Reinvigorating Global Commitments to Children Living with HIV

J. Stephen Morrison: Hello and good morning, good afternoon, good evening wherever you may be. I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies in Washington, D.C. And welcome to this CSIS program today, “Reigniting Global Commitments to Children Living with HIV.” We’re really thrilled to be assembling this remarkable group of talented experts to speak to this topic today. I’ll be turning momentarily to introduce the two guests who will help us open the conversation momentarily, Chip Lyons and Deborah Waterhouse. I’ll come to them in just a moment.

Today we are publishing a very important study authored by Katherine Bliss, the lead author, “A Brighter Future for Children Living with HIV: Reigniting Progress Towards an AIDS-Free Generation in the COVID-19 Era.” Congratulations to Katherine. A special congratulations and thanks to our colleague Michaela Simoneau, who’s worked tirelessly throughout this entire project. And a special thanks to ViiV for all the support that it’s provided to us, both financial, technical, moral, and many other forms, and the other partners here, like EGPAF, who have been with us throughout this entire process of this working group and the deliberations. From our team, our production team today, I just want to offer quick thanks to Mary Wright, to Graham MacGillivray, Clifton Jones, who’ve made this production possible here today.

Our conversation for the next 20-25 minutes is with Deborah Waterhouse, CEO of ViiV Healthcare, and Chip Lyons, President and CEO of Elizabeth Glaser Pediatric AIDS Foundation – both longstanding friends of CSIS and experts in this – in this field. We’re going to cover quite a bit of ground, and so we’re going to be brisk as we move forward. I want to remind the audience, if they want to submit questions they can do that via the CSIS event webpage, and we will attempt to work those remarks into the course of this conversation and the subsequent one.

Let’s start with you, Deborah, if you could speak for a few minutes. Great news, first of all, that the FDA and the European Medicine Agency have approved child-friendly formulations of dolutegravir and that there’s been agreement with generic producers to make it available to lower- and middle-income countries at a much-reduced yearly price – $36 per child. That’s really – that’s really terrific news.

Why don’t you start by sharing with us what have ViiV learned in this period about how COVID-19 is affecting the ability of children to access HIV programs, testing and treatment? And how has ViiV adjusted its own approach and outlook to R&D, research and development, and also the sort of partnerships you would have with advocacy groups around the world in this period? It’s very important – as a lead private sector partner – very important to hear your insights on these important issues. So welcome. It’s great to see you. We’re delighted you would join with us. So why don’t you kick things off, Deborah?

Deborah Waterhouse: Thanks, Stephen. And thank you so much for inviting me to be here today alongside the other panel members. So just to answer your question, I think, obviously COVID-19 has disrupted HIV services globally, including those that prevent vertical transmission as well as family planning, adversely impacting HIV treatment and prevention for children. So you know, the COVID pandemic has had a significant, you know, impact.

We’ve seen a difference in outcome according to the strength of the infrastructure – the health infrastructure – by country. And it just really brings home the importance of investment in core health infrastructure, because that’s really allowed different countries to respond to the COVID pandemic and keeps HIV care services going, you know, throughout. So there’s a lot of lessons there about pandemic preparedness, strength of health care systems, which I think we need to bear in mind as we move forward beyond the pandemic.

I think if I think about what we’ve learned – so our absolute priorities were, first of all, to make sure that there were no interruptions in supply. So we had some real ups and downs in terms of the demand on what our factories were producing and we didn’t have any stock outs anywhere in the world. And we supported our partners to, as far as possible, ensure that they’re in the same situation.

We also managed to keep all of our clinical trials on track because it’s really crucial that there’s not, you know, an interruption in the innovation, which is still significantly needed, you know, in the HIV/AIDS world, particularly for children. So, we managed to keep all of our clinical trials and our regulatory submissions and approvals on track. So those were really our two priorities, because those are the things that, well, in the short, medium, and long-term deliver the greatest benefit for children and adults who are living with HIV.

We also found that we were hearing a lot of feedback from our community partners and also from conditions around the world that there was a real need for funding to study how COVID impacted people living with HIV, and what the outcomes of those who were living with HIV who acquired COVID experienced. So we’ve really set up a significant kind of grant system funded by ViiV, which has helped fund new clinical research to understand HIV and COVID together, but also to support community groups that were really hit hard by a lot of other funding streams being withdrawn. And we have stepped in and tried to support those partners as significantly as we can.

And they’re always, you know, in our positive action programs, they’re usually programs that are grassroots based. So I think about what we do in South Africa to help strengthen public health systems, we were involved in supporting some of the community groups to employ HIV counselors who were then providing additional support to families to ensure that testing of children continued and treatment of children living with HIV also continued. So lots of grassroots programs and additional funding there, but also a lot of additional clinical research. So we set up a fund which was called the COVID-19 Emergency Response Fund. And it’s certainly been a fund that’s been greatly in demand.

J. Stephen Morrison: Thank you very much, Deborah. That’s extremely useful. Thank you.

Chip, let’s turn to you to get things rolling on your side. And you’ve recently published some commentary calling for global and community leaders to respond to COVID-19 and learn more from the early mistakes that you’ve identified in the HIV response – particularly around waiting to develop therapies for children until well after the needs of adults had been satisfied. What’s the current situation, as you look at it, in terms of developing pediatric diagnostic formulations for HIV? And what do you see as the best way to ensure the needs of children are not left behind in the COVID-19 context?

Charles J. Lyons: Thank you, Steve. I’m happy to speak to those and make a few points. I do want to just call out the report or the briefing notes that you’ve just launched and really applaud that work, and Katherine’s authorship of the report. We need a constant drumbeat around the pediatrics agenda. We’ve seen time and time again what happens if we take our eye off the ball. It’s not that policymakers aren’t – it’s not as if policymakers are opposed to kids, but they’re often forgetful of kids. And that can lead to – at budget crunch time and other times – kids get put aside. So your report is timely, it’s additive, and it’s very compelling. So thank you for putting that out there and doing all the work behind it.

We’re at kind of a high-water mark when it comes to the tools available for pediatric HIV and testing. We’ve seen a number of improved pediatric formulations come to market. Tremendous development because of Deborah and ViiV, and her team, and the partners that help them, including driving that price down, is just – is remarkable. That was a part of – an outgrowth, another thing we’ve seen over the last couple of years is just the real power – as Deborah likes to put it – the power of partnerships. The Vatican took steps to try and accelerate working with regulators, drug companies, other stakeholders, UNICEF, WHO, ourselves and ViiV on the development, the registration, introduction, uptake of HIV and TB diagnostics and medicines for children.

So they’ve been accelerated. We have the first tentative FDA approvals for a generic medicine within five months of regulatory approval for an originator of project. These are all movements that put us in a really strong position. Your report is – you know, first, the title is hopeful, and the sub-headline is necessary. We’ve got to reignite the priority attached to kids because the tools we have in hand will allow us to end AIDS in kids. But the tools have to be used steadily, consistently across countries with the highest burden, and so on.

