, while Democratic Senator John Kerry and I crafted the intricate, earlier global HIV/AIDS legislation, first introduced in 2001 and expanded in 2002, that would become the foundation for the 2003 PEPFAR bill.

Christian evangelist Franklin Graham, a close friend to Senator Helms and my personal friend with whom I have traveled on multiple medical mission and international relief trips, also played an essential role. His organization Samaritan’s Purse hosted the February 2002 global “Prescription for Hope” summit in Washington, DC, urging Christians to let go of any stigmas and commit to battling the disease. He said, “Many people have seen this as a homosexual problem, or it’s an intravenous drug users’ problem, or it’s a prostitutes’ problem. It affects all of us. Forty million people are infected,” Graham explained, sharing some of his firsthand experiences with Samaritan’s Purse, the international relief organization which globally aids the world’s poor, sick, and suffering, following the model of Jesus Christ. “We need a new army of men and women who are prepared to go around the world to help fight this battle,” Graham said.

Senator Helms joined Graham in a surprise appearance at the Summit; he told the packed arena how he had long been wrong on this issue. He followed these remarks up with a powerful piece in the Washington Post, where he wrote: “In February I said publicly that I was ashamed that I had not done more concerning the world’s AIDS pandemic. … Indeed, I have always been an advocate of a very limited government, particularly as it concerns overseas commitments. … But not all laws are of this earth. We also have a higher calling, and in the end our conscience is answerable to God. Perhaps, in my 81st year, I am too mindful of soon meeting Him, but I know that, like the Samaritan traveling from Jerusalem to Jericho, we cannot turn away when we see our fellow man in need.” Helms boldly announced that he and I would seek a special $500 million appropriation to initiate a program to prevent mother-to-child transmission of HIV.

While we were building momentum in the Senate, the White House was building its own internal support for major action. Then-National Security Advisor Condoleezza Rice, White House deputy chief of staff Josh Bolten, and President Bush’s head speechwriter Mike Gerson began exploring the feasibility of a major global AIDS initiative. Bolten sent Dr. Anthony Fauci – who occupied the same role he did until his retirement last month as director of the National Institutes of Allergy and Infectious Disease – to investigate on the ground in Africa to determine if a significant U.S. investment could be transformative. Fauci saw how the medical personnel in African nations were decades behind American HIV treatment, equating their approach to putting “bandaids on hemorrhages” since they lacked the life-saving antiretroviral drugs that had revolutionized treatment in developed nations. He quickly concluded that with the right approach and with sufficient resources, the American people and we as a nation could halt and then reverse the course of this devastating disease.

From a Speech, to Legislation, to Law

On January 28, 2003, I sat in the audience with my Congressional colleagues as President Bush formally addressed Congress and the nation, proposing “the Emergency Plan for AIDS Relief — a work of mercy beyond all current international efforts to help the people of Africa.” The President explained that, “This nation can lead the world in sparing innocent people from a plague of nature.” His initial proposal, which we in Congress fleshed out in legislation, committed $15 billion over five years in Africa and the Caribbean with a goal to prevent 7 million new AIDS infections, treat at least 2 million people with life-extending, antiretroviral drugs, and provide humane care for millions of people suffering from AIDS, and for children orphaned by AIDS.

I was one of the few people who knew in advance this announcement was coming, since as Senate Majority Leader and the only doctor in the Senate, it would fall to me to get the bill across the finish line – a heavy lift because of the historically partisan nature of the issue. President Bush wanted to have a signed piece of legislation to share at the G-8 meeting in June, meaning we had just four months to turn this groundbreaking proposal into law.

I shared with my Senate colleagues my personal experiences of treating AIDS-infected patients on my many medical mission trips to Africa with Dr. Dick Furman and Samaritan’s Purse. In some countries, whole generations were missing from the workforce due to the debilitating prevalence of the disease. In Botswana, for example, life expectancy had dropped to a shocking 37 years of age because of HIV/AIDS. We were also acutely aware of the risk of global terrorism, coming on the heels of September 11^th, and it was clear the havoc this illness was wreaking on nations didn’t just impact health outcomes, but their economic and political stability as well.

With effective, bipartisan leaders in the House of Representatives in International Relations Chairman Henry Hyde and Representatives Tom Lantos and Barbara Lee, we were able to build on the foundation of the original Kerry-Frist global AIDS bill and construct bipartisan legislation that passed overwhelmingly, in record time – and in time for the G-8 summit deadline. Its signing ceremony on May 27, 2003 with President Bush is one of the proudest moments of my time in Congress, since its enactment meant the difference between life and death for so many generations to come.

The PEPFAR Impact – 20 Years Later

What has happened in those 20 years since? Over 21 million lives have been saved. Five and a half million babies have been born HIV-free to mothers living with HIV. We as a nation helped at least 20 countries bring their HIV epidemics under control or reach their UNAIDS treatment targets. And we leveraged the PEPFAR platform to respond to other global health threats, including COVID-19, H1N1, and Ebola, with support for more than 70,000 facility and community health clinics and over 300,000 healthcare workers. The health infrastructure in facilities and training we built lifted the whole of health and well-being for nations across Africa.

Had we not taken this leap of faith in 2003, had the Bono’s of the world not felt (and acted) so passionately, had the Jesse Helm’s of the world not been willing to say “I was wrong and I now have learned and changed my mind”, had the American taxpayer not stood up and said “I want to lead and help change the world for the better”, HIV/AIDS would have become the leading cause of burden of disease in middle- and low-income countries by 2015. PEPFAR changed the course of history.

With the 20^th anniversary of PEPFAR approaching, I’m grateful for all the diverse individuals who came together around a common goal of health, hope, and healing. The story I share today is one piece of the story – just a bit of the backstory that most have never heard – that is PEPFAR. There are so many stories of commitment, faith, and compassion from the halls of Congress, in the White House, in faith communities, and on the ground in African nations, that made the remarkable success of this plan possible. It was an example of American exceptionalism and unity at its finest – something only our nation and people could have achieved, and worth remembering today, on World AIDS Day 2022.