Photo: © Steve Forrest / IAS
This transcript is from a CSIS event hosted on August 7. Watch the full video here.
J. Stephen Morrison: Good afternoon, good evening, good morning. Welcome to our online audience and the audience of experts assembled here at the Center for Strategic and International Studies here in Washington, D.C.
I’m J. Stephen Morrison, senior vice president here at CSIS, where I direct the Global Health Policy Center. We’re thrilled to be able to pull together this discussion around what transpired recently at the International AIDS Conference in Munich, Germany.
Special gratitude and congratulations to Birgit Poniatowski, the head of the International AIDS Society, that organized a very successful meeting. Kudos to her and her team who worked really assiduously over many months to pull that complex gathering together. We’re also delighted again to be able to join with KFF, previously known as the Kaiser Family Foundation, in cosponsoring this gathering. This is – we’re trying to calculate. This stretches back – this tradition stretches back to at least 2006, perhaps earlier. We’ve been doing this for almost a full two decades. A special thanks to the staff here who worked also to pull this together – Carolina Andrada, Corey Donnelly, and Anna Russin on our staff; and our production team, Eric Ruditskiy and Qi Yu.
We’ll hear from the three speakers in a moment. We’re going to – I’ll introduce them. We’re going to run through opening remarks from each of them. And then we’re going to open the floor for conversation with those who are assembled here. And there’s microphones for that. We will, I think, hear a mixture of remarks about what transpired there, on a mixture of themes, but at a high level I think the conference brought forward a mixture of intense optimism and intense angst. And we’ll hear more along those lines.
The optimism pointing to some very promising technological innovations – long-acting injectables for both PrEP and prevention received an enormous amount of attention. And a lot of discussion around the contributions from the corporate sector in the hopes for access and affordability looking forward. The angst and uncertainty has to do with the broader phenomenon that HIV is a priority – as a priority, both politically and financially, finds itself in difficult straits, with uncertainty hanging over that. There’s been a generational change. There’s the impacts of the geopolitical wars in terms of budgets for – and huge humanitarian and migration demands. There’s climate change.
We’ve seen in the partner countries, and particularly in southern and eastern Africa, the debt load that was accumulated during COVID cutting into budgetary commitments. And we’re seeing here in Washington and elsewhere a sort of populism that’s feeding a reconsideration of the value of engagement in foreign aid and the like, and questions around the strategic purpose of these programs that have been the foundational programs of PEPFAR, Global Fund, and others, which have been now in their second – entering their third decade.
One of the issues that we’ll hear more about also is the question of U.S. leadership. In this period there’s an extraordinary dependence on U.S. finance and leadership here. Roughly three quarters of the dollars expanded from donor sources coming from the U.S. There’s somewhat of a dangerous vulnerability or dependence, particularly depending on what happens in our own elections looking forward. So it’s a – it’s a very important moment, as always.
We’re going to hear first from Becky Bunnell, Acting Principal Deputy for U.S. Global AIDS, Coordinator for PEPFAR, President’s Emergency Plan for AIDS Relief, the Department of State. Following Becky, we’ll hear from Jen Kates, Senior Vice President and Director of Global Health and HIV Policy at KFF. And following Jen, we’ll hear from my colleague Katherine Bliss, the Senior Fellow and Director, Immunization and Health Systems Resilience.
I want to mention that Katherine published a history of the International AIDS Conference in 2012, at the occasion of the AIDS Conference returning to Washington, D.C. after, I believe it was, a 23-year gap. An excellent piece of work. You can still find it on the CSIS website. It’s, I think, the singular most important piece up to that time that tried to take – to make sense of the evolution of this conference over its many years, and how it had evolved. And I think Katherine made a major contribution in putting that piece together and so I encourage you, if you have the time, to go back and look at that.
Becky, thank you so much for all you do at PEPFAR, and thanks for making the time to be with us this afternoon. The floor is yours.
Rebecca Bunnell: Thanks so much, Stephen. And thank you for organizing this opportunity for dialogue. It’s really important after the sort of excitement of IAS to have a chance to actually process it. So really look forward to the discussion.
I was going to just take a few minutes to talk about some of the high-level things that struck me, and I think our team, at IAS, and then link it to our preliminary plans for where we’re going, our journey onward towards 2030. So maybe just to touch upon, like, three major buckets of things from IAS. You know, the first is always the data, for PEPFAR. And I think, as always, the UNAIDS report and what was released painted a mixed picture.
On the one hand, the tremendous progress that we’ve made. And I think those of us who’ve been involved with PEPFAR were very happy to see that while there has been a 39 percent decline globally in new HIV acquisitions, there’s been a 56 percent decline in central, eastern, western, and southern Africa, in the areas where we’ve really had the biggest investments.