All of this is a part of innovation that is constantly referred to. And we’re seeing manifestations of a real commitment to innovation. But in many respects innovation is pointless if it doesn’t have clients and clinical level impact. And so, you know, we’ve seen COVID-19 has disrupted the rollout of pediatric DTG, despite heroic efforts by ViiV, both at the national and sub-national level. Point of care early infant diagnostics are not being widely used in most countries, despite overwhelming evidence showing the dramatic impact that same-day test results have on treatment initiation for children.

And I would say, you know, COVID – there’s an aspect of COVID-19 that’s been satisfying to see how pediatric vaccine trials proceeded rapidly, as compared to pediatric trials for other lifesaving medicines, including HIV and TB. Pfizer announced this week that it expects to have vaccine data for children age 15 – five to 11, rather – in September, and for children in younger age bands later in the fall. Having that, you know, across 12 months from adult availability is a tremendous accomplishment.

And it’s an example of keeping kids forward, even if the public health requirement is uncertain about the need for vaccine for kids. You got to know through research. You don’t wait until there’s – well, we often do wait until there’s a calamity. And so, you know, there are a number of indications – practical ones, regulatory ones – that the reigniting the progress for kids – this may be a time we can actually do that.

J. Stephen Morrison: Chip and Deborah, you know, the central issue that I think Katherine was trying to get at in the briefing and in the working group activities and discussions that predated that, that led up to that, is that it’s really been a struggle, right, on pediatric HIV in terms of continued focus, prioritization, demonstrating the sort of progress, and trying to – trying to make sure that there is – that it’s getting onto the screen of senior policymakers, that it’s getting incorporated into strategies, and the like.

Are you suggesting, Chip, and then – that the force of this pandemic and the emphasis upon children, which – if they’re going to go back to school there’s obviously enormous pressure right now on getting the – on getting the vaccines out – approved and out for children. Is this going to have a spillover benefit, in your view?

Charles J. Lyons: To be clear, Steve, is COVID going to have a spillover benefit?

J. Stephen Morrison: For pediatric HIV?

Charles J. Lyons: Well, COVID is a monster threat to pediatric – to progress on the pediatrics agenda. We’re not going to achieve the goals that we talked about, including reducing new – the new infections to 20,000 a year – which is the target for 2020. But what we have to be clear about is that if we don’t mitigate and turn the corner on COVID, we are not going to achieve our goals around pediatric HIV and AIDS. COVID has forced a number of changes that we can benefit from. And I think we’ll hold onto those. One example is the use of multi-month dosing and an increase in self-testing.

It’s a shame that it took a pandemic to force those changes, in terms of age, eligibility, and so on. And those changes, improvements – for example, multi-month dispensing – are not a panacea. They come with risks. If someone’s not going back to the clinic as frequently to get their HIV services they still need to go back for other services, including reproductive health care and so on. And when you move back and forth and change things around, you – there are risks that attach to that.

So, you know, I think COVID – (laughs) – COVID has disrupted so much. And we don’t see the end. And we don’t see the plans for rapid distribution of, we hope, soon available vaccine for COVID. But there’s so much that we can not just learn from the HIV experience but leverage from the HIV experience. I mean, the phenomenal reach and effectiveness of PEPFAR and its partners in ministries of health, and so on. Those are things that can be tapped and used for the response to COVID.

So, in no way do I want to give a sense that COVID is helping. Quite the opposite. But we don’t have a choice. We have to go headlong into it. We have to help mitigate it. We have expertise, and service delivery, and reach that can be deployed for the benefit of rolling out COVID vaccine. And we need more focus on that than just the supply issue of availability of vaccine.

J. Stephen Morrison: Thank you. Deborah, your thoughts on how to – how to bring higher visibility to these concerns to senior policymakers?

Deborah Waterhouse: So, as is usually the case, I actually agree with Chip on all of those fronts. And I think the issue with the pandemic is that it’s demonstrated that we need sustainable HIV investment, driven by political leadership that is fully committed, which is responsible, accountable, and enables a country and community-led response. So we can see the damage that not having the focus, and the political will, and the investment that we need in HIV – the impact that that can have on our ability to deliver successful outcomes, both in terms of reducing new infections and reducing the number of deaths.

We’re way off where we want to be, which I am extremely disappointed about, in terms of new infections. And we’re going slightly backwards on the child transmission. So I am with Chip. I believe we’ve got to get through the pandemic before we can really start to turn our attention, you know, fully at a global level, back to the – you know, to the challenges you face in terms of, you know, children who are living with HIV, that treatment, or diagnosing those that are at risk of becoming HIV positive.

But you know, there are so many learning from HIV that we can apply to COVID situation. I hope we learn those lessons and I hope we approach this pandemic in a truly global way, because only when we started to do that with HIV did we start to see numbers come down in terms of new infections and, you know, children and adults alike start to face a brighter future.

J. Stephen Morrison: Are you seeing in the UNAIDS-hosted high-level dialogue – are you seeing the gravity and urgency of what you’ve just been describing reflected in the deliberations there? I mean, what you’re – what you’re describing – what each of you, Chip and Deborah – what you’re each describing is a crisis. And one with an uncertain trajectory. Do you see that reflected in the discussions?

Deborah Waterhouse: I do, actually. So I’ve been watching with interest all week the proceedings. And, you know, there are some incredibly ambitious and powerful goals in terms of reducing new infections, reducing AIDS-related deaths, and then some very specific pediatric commitments, which I was, you know, very excited about in terms of eliminating new infections with children and ending pediatric AIDS. I mean, that is a dream that we have held, along with our partners, for many, many years. So I think the goals are really ambitious and the quality of the dialogue and the gravitas of that dialogue has been, you know, extremely encouraging.

For me, I then need to see those commitments turn into a plan in terms of something that will lead to, you know, large-scale adoption of the – you know, the tools that we have in our hands today, and an ability to sort of accelerate some of the work that we have started, but that COVID’s gotten in the way of, such as ensuring that pediatric dolutegravir, in its dispersible format, is rolled out, you know, across the countries that need it most, because we’ve worked so hard to develop the medicine, and to partner with generics, and EGPAF and others to make sure that the product is there and we’re ready to go. But COVID has gotten in our way. So I’d really like to see us get back on track with that.

I think there’s a lot to be learned from the Rome Action Plan, which Chip referenced earlier. We met together in 2017 and we set out an ambitious plan, some really specific actions that each of us would take away. They were time bound. We knew who needed to do what. And we tracked those actions every single quarter since 2017. And as a result, we’ve had huge progress against the – sort of the goals that we set for ourselves. So I would like to see an action plan with some granularity coming out, you know, of the follow-up to the U.N. meeting, which helps us have a very clear pathway how we’re going to meet the goals, not just have them and then find that we’ve not met them in the coming years.

J. Stephen Morrison: Chip, your thoughts on whether the – whether what we’re seeing this week is really addressing these – the dimensions of this crisis, or what more is needed?

Charles J. Lyons: I agree with Deborah. I think in many respects – I’m sorry, Steve, go ahead and finish up.