There was also cause for concern in the report. We now have close to 40 million people globally living with HIV, of whom just a year ago in the last report, we only had 39 million. So there’s been an increase. We had 1.3 new incident HIV infections in the last year. That’s more than three times our 2025 target for incidents. So we’ve got some work ahead of us.
And likewise, I think in the conference itself, aside from the report, there were a number of data presentations that, again, signaled to the work we have ahead of us, including data around cycling in and out of care, interruptions to treatment, which is a growing concern. A lot of discussion around advanced HIV disease. These are all signals of areas we have a lot of work left to do.
Likewise the area of equity. I’m hoping Jen will talk about it, because she did a wonderful presentation at IAS. But I’ll just highlight a couple things that really touched me. One was an analysis of data from 33 African countries of over 70,000 people living with HIV that clearly showed the links between stigma and reduced engagement in every stage of the HIV care continuum. So clearly, we have our work cut out in some of those areas.
It was also striking to see the uneven progress across countries and regions. You know, if you look at the number of people – since 2010, where have we seen incidents going up? It’s really been in Eastern Europe and Central Asia, the Middle East, North Africa, Latin America. And then there are countries like the Philippines, where we’ve seen 3-400 percent increases. So all of that was, I think, in the discussion at IAS that maybe we need to shift our eyes to some other regions where we haven’t put as much focus.
I was particularly struck by the impact of crises on our work and our successes so far. You know, the impact of war, instability, economic shocks, climate was apparent. It was particularly striking for Ukraine. There was an extraordinary display, I think, from the providers from Ukraine at the meeting of their bravery, their dedication, their work going to trace every last patient – whether they transfer it over into Poland, whether they had to reach them remotely by phone. They were really on top of trying to ensure there weren’t interruptions in treatment.
And during the conference – actually, during a panel that I was on with some of these colleagues – one of their colleagues, somebody that we were funding to do a survey of key populations, was killed on the front line in Ukraine. And they powered on and went forward with the work right there in the conference. And it just it was moving to see their dedication, in spite of all these challenges that they were facing. So that was striking for me.
And then, of course, you know, the big headlines around PrEP. I think we were proud from the PEPFAR side to be able to talk about our experiences doubling the number of people on PrEP in the countries where we work now up to about 2 million people. Also the work that we’ve done in rolling out CAB-LA. And we’re continuing that work. We’re very excited about that. But there’s some valuable lessons learned from that, that I think will help us as we look forward to other opportunities in that realm.
And, of course, a lot of excitement and a lot of sidebar discussions, both with Gilead and others, around lenacapavir and the promise that it holds. I think I was reflecting on the fact that, you know, throughout our response to HIV there’s been these wonderful moments of technological, or innovation on the sort of research and development side. Our challenge is to match that innovation with implementation innovation, and to really think strategically about how can we make sure there’s equity and who reaches – who this new products and new tools reach, but also innovation in the models of service delivery?
So we could – I suspect we may talk more about that, but there’s a lot of things we have been thinking about since then, and even during that week, about, OK, how can we get things moving? What are we going to need to do? And we’ve got a long list of what we need to do to get there. I think the other – the third and last thing I’ll just mention from the main meeting that really struck me was the conversation around sustainability. This is something we’ve been talking about a lot, you know, within the PEPFAR family.
But there were two major things I saw that gave me hope. One was the engagement of youth. We had a number of engagements. Ambassador Nkengasong on had engagements with youth. And obviously when we’re thinking about sustainability part of it is really bringing in a new generation and ensuring that they’re going to be poised for protecting themselves in the future. And there were some very strong youth champions, which was marvelous.
The other thing was I had the opportunity to attend a few – both a satellite session and then a sidebar discussion with leaders from countries focused on sustainability. In the satellite session, I think there were seven countries – Mozambique, Zambia, Kenya, Tanzania, Nigeria, Uganda, Zimbabwe. And in each of their presentations, leaders – either the minister of health or the head of AIDS control program – really laid out what they were doing, thinking about sustainability beyond just the sustainability road maps, but other concrete actions. So that gave me a lot of hope.
Likewise, a panel with the national AIDS control leaders. Still a lot to do here. I think we’re going to need to see, you know, how things play out in sustainability. And we need to be clear on what are going to be the areas of continued, PEPFAR, multilateral, global support that are going to be needed going forward, because there clearly are areas of need that will remain. But I was struck and very pleased to see that those dialogues were happening.
So let me share, just thinking about all of those observations, just a couple things that we are doing within PEPFAR that we unveiled both in the meeting in Munich and subsequent to that. We’ve had several convenings with various stakeholders in the last week, week and a half, to just kind of paint out where we’re going, given all that I just mentioned. One is that PEPFAR just announced an action plan for key populations. It’s on our website. Happy to talk about it if we want any discussion.