J. Stephen Morrison: And just what more is needed.

Charles J. Lyons: Yeah. I very much agree with Deborah’s characterization. And I know there were a number of voices, but I think we need to applaud the leadership from the U.S. at very difficult moments in the negotiation of political declaration. It’s not as progressive of a political declaration as we might have wanted, but it moves us forward from the previous one and it’s got the elements that – the specific points that Deborah referred to in terms of pediatrics, and so on. It also is – it’s a recommitment.

I mean, part of what we have to do is keep ourselves focused and working on those things we’re working on before COVID when it comes to pediatrics. You know, at the Global Accelerator for Paediatric Formulations Network that’s housed at WHO, GAP-f, they’re going to keep working on various aspects of the pediatric agenda. In other ways, we can’t allow COVID – I mean, it’s a tough balancing act, right? We can’t allow COVID to dominate our lives, and yet for 18 months it’s dominated our lives. So how do – how and where do we keep pushing?

And I think, you know, to follow up on both the political declaration but also a really excellent – we need to also be applauding the UNAIDS strategy that was approved, and the seriousness of purpose around the pediatric and adolescent agendas there. What’s – it’s also going to take new layers and kinds of advocacy because, going back to the earlier points, we have the tools, we’ve got a political declaration that sets the tone for the next five years. We’ve got a strategy characterized and approved by UNAIDS with enormous amount of input. Kids are there in specific areas.

The shift that has to occur at the national level is a political determination to get it done. And I think some of our advocacy needs to focus on deciding whether we’re serious about this to the point where real policy is changed, real priority in tracking that. If a president of a country wants to end AIDS in kids, the tools are there. And they know how to run a Cabinet meeting and take other steps to make sure there’s accountability to constantly reduce the number of new infections, the number of kids that have been exposed to HIV that are not on treatment that are getting shifted onto treatment. This is a doable proposition, but it’s just been made very difficult, additionally complicated, from COVID, for all the obvious reasons.

J. Stephen Morrison: Thank you. Before we close, I want to bring things back to the G7 summit that’s unfolding in Britain. I’m sure there’s a lot of excitement in the U.K. there, Deborah, as this is – as we’re rolling up to this. One of the central concerns at the G7 summit is the vaccine crisis, the enormity of it, the urgency of it with variants, the simple scale – staggering scale of the gap. The solutions that have been put forward thus far haven’t begun to match the scale. Obviously, India has been a wake-up call. The timeline required for dealing with this is much longer, and the sticker shock. There’s now an estimation of $50 billion required in the next 18 months to address this. There are calls for greater transparency, for donations, for increasing production capacity.

But back to the discussion here of relevance to pediatric AIDS, there’s a big focus, I believe now increasing, on getting donors to strengthen – to commit to strengthen the capacity of low- and middle-income countries to manage – to deliver – to receive, manage, and deliver vaccines. And that, it seems to me, is a – is a concern of great magnitude right now. I’d like to ask Chip and then Deborah to sort of offer your thoughts on that at this moment in time, which seems to be a poignant – a very poignant matter.

Charles J. Lyons: A hundred percent, Steve. And thank you for CSIS and others for putting forward the open letter to the G7. I think the five points, if I recall that correctly – it was earlier in the week – I thought were spot-on. We have a fundamental – we have two challenges. Or, we have many challenges around – but two strategic challenges around COVID. One is supply and one is distribution, as you just said.

Supply’s getting a lot of attention. It’s getting a lot of money, and so on. I don’t see it in a commensurate way on the distribution side. It’s not going to be enough, obviously, but maybe it’s not obvious enough, to have vast supplies of COVID vaccine on the ground in specific countries that, for a very long time, have been characterized as having health systems that need strengthening. They have routine immunization programs, which essentially focus on the kids. No one’s ever had to immunize everybody in the country that is willing to be immunized. They’ve never had to mobilize an adult population that might be a little skeptical about the vaccine, or where this came from, or what have you.

We’re already seeing some countries shipping 10,000 doses to another country within the continent because they weren’t ready to take up 10,000 doses. What happens if they get 10 million doses? So we – there’s a window to focus on this. And it needs the same kind of attention, microplanning, considering how to get at the subnational level communities and others aware, responsive, willing to take the vaccine. We have a tremendous vested interest in the success of every single country doing – pulling off a national immunization campaign that they’ve never had to do before. And if there’s sticker shock, it’s going to be the cost of not doing that in terms of damage to economies, and communities, and so on.

J. Stephen Morrison: Thanks, Chip. Deborah, I’d like to offer you the chance for the last word here. Your thoughts on what we can expect out of the G7 summit?

Deborah Waterhouse: Thank you very much. So I think – well, I agree with Chip’s comments, so I’m not going to repeat. I’m just going to – I’m just going to kind of build on a couple of points. We need to take a global approach. I think supply is becoming a more recognized problem, which people are stepping up to tackle. I do believe that a challenge will shortly become distribution. And I think that is, unfortunately, going to be easier in countries where you’ve got, you know, a more robust health care system versus those that have always struggled to – you know, to deliver.

And it won’t be the same either within the country. So from the work that we’ve been doing we can see that within one country you’ve got different provinces or counties where in some places they’re actually much better prepared than others. So we shouldn’t think that it’s even about having a bespoke plan by country. Actually, it goes down to province by province. And we see that very clearly with HIV, both adults and pediatrics.

So I think, to Chip’s point, we need to solve the supply issue but at the same time be thinking about the distribution issue at a very granular level, country by country, and be offering support to strengthen distribution and health care, you know, systems, as opposed to just thinking a donation of X million is going to solve the problem – although I do really want to acknowledge the leadership by the U.S. of the 500 million doses of the Pfizer vaccine that the U.S. is offering, you know, to, you know, less developed countries.

So I want to acknowledge that supply commitment. But actually, now we need to move our attention to – you know, to the delivery and strengthening health care systems. And if health care systems deliver for COVID, let’s hope that when we are out of the pandemic those systems are strengthened in a way that can also support us to tackle the HIV epidemic too, with a very special focus on children.

J. Stephen Morrison: Thank you so much, Deborah. Thank you, Chip. Thank you for your leadership, for your continued commitments, and the commitments of your respective institutions. We’re very grateful and delighted that you could be with us today. Thank you so much.

Charles J. Lyons: Thank you, Steve.

Deborah Waterhouse: Our pleasure. Thank you.

J. Stephen Morrison: I’m going to turn the – thank you. I’m going to turn the program over to Katherine – my colleague, Katherine Bliss. Thank you.

Katherine E. Bliss: Steve, thank you very much. That was a really interesting discussion and great panel. I think a number of the themes that Deborah and Chip raised will carry through this discussion as well. My name is Katherine Bliss, and I’m a senior fellow at the CSIS Global Health Policy Center. And it’s really my pleasure to have a chance to moderate the second session of our event today. We’ve got a wonderful lineup of experts with us to share their views on what it takes to really accelerate progress and meet global goals on eliminating new infections in children and scaling up access to cutting edge testing and high-impact treatments.

I’m pleased to welcome Dr. Angeli Achrekar, the acting U.S. global AIDS coordinator based at the U.S. Department of State in Washington, D.C.; Dr Siobhan Crowley, head of HIV at the Global Fund to Fight AIDS, Tuberculosis, and Malaria based in Geneva, Switzerland; Dr. Shannon Hader, deputy executive director of programs at UNAIDS and assistant secretary-general with the United Nations; and Ms. Maximina Jokonya, the coordinator for the HER Voice Fund at Y+, the global network of young people living with HIV and based in Zimbabwe.

Now, the UNAIDS board approved its new strategy, “End Inequalities, End AIDS,” earlier this spring. The United States PEPFAR program recently completed a new COP process with country teams to develop operational plans for the next phase of work. And the Global Fund is developing a new strategy to be finalized and approved later this year. All of these efforts and strategies present opportunities to hear from and engage children living with HIV, their families, and caregivers in an effort to reignite progress on improving and expanding pediatric services.

Now, at the same time, I mean, this week alone has been quite a week for the HIV community. There’s been the high-level meeting and affiliated side meetings focusing attention not just on the challenges the COVID-19 pandemic has posed to making progress on meeting ambitious global goals, but also really examining the social and legal factors and the policy environments that hinder equitable access to services and exacerbate the inequalities that are so inextricably tied to vulnerability to HIV. There’s also a new political declaration and a youth statement on the political declaration urging member states to do better for their young people, including the provision of sexuality education, greater access to the full range of HIV diagnostics treatments and services, and support for youth-led responses to HIV.

So, Shannon Hader, I want to start with you and the high-level meeting this week. There have been a lot of plenaries and thematic panels, some focused on women and girls, others on youth-led advocacy and services. We’ve got a political declaration and, from yesterday, now also a youth statement saying the declaration really doesn’t go far enough. So I’m going to ask you to start out, you know, what were UNAIDS’ hopes and expectations going into the high-level meeting? And after three days how do you feel it’s gone so far? I know there’s a little bit left for today. Were there any surprises around the discussion around children and youth, or in the pushback from the youth statement?

Shannon Hader: Mmm hmm. Yeah, thanks, Katherine. And let me just start by congratulating you, and CSIS, and Stephen on your new analysis and paper. Really exciting. And very happy to be here with everybody today.

Yeah, high-level meeting and also, as you mentioned, the global AIDS strategy. You know, we’ve got a theme: “End Inequalities. End AIDS.” You know, and, you know, when we look at what’s happening, one of the most glaring inequalities or disparities in the HIV response is for children – failing to meet the needs of children living with HIV. And, you know, we launched right before the HLM just the updated 2020 data of where we got to at the end of the 2020.

And the results are not surprising because I think, although – and we’ve heard earlier in the panel – if you look over the decade, we’ve made tremendous progress for kids and young people. But if you look over just the last few years, that’s plateaued. We’re stalled. And we’ve got to do something else. Children living with HIV face a stark reality. They make up 4 percent of all people living with HIV and they make up 14 – 1-4 – percent of the deaths. And that’s because treatment coverage is abysmal. It’s nowhere near what it is for adults or women or pregnant women. We know there are over 850,000 kids living with HIV that are not on care and treatment, two-thirds of whom are over five years old and so aren’t going to be found just by infant services. So sorry to start there, but, I mean, that’s the context that we’re coming into this HLM with.

And I do think, and agree with, I think, the youth statement, that the political declaration, you know, could have been bolder. It is a member state activity. I think it’s not as far as we had hoped it would go, perhaps. But it’s also very much a complement to and aligned with the new UNAIDS global AIDS strategy. And I think when you put these together they do become tools at country level for civil society, for technical leaders, for decisionmakers to ground some of their decisions in what we’re hoping are global norms.

But I did want to build on a couple of things that Chip mentioned in the last panel, which is – you know, they’re talking HLM, or especially the global AIDS strategy, you know, this year this was the most inclusive, I think, strategy development process ever. We had inputs for over 10,000 stakeholders in 160 countries. And yet, as many folks might remember, the very first zero draft framework didn’t have a special section for kids. Didn’t have a special section for youth. And I think it’s a – it’s a stark reminder of how quickly it is for kids to be overlooked. You know, the pediatrician voice on that is, you know, kids being looked at as little adults, and just folded into the same sections with the same issues as them. And that has never worked.

But, you know, and no worries. We got there, right? Thanks to the inputs of stakeholders – and, frankly. UNAIDS was never going to let a strategy be finished that didn’t have special sections for kids – we do have specific result areas for kids. And we do have a new result area for youth and youth leadership, which is another reason why I like the youth statement that’s come out, because we need young people who are involved and affected by HIV to really be driving us forward. So I was pleasantly surprised, I guess, by seeing that come out this week. And I want more. I want to see more.

And I have been not surprised by some of the deliberations. I think we knew where there has been concerns and conservatisms that get in the way of some of the evidence-base and translating that to action. But especially when it comes to kids, whether it’s vertical transmission or kids living with HIV, I am always perplexed. Politicians like kids. Everywhere in the world kids are a winning topic for politicians. But the reality is, I think, the remaining factors that are getting in the way are somehow difficult. You know, I hope that – you know, we’ve seen presidents and prime ministers carrying around cards in their pockets under COVID that says how many people died yesterday. I sure wish we could switch that over, as we recover, to a pediatric AIDS card. How many kids are living with HIV but missing in my country right now? And how do we find them?

And maybe it’s a little bit that it’s complicated to think about surges to recover from some of these gaps, and then systems. You know, we shouldn’t spend five years finding these 850,000 kids who are already living with HIV. And also, some of the gaps that are missing beyond the uptick of innovations like the previous panel talked about, you know, they do get more and more complicated. We need to make sure that these services are supportive of parents, so they want to bring their children in for care. We need to make sure the systems become differentiated.

We still know women and parents who are members of key populations oftentimes have very abysmal and discriminatory care. And that hurts their children as well. We know that there are a certain amount of our remaining new infections that are from women getting newly infected during pregnancy or breastfeeding. You know, who are those women? And they’re going to be disproportionately young women. And how are we reaching them more intensively in a preventative manner?

So I guess, you know, it’s been a great week. I’m glad that in the strategy, and therefore in the political declaration, kids and youth leadership have specific places and specific targets. But I think we still have a long ways to go to flip the script to, you know, maybe look at our global framework as supporting what we need for political will and political action on the ground at country and regional level. And we look forward to working with everybody to do that.

Katherine Bliss: Shannon, thank you. Siobhan Crowley, let me – let me turn to you. You know, in addition to the high-level meeting we’ve also got the G7 summit starting tomorrow. COVID-19 is obviously going to be on everyone’s mind. Chip and Deborah and Steve talked about that a little bit. But, you know, HIV has played a big part in G7, G8 summits in the past – including Okinawa, I think, in 2000, Genoa in 2001 – which is where they formerly endorsed the creation of the Global Fund. And Shannon has just said that politicians love kids. They’re a winning topic. But, you know, now the Global Fund is also very much involved on issues beyond AIDS, tuberculosis, and malaria, including supporting the ACT Accelerator’s diagnostics pillar and the health systems connector.