But it’s got four different components. The main thrust of it is to really embed some sustained amount of funding to support key population work going forward, because we see this as essential for the response, essential for equity. And we wanted to do something beyond a kind of one-off commitment. So I think that, which we had worked on prior to the meeting, really met the space that was presented at the meeting.
The other two things – and I do have slides if people want to see it – but I’ll just say that Ambassador Nkengasong kind of showcased – maybe we will pull up the slide – the future state goal for PEPFAR. And what are we thinking? This is still a draft, but our vision for where we would be in 2030 and beyond is really a state where the large majority of HIV prevention care and treatment programs will be led and delivered by government or by other domestic entities, with community engagement and government accountability. And that’s sort of the north star that we’re driving towards.
And then we also released our still draft framework of what our next two-year country operating plan process will be looking at, both in terms of the goals of sustaining the gains, accelerating progress, and advancing sustainability, and some of the how as how we would get there. So you can take those down now. You can stop the slides. I’m just going to stop them there. Thanks.
So I wanted to just give you a glimpse of that because I think we felt quite validated – and we’ve tweaked a little bit what we came into Munich in based on what we heard – but we felt quite validated by what we heard from the global community at Munich that we’re leaning in the right direction in what we’re forecasting as our journey to 2030. So let me stop, Stephen.
Dr. Morrison: You had an intense meeting beforehand.
Dr. Bunnell: Yes.
Dr. Morrison: What were the messages being conveyed by your partners to you, that were at all surprising to you?
Dr. Bunnell: Yeah. They were not part of that meeting. In the pre-meeting we had, it was just an internal meeting of the PEPFAR family. We have subsequently had some engagements. Just last week, we had engagements with some of our implementing partners. Yesterday, I think at seven in the morning, we had engagements with ministry of health leadership from around the world. And then we had a larger engagement yesterday morning with civil society.
And I think I was surprised that – let me start with implementing partners – that, you know, large implementing partners, who could have seen this as a threat, were engaged with us that, yeah, this is the right direction of travel. This is – we recognize that this is the way we have to go, even though it may mean changes for their institutions, their organizations. I think the ambassador received strong validation of that direction of travel. Similarly, from the ministries of health yesterday we also received that.
You know, always there’s some concerns that individual countries may have, et cetera. But I think in general we’ve heard a lot of support. The ambassador’s message, which is an important one, is that we have to be bold, and we have to be courageous to evolve in the direction we need to go at this point. Yeah.
Dr. Morrison: Thank you. Thank you very much. Jen Kates.
Jennifer Kates: Great. Thanks, Steve.
Dr. Morrison: We’re back again.
Dr. Kates: We’re back again. Thanks to you and CSIS for partnering with us. I could – we could not figure out for how long. And thank you for doing this while I was trying to make my way back to the U.S., and getting this set up.
So I’m going to probably echo some of the things we already heard, but add a little bit more from my perspective. So this was the 25th International AIDS Conference. And it is the largest HIV conference in the world. And I went back to look at sort of how – I just left the governing council, so I finished my service there. But I was looking back at how we describe it. And it says, the conference, quote, “sits uniquely at the intersection of science, advocacy, and human rights, bringing together scientists, policymakers, healthcare professionals, people living with HIV, funders, media, and communities.” And I think that’s a really good, long sentence. But it really does capture what is fairly unique about this particular conference, which itself was first held in 1985.
In terms of the Munich Conference, to me this was the first truly post-COVID conference. The Montreal Conference two years ago, we were still, I would say, in a pandemic and still – you know, a lot of it was hybrid and there were a lot of other questions and considerations. But this is truly, like, we’re out of that phase. And so, you know, back in 2022 there were shifts underneath – you know, the ground was shifting, but I don’t think it was clear how permanent and what those were. To me, one of the big take-homes from Munich is the ground has shifted, and we can see what those shifts are, and they’re permanent. And I’ll come back to that.
So just the three things I wanted to touch on. One is the theme of the conference. Two is some more on the new science. And three is this larger picture. So on the theme, just important, I think, to emphasize or mention to those who weren’t there, the theme was deliberately chosen to be put people first, to focus on those who are most affected. This was a really, you know, important decision that the conference organizers came up with and wanted to do, which reflects what’s happening, I think, in the larger HIV discussion about how programs are designed, how countries are pursuing their goals, how donors are, that really putting people most affected at that center and leading that conversation is going to be what’s needed for success.
Also, and you mentioned this about Ukraine, the conference itself – so when we – when Germany was chosen, one of the reasons Germany was chosen was so that a spotlight could be put on Eastern Europe and Ukraine. Since the conference couldn’t, obviously, be held in Ukraine, there was a really strong feeling that it would be important to showcase – highlight, showcase, allow people from Ukraine to be there and talk about their experience. And of course Andriy Klepikov, who many of us know, is on the governing council but was also asked – selected to be the regional cochair. So he was very prominent in the conference itself.