So I just wanted to ask, you know, to what extent do you foresee collaborations, renewed commitments to HIV – especially children living with HIV – at the G7 level? And are you concerned that the global focus on the pandemic and health security means that the funding and political will to really advance on preventing HIV infections in children and initiating those living with HIV on therapy may be diminished over the next period?

Siobhan Crowley: Hello. Good morning, afternoon, evening to all. And thanks very much for the invitation, Katherine, and CSIS. Yes, I mean, first part of your question, the G7 has always demonstrated strong leadership on global health, which includes, as you said, the creation of the Global Fund. And, you know, yes, we have to celebrate the enormous progress made by the partnership. But nine years before 2030 we’ve still got – I mean, as Shannon was referring to – HIV killing 700,000 people a year, the 1.7 million infections, including the ones in children that are completely and utterly preventable. And we know that it still is sort of affecting disproportionately the most vulnerable and marginalized.

So and when at home, you know, in the U.S., for example, or in the U.K., where I’m from, or Australia, where I’m also from – (laughs) – vertical transmission has been almost eliminated. So I think inequalities are holding back our collective response. And I think the fact that HIV/TB/malaria is still killing millions of people when we have the means to stop is ultimately a political choice.

I am concerned – (laughs) – that the focus on COVID is going to detract from the fight against HIV a little bit, as Chip was saying. We can’t pretend that is not going to, you know, be, quite rightly, the focus of discussions at the moment. But I think we have the capacity to focus on more one – more than one problem at a time. And I think we are overly focused on vaccines – again, as the previous panel sort of said. We’re not sufficiently thinking through what’s the health systems and institutions we need to deliver the public health response, the data, the test, the treatment, the PPE that is necessary.

And, you know, it’s interesting to me, the prevention equity in HIV is a nightmare for us because, you know, nobody’s concerned about that. They’re worried about treatment equity. Whereas with COVID we’re obsessed with the sort of prevention equity, but we have not sort of been concerned about the treatment and management equity. So it’s an interesting sort of contrast. I think the other thing – you know, there’s several things that the international commitment to the response on COVID has shown us what we can do when we wish to come together, when we wish to take this on at a global level.

The other thing is our HIV platform has been extraordinary. So the research from COVID, you know, came out of the HIV research platform and network. Huge contribution and commitment over years by the U.S. And I think, you know, for me, and sort of speaking a little bit candidly, I think the political stop/start support for issues is the shortsightedness. And I have to say, I feel incredibly sort of super-charged that the U.S. has shown both real solidarity on the COVID response but has not stepped back at all from their mission and mandate with respect to the three diseases, in particular HIV.

And at the Global Fund, we’ve – that’s been super clear to us. And, yes, you know, as you say, we’ve tried to sort of step in and provide an agile responsive mechanism to the dire situation in low- and middle-income countries with respect to the nonvaccine parts of COVID. But we’re also trying to make sure that the countries can continue to move forward on the commitments and the ambitious targets we had for HIV. And I think that’s – this is a huge challenge to us, frankly. (Laughs.)

I’m worried, as Shannon said, you know, children are always overlooked. They never have a voice. And even in our own constituency, youth are meant to talk for children. Youth are not children. Youth are worried about their futures. The fact that they even survived childhood to be a youth means they look forward. And children are just – everyone – nobody disagrees that they matter, but nobody actually takes the steps required to actually respond. And we have seen this – you know, we’re 40 years into this. And still, I think we have to feel somewhat shamed together, you know, collectively, that we haven’t made better progress. But I think if we look at the data, we were making progress, but we’ve sort of stalled now. And, you know, COVID may make us sort of step further backwards. And that deeply, deeply concerns me, yes. Over.

Katherine Bliss: Thank you. Angeli Achrekar, let me turn to you. You know, PEPFAR programs have just wrapped up the COP process for the next fiscal year. But at the same time, there have been calls for using the PEPFAR platform – you know, Siobhan has just talked about the importance of, you know, the existing and historical investments in health systems and systems of delivery for HIV, tuberculosis, and malaria. There have been calls for using that platform for responding to COVID-19, including testing and communications, as well as the delivery of other services.

So, let me ask you, you know, how have PEPFAR platforms supported countries’ COVID-19 readiness and responses to date? And, you know, to what extent will continuing to support the pandemic response help or hinder efforts to support activities focused on children living with HIV? And is this a zero-sum game or can they be mutually reinforcing?

Angeli Achrekar: Great. Thanks very much, Katherine. And, first, a big thanks to you and Stephen and the CSIS team for hosting this really important session. And also congratulations on the report and the briefing that was just published.

So thanks for the question. You know, PEPFAR – as you all know, we work in partnership with all of you on the panel here, and I know many that are listening in – you know, we’re laser-focused on ending AIDS. That is our mandate and that’s what we’re focused on. But to do that over time, we’ve had to strategically invest in critical systems. These PEPFAR investments over time have resulted in nearly 300,000 health care workers, community health workers, you know, over 3,000 labs, 70,000 health care sites where we have very specific data surveillance that is occurring, supply chain, and others.

We’ve worked – and these aren’t PEPFAR systems. These are local systems that we have – that we have worked to strengthen over time. And that now exists in the 54 PEPFAR supported countries in which we work. These systems have been essential to controlling – and the work that we’re doing together to controlling the HIV epidemic. But they’ve also helped keep Ebola, H1N1, other deadly disease from raging out of control. And they have been vital for the ongoing response to COVID-19. So not only have they been critical to responding to the HIV response, but they have also been critical in quelling the rage that has been happening related to COVID-19, for instance, and also ensuring that we can protect our HIV gains as we – as we experience and continue to go through COVID-19 and these dual pandemics.

So, you know, we must support the – and this sort of harkens back to the previous – to Chip, and Deborah, and Stephen in their session. You know, we really must support the pandemic response to ensure continuity of our HIV services within the framework of the national programs. And again, including activities focused on children living with HIV. It’s important to note that, you know, through COVID – and last year, at the height of the COVID pandemic, we saw really critical dips in pediatric viral load and early infant diagnosis coverage. We’ve started to recover in the last few quarters, which is – which is good news. The equipment and supplies for laboratory testing are the same for HIV viral load, early infant diagnosis, and COVID-19.

So we’ve been working with governments to ensure standard operating procedures are in place to ensure both children living with HIV and HIV-exposed infants are prioritized for these tests. So, again, we are trying to figure out how we need to mutually, you know, work together to both respond to COVID, which is impacting our programs, but also how we can prioritize children in the midst – in the midst of that. So some countries, for example, like the DRC, are making great use of point of care technology for dual diagnosis of HIV and COVID-19, and will target pregnant and breastfeeding women, children and infants for viral load and early infant diagnosis.

So ultimately, we want – we want appropriate systems in place so that clients, beneficiaries – including children living with HIV, health care workers, community health workers – are protected from COVID-19 and feel comfortable engaging – comfortable and safe engaging in health-seeking behaviors and clinical and supportive HIV services. So again, trying to figure out how these can go together as we – as we wade through both of these pandemics. Thanks.

Katherine Bliss: Thank you. So really, you know, some of those – the testing platforms can be used for both, but really finding ways to prioritize the populations of pregnant and breastfeeding women and children, while delivering other – you know, using those for other services at the same time. Thank you.

Maximina Jokonya, you are the coordinator of the HER Voice Fund, working with adolescents and young people living with HIV to ensure that their views and experiences are taken into account, particularly as strategies for improving and expanding health services, including those for HIV, sexual and reproductive health and rights, et cetera, are developed. And, now, many of the HER Voice Fund ambassadors were involved with the high-level meeting this week. And of course, Y+ Global was part of the groups of organizations that put together the youth statement.

So I wanted to ask you to talk about your own experience finding your voice as an advocate for health issues, and what do you see as the biggest challenges young people face in being heard? You know, we’ve heard that children – you know, the youngest children really are often left out of those discussions – in part because they are so young or, you know, we rely on their family members to talk for them. But, you know, as young people develop their voices what are the challenges they face in being heard – whether it’s at events like the high-level meeting or more local level discussions? And what really gets missed when youth are not integrated into the strategies and response with respect to HIV?

Maximina Jokonya: Thank you so much, Katherine. And thank you to all the speakers that have spoken before me. I really did need to acknowledge that, you know, we have achieved so much in terms of, you know, meeting the needs of young people, especially those that are living with HIV. But unfortunately, you know, HIV continues to impact us as young people. It continues to affect us as young people in all our diversity. But the main question, or the query that we have is that we always remain marginalized, we’re always relegated, you know, as a recipient of services not as equal actors in terms of the fight against AIDS.

Some of the challenges that we also face are – continues to be, you know, as structural barriers, continue to be administrative, continue to be language barriers, those that haven’t been acknowledged by – whether it’s government, whether it’s funding, whether it’s anyone that really is in the HIV response don’t really recognize this. But at the same time, it’s really fear that diminishes our opportunity in terms of, you know, how do we share our own expertise as young people in all our diversity? You know, moreover, you know, the issue of COVID-19 currently is accelerated in terms of the barriers that we have, in terms of engagement at these meetings that you have talked about, which means for us we will continue to not have a voice, we continue not to be able to engage fully as we are supposed to be engaging as well.

As we highlighted that, you know, pediatrics, they don’t have a voice just because they are young. And Dr. Crowley, all – (audio break, technical difficulties) –

Katherine Bliss: Well, let’s maybe – let’s see if Maximina’s connection comes back. We’ll come back to her question. While we’re waiting to see if she comes back, Shannon, let me turn to you just to follow up on one of the points that you made earlier, that it’s really – you know, it’s one thing to – you know, there are questions around, you know, improving access to prevention and early infant diagnosis and treatment. But, you know, there’s a population of sort of older children – you know, around the age of five and older – who are also missed. And I wanted to ask you just to elaborate on, you know, what makes finding those older children living with HIV so difficult? And, you know, to what extent are there community-level programs and initiatives that can really be helpful in gathering that kind of data to really improve our potential to identify, locate, and bring services to that population?

Shannon Hader: Sure. I see Maximina’s back. Do you want to go to her before – in case she loses bandwidth again?

Katherine Bliss: Sure. OK, so hold that question. Let’s go back to Maximina for a second.

Maximina Jokonya: I’m so sorry. My internet just got cut off.

Katherine Bliss: (Laughs.) It happens.

Maximina Jokonya: My apologies. Yeah, so I was thinking about, you know, equally being involved and equally being treated as partners as well. So one of the things that Dr. Crowley also indicated that, you know, we know that we’ve got children as well as know that we’ve got young people. But, you know, there is definitely a lack of political will – either from the governments, either from the finance, from the implementers themselves – to recognize us and really engage us and be able to recognize issues that will affect us at the end of the day, so that they could really have, you know, as, when at the discussions to treat us equals is expects as some people who knows exactly what they’re talking about. We’ve got the solutions in terms of what affects us as young people.

So that lack of – you know, lack of political will in terms of, you know, recognizing young people as able, equal partners, I think that’s the way that the other issues also comes into play. And also, just to further explain to that is that we are not recognized in all our diversity. We love to treat as young people, you know, as a homogeneous group, as well as, you know, have interventions for some young people, leaving other young people aside. For example, we can talk of, you know, young people – I’m a young person who is living with HIV. We are young people who use drugs, we are young people who sell sex, we are young people who have sex with men.

So in all our diversity, in who we – in all our autonomy, make sure that, you know, during your high-level meetings, when you are doing your local meetings as well, accept us as we are, because that’s one of the challenges that we are also facing. That, you know, they select in terms of young people that they want to deal with when it comes to these meetings, and other group is also selected from that. So at the end of the day this is nonmeaningful engagement in terms of HIV response, form our side as young people as well.

Talking about, you know, these high-level meetings that are going on, not just this current one but just, you know, in all of those conferences, everything that HIV global space, I was also thinking in terms of, you know, leaving no one behind. And I’m thinking of that young person who is in the rural areas, who doesn’t have a voice. What are we doing in terms of that? That’s another barrier that we have, in that there are certain young people that are being left behind in terms of engagement into these, you know, high-level meetings, which means their voices are not on the table.

So these, especially now when you’re looking at the COVID-19 situation, which worsens the issue, so we need to make sure that when we’re saying leaving no one behind, in these barriers that we’re facing as young people, how are we engaging in all our diversity, especially those young people that are – that are also in the rural areas as well. One thing that I also wanted to highlight is that some of the barriers – it also goes back to the – you know, the data that speaks to young people as well.

I know that we know that speaking – you know, going down to children, adolescents, young people themselves, the data that speaks to us as young people is not adequate enough. It’s not disaggregated accordingly. Oftentimes, we are just being put – you know, all the data that speaks to us, it’s just, you know, put in the – with the rest of the adults. We are just, you know, put in that pool. At the end of the day, our engagement really diminished just because we don’t have a voice, just because we don’t have that data that speaks to us as young people as well.

The other thing that I needed to highlight is the issue of – you know, lack of political will from the country governments themselves, you know, to prioritize young people, to prioritize children as well. You know, we have generally few or no policies that speaks specifically to children, that speaks specifically to addressing young people, especially when looking at the HIV response. The policies that are there, they are speaking to, you know, adults in general terms when it comes to HIV response.

At the end of the day, we are left behind. We don’t engage, you know, at the level we should be engaging because we don’t have anything that back us up in terms of policies. So that’s one of the things, is one of the barriers that really impedes us from being – you know, engaging in a more strategical way for us, for our voices to be at the end of the day. So we need those political commitments from the government going to the global level as well.

You know, I’ll end up as – you know, just stating by saying that, you know, we still have the same people, you know, who have made these restrictions, these barriers that you’re talking about – they are the ones that are still sitting at these discussion tables. They are the ones that are sitting at these high-level meetings, you know? But we don’t have the critical people in place. We don’t have the young people themselves in place. So as much as we want to change the narrative, if we don’t have the young people at the discussion table, if we don’t consider them in all their diversity, we are losing the game. We are losing, you know, what we want to achieve at the end of the day.