And it meant that throughout the conference there was a really, I think, important emphasis on what is happening in conflict situations, with Ukraine being the main example. But that was at, you know, everything from the opening ceremony to so many sessions. So it was really powerful. And the anecdote you told probably being the most powerful. Also, I remember I think it was one of the main sessions where the we saw a hospital one day and then the next it had just been destroyed – a children’s hospital. So that was very powerful.
A quick note on the new science, because this conference, as it has evolved over time, is not really where scientific breakthroughs are brought, to this conference. Scientific breakthroughs now are on pre-pub documents on the internet or at very science-focused events. So we don’t always – I don’t think of this conference as the place where we’re going to get a lot of new science. However, we got some really powerful new science that was exciting to hear and think about. We’ve already heard, the first being, you know, the PURPOSE 1 results. It was the double random control – randomly controlled clinical trial, double blind study, a twice yearly injectable, lenacapavir.
I’m just going to say a few stats from it, because to me it’s really powerful that you can put together this kind of clinical trial. Over 5,300 cisgender adolescent girls and young women ages 16 to 26 in South Africa and Uganda – double blinded study. And that alone is a big feat, to put that together. And then, of course, the most exciting, it demonstrated 100 percent efficacy. And I actually am not aware of – I’m sure there has been – but I’m not aware, certainly in HIV, of there ever being 100 percent efficacy of a clinical trial result. It’s truly an unbelievable achievement.
And you can see that when it was talked about, when Linda-Gail Bekker got to present it initially, just the emotion that was in the room to have achieved this was – you could feel it. So that was very exciting. But the conversation, I think what was really important, was – it was all about we can’t fail now. We have this incredible intervention, which we’ve had different versions of it since 2012 and have largely, until recently, not reached most people with it. We now have something that we know cisgender women want and use, and it’s 100 percent effective. What are we going to do as a community to get it to people? And so most of the conversation was on approval and pricing and roll out. And it was a hard conversation. I don’t – there’s not really good answers yet, but there’s incredible focus there. So that’s – to me, that’s going to be the next – the big emphasis for going forward.
There’s also PURPOSE 2, a companion trial is still running, which is taking place in Argentina, Brazil, Mexico, Peru, South Africa, Thailand, and the U.S. Same, you’re looking at twice yearly len. And this is for cisgender men, transgender women, transgender men, and gender nonbinary individuals. So hopefully we’ll see those results at the end of this year, early next. And hopefully they will also be as exciting, because that would just, of course, change our – would greatly expand our ability to prevent HIV.
There was also another cure announcement, the seventh example of some – a person who’s been effectively cured of HIV. This was the second Berlin patient. And this was, from a science perspective, very exciting. A new – the case was a 60-year-old German man living with HIV who had was diagnosed with leukemia and therefore had a blood stem cell transplant. This took place in 2015. The donor – so this is very technical, and I’m going to try to be very high level. And this is not my area of expertise. But the donor had a particular gene mutation that is notable in part because it was not fully immune to HIV. In any event, the patient stopped taking antiretroviral therapy in 2018 has had no virus since. So is effectively cured.
This was – this is a big deal. It’s a big deal from the science perspective, not from an immediate clinical perspective. It’s not like – you know, most those people with HIV don’t fall into needing stem cell transplants. That’s not a – it’s a risky procedure. It’s not one that is a clinical reality at this – for this – for a cure. But what it did show was the direction of research and the possibility, increasingly, of gene editing techniques and other ways that we can potentially approach a cure. So from a science perspective, I think it was really exciting.
But for me, and probably for this audience, the bigger issues were the larger discussion around, what do we – what is happening? And as I mentioned, I think there’s been this permanent shift that is now quite evident, which is, you know, the post-COVID world has left us quite vulnerable in the in the sense of distrust and mistrust of public health and science. Which is not a good place to be. And there’s this significant questioning of the global health landscape, not within the HIV world itself but around the HIV world, that just had not really been there. There’s always been starts and discussions, but this was really that, to me, was that conversation has happened. It’s there.
And it’s defining everything – whether it’s the future of the global health initiative that was – that from this past year, whether it’s focusing on climate change and all of these other challenges. There’s a real shift away from looking at disease specific programs looking at HIV. And these are seen often as the programs of yesterday. Donors are questioning, how long do we need to be doing this? PEPFAR reauthorization, you know, just watching that play out, multiple replenishments. All the things that I believe everyone here knows, but it just taken together these are troubled waters, in a sense, for HIV that have to be figured out.
There was also attention to the financing gap that still exists that UNAIDS documented. And from our part, we