We need to make sure that they are part of, you know, the discussion table, they are the young leaders, they are able to contribute adequately to the HIV response at that level. That way we are able to make sure that, you know, the interventions that are coming in, everything – (inaudible) – is at the end of the day we’re able to combat HIV and AIDS at the end of the day. I’ll stop here, Katherine, and you can continue the talk. Thank you.

Katherine Bliss: Thank you. So, you know, politicians may love young people and children, but frequently they’re sort of placed in a kind of umbrella category, and it’s really important to understand the many different experiences and just the diversity of youth as a category, and to ensure that young people from rural areas and from different walks of life, that their perspectives are really incorporated in order to make more effective policies.

Well, so, Shannon, turning back to you, you know, thinking about these, you know, sort of – beyond the infant age, beyond the toddler age, these older children living with HIV who are, you know, sometimes difficult to find, what are some of the strategies at the community and district levels that can really help find – you know, generate that kind of data, generate data that, as Maximina has said, you know, can be relevant to those kids and those categories, but, you know, also identify those groups and bring appropriate treatment to them in a timely way?

Shannon Hader: Yeah. Thanks for that. You know, I think there’s a few things. Actually, perception and awareness I think is a big deal, for both providers and parents. I think people are surprised to know that two-thirds of those missing kids are five years old and older, because we think of babies. When we think of vertical transmission, we think of babies. And it’s still, of course, very true that infants are at the most risk of dying very quickly if they’re missed and they’re not treated. But particularly infants that are infected through breastfeeding, they’ve perhaps survived. And even with a small portion of the kids who survive infancy not being diagnosed, how that builds up year, after year, after year is huge.

And so I think that – just even knowing at a local level you have to think about, OK, where do we find these kids? What’s different than dealing with infant clinics, and how we incentivize it. Certainly, I think t’s not going to be a single access point or a single bullet. And I think the work that EGPAF has been doing, some of the work that PEPFAR has been doing, to try to figure out where are these kids and how do we find them, we have to continue. Certainly, one strategy is, you know, you find them through the parents. Parents are much more likely to be on treatment. Can’t you find the kids? So index testing. Sometimes I think we’ve let index testing get a little bit too clinical and a little bit too just tracking the case, as opposed to supporting the people.

I think you have to – we have to ask parents, you know, what would it take for you to want to know that your kid is positive? Of course, everybody wants their kid to be healthy. But if they haven’t been that sick and, you know, do you really want to open up a box that might have something bad inside that scares you, unless there’s the support around to take that on? How do we communicate and how do we get there?

How do we make sure that there’s a bandwidth for health care providers in places where kids who are not thriving show up, whether they’re feeding clinics or other kids of clinics, so that this is not just a burden that we can’t deal with? How do we, with older children and adolescents, be working on lowering the ages of consent for your own health care so that older adolescents do have access to self-testing, to going to a clinic on their own, things like that?

And then I do also want to – want to complement that by saying, but if we don’t want to have to face this every single year and every single year, we do still need to find every single positive kid who’s being born who is an infant. And right now, we still only have 60 percent coverage of EID at two months. So we’re still missing 40 percent of the exposed kids. And who knows if those are, you know, proportionately or disproportionately HIV infected. But they’re important.

And maybe building on what Angeli said, maybe one of the benefits from COVID is maybe if we look at the colliding pandemics there is a little bit of awareness that having viral diagnostic capacity is not a luxury. And perhaps we can get more interest when we put these pandemics together to not just procuring but actually, you know, committing to the maintenance of point-of-care diagnostics and viral diagnostics at the scale and, you know, resourcefulness that we need them at.

Katherine Bliss: Thank you. Maximina, building on what, you know, Shannon has talked about, you know, in terms of reaching these older children with services and really incorporating the families into those discussions, let me turn back to you. You know, with – during the pandemic, with schools closed and many families experiencing increased economic hardship, it’s been a challenging period for – for all of us – but especially for children and adolescents, in particular. And I just wanted to ask you to say a bit about the role of the HER Fund ambassadors during the pandemic, and the role that you see young people – at the risk of using that umbrella term – (laughs) – but you know, the – at least your peers, the people you work with, the role that you see them playing in responding to the crisis.

Maximina Jokonya: Thank you so much, Katherine. So, HER Voice Fund has been really instrumental, especially with the support from Global Fund and ViiV Healthcare. We are very grateful. So, you know, ambassadors are adolescent girls and young women who are the leaders, who are articulate, who can really advocate for the issues of adolescent girls and young women, but in young people in all their diversities as well. So, during the pandemic we know that everything was shut down and lockdowns were in place. And most of the times, you know, adolescent girls or young men were in isolation, and also young people – actually, a broader term – were also in isolations as well.

So, this is where we start, you know, the issues of young people really have got to arise where we didn’t have access to services with sexual and reproductive health, with any treatment that may save, really. And also the issue of GBV, intimate-partner violence also really increases at the same time. But you know, the harder part of it was that, you know, where we deemed that it is a safe place, where, you know, survivors or at risk, for example, of GBV or intimate partner violence, or to access a treatment – the places where we thought they are safe, they become unsafe because of COVID-19. So we find ourselves in a bit of a hard – a hard place, especially for young people. So, ambassadors really came in and be instrumental in terms of, you know, one, advocating for the services that are the right approach for young people – where can they access them in the right place, in the right time as well, for them to access them.

So we have seen that, you know, ambassadors themselves, they could actually, you know, go onto their bikes, being front-liners themselves, go onto their bicycles, take a treatment to – you know, to local communities, go and share with the young people themselves, especially those that are living with HIV. They would go to the communities, they’ll go and distribute ad, they would go and, you know, have a big of counseling for those young people. Just because, you know, every services that we know in the norm had been disrupted as well. So ambassadors have been key in terms of doing that.

Also, just to look at – you know, at key decision-making level as well, where decisions are being made over the lockdowns and COVID-19 situations, ambassadors were also involved, you know, in terms of, you know, advocating for the issues of young people, as well as adolescent girls or young women. That is pertaining to sexual and reproductive health, HIV in broad terms.

We could – we saw that, you know, ambassadors would be engaged in terms of round of request for proposal that countries to the Global Fund, the way they – in terms of the CCM meetings that were going on, giving presentation to the current issues that are really emerging in terms of young people and how they can be really addressed in the new funding mechanism that will going to be coming in those countries as well. We can talk of C19RM. That is currently ongoing. Ambassadors are really engaged in those processes as well, making sure that the issues of AGYW and also young people in all their diversities are also included in those processes as well.

So they’ve come to be the leaders that we want. They’ve come to represent other young people. They’ve come to represent their issues at the end of the day, and we have the voice, you know, at the end of the day at these decision-making processes as well. So I think that’s what we have seen in terms of, you know, engagement of HER Voice Fund ambassadors as well.

Katherine Bliss: Thank you.

Maximina Jokonya: In terms of – yes, you can – you can go ahead. Thank you.

Katherine Bliss: No, that’s great. I wanted to just shift to – you know, you mentioned, you know, the importance of really incorporating, you know, the work that they’ve done both in helping to develop strategies at the local level and really providing input into these national and global level.

And we don’t have a lot of time left, but I want to turn to Siobhan Crowley just to ask if, you know, the Global Fund has been undertaking consultations over the past year, and a number of different opportunities to provide input into the new strategy that will be approved by your board, I think, in November of this year. Can you just, you know, preview the extent to which you see prevention of vertical transmission and services for children living with HIV, how that’s going to figure in the new strategy? And then I’m going to give Angeli Achrekar, you know, another quick question as well. I know we don’t have a lot of time.

Siobhan Crowley: Thanks, Katherine. Yes, let me, I mean, briefly say, as you know, we’re developing our next strategy and the sort of precise language and nuances are being refined currently by the strategy committee, and they will go to the board for final approval in November. Some things are clear, very clear. Fighting the three existing pandemics of HIV, TB, malaria remains our core mission. Making sure that we are supporting people-centered systems that are resilient to deliver impact, making sure we sort of build engagement and leadership of affected community to leave no one behind, and sort of maximizing health equity are definitely staying there, as they have been in the previous.

The one that’s been causing a little bit of trouble, of course, is the pandemic preparedness and response. And I think, you know, how much that features is the sort of tension that’s being worked through. I think what is super clear, that, you know, we don’t want to think about sort of walking into global health security, because that has connotations of sort of security and is perceived as, you know, security of rich countries and poor. And we’re very focused on sort of addressing impact in low-income and middle-income countries, and sort of finishing the fight against the three diseases.

So leaving no one behind, you would like to think that children will feature, because that clearly is, as Shannon very clearly – you know, the numbers can’t lie, don’t lie. (Laughs.) It’s where we’re lagging behind. And the burden of new acquisition in young girls in particular, of course, is something that stands out. And those things are critical. I think what you will see – and I think it’s interesting to sort of reflect. If you reflect, the wonderful thing about PEPFAR is it didn’t matter what administration was in power, the sort of unwavering commitment to ending AIDS has been there, you know, irrespective of administrative changes.

But what has actually happened is they’ve sharpened their instruments – for action, have gotten sharper and sharper. You know, level of attention and drilling down. And while that sounds sort of somewhat – you know, it sounds horribly clinical, or whatever – it has meant that we’ve been making more progress. And for the Global Fund, that’s also something we want to see. There’s a couple of other strategic shifts. You know, we are a country and community-led organization. We’re a partnership. So, you know, what are the partnership enablers for us?

And unfortunately, you know, as each speaker and particularly Maximina has said, is, you know, sometimes governments don’t want to listen. They don’t want to look at some of these groups of people. They don’t want to hear what matters. And sometimes the communities that are loud and vocal, they don’t really have much time for children. You know, it’s not sort of part of their sort of – sort of, you know, immediate sort of sphere of concern. So we do find that there is – sometimes these things get lost. And I – you know, I don’t know that we’re going to see the sort of specificity that Chip and – (laughs) – but the power of the – you know, treating this problem in a global way does give us power, because we’re a partnership model.

And so where countries are not sort of leaning in in the way that we’d like them to, we can use the partnership modality to sort of force some of those things. So I hope it will be there. It’s not up to me to decide, but it’s definitely being put on the table often. And we have the youth council, I think as you referred to, so, you know, the report directly into Peter, our executive director. They have directly interacted with the board this time around. So I think the youth voice is very definitely present, and we will see that. You know, it’s not through lack of trying, but I think, you know, the community of people who care about children and who are prepared to do battle for them have – I haven’t seen them be as visible as I would have liked, I have to say. And that’s not because they haven’t been trying, I think. Anyway, let me stop there.

Katherine Bliss: Well, Angeli Achrekar, let me turn to you. You know, we’ve heard a great deal about the high-level meeting and all these – you know, the UNAIDS strategy, the Global Fund’s strategy is coming forward. You know, PEPFAR has wrapped up one phase of work in 2020 and, you know, looking ahead to work over, you know, the next – the next period.

You know, what do you see as the greatest areas of opportunity for the United States, you know, in the context of, you know, what as a country we’ve gone through with COVID over the last year and a half and our domestic, you know, situation, our foreign policy. You know, what do you see as the greatest opportunities for the U.S. to redouble its efforts and really contribute to reaching these global goals related to children and HIV by the end of the decade? So, looking ahead to 2030.

Angeli Achrekar: Great. Thanks so much, Katherine, for that question. And, you know, I just really – just throughout the week just really appreciated the strong focus, I think, that has been throughout the week in particular, on pediatric HIV/AIDS, and what we are going to be doing together in partnership as we look toward 2030 and, you know, with the various strategies that are in place.

We too, from PEPFAR, remain absolutely committed to ending HIV and AIDS by 2030, but also particularly putting that fine focus on children living with HIV and the work that Shannon pointed out so clearly – you know, the work that is yet to be done. I mean, these gaps that exist are devastating. And so we’re certainly focused on that, focused on putting resources where they matter, looking at the data in a very disaggregated manner to make sure that we’re targeting our interventions in the way that we need to, to address those needs.

In terms of the greatest opportunities to reach the global goals related to children and HIV, you know, it’s been said before. You know, we got the tools and the strategies necessary to prevent HIV transmission and to identify and treat children living with HIV. But program after program, country after country, community after community struggle with bringing those tools and strategies to scale. And I think, you know, we heard loud and clear their political issues related – or, you know – political issues related to that. There are a number of different reasons why we haven’t been able to do that. But we remain firmly committed to working with all of you to focus on scaling those tools and strategies that matter for children living with HIV.

As I noted, we’re fully committed to ensuring all children living with HIV are diagnosed, linked, and retained in care, and are immediately started on dolutegravir-based regimes in order to achieve that viral load suppression. And, you know, as was stated in the previous panel, you know, we’re just thrilled – we’re absolutely thrilled about pediatric DTG, you know, and the approval down to four weeks of age and what that could mean to have the superior drug regime for kids available.

So we have been constantly working with our partners to push country teams to transition all children to pediatric DTG as quickly as possible, irrespective of the amount of lopinavir/ritonavir that countries have in stock. It’s just not acceptable to have a superior regime and not push in that direction to get kids there. Currently we have four countries that have already received their first shipment of pediatric DTG. To date we have 19 countries that are receiving their pediatric DTG by the end of this year. So again, we’re actively pushing and pressing in this direction.

I think, just to say one more thing, you know, another area of great importance for PEPFAR is preventing mother-to-child transmission through enhanced access to PrEP for pregnant and breastfeeding women, integration of women’s health services into family planning and maternal and child health service delivery sites and utilizing service delivery sites as entry points for vulnerable sub-populations, including adolescent girls and young women. So I’ll stop there, but again we’re fully committed and looking forward to working with all of you to continue to move the dial.

Katherine Bliss: Well, Angeli Achrekar, Siobhan Crowley, Shannon Hader, and Maximina Jokonya, along with Deborah Waterhouse, Chip Lyons, and Steve Morrison from the first panel, thank you all for taking the time to share your views and expertise. This discussion today focused on reinvigorating global commitments for children living with HIV. And thanks again to ViiV Healthcare for making this event and the associated work possible. Thank you all very much.

Shannon Hader: Thank you guys.

(End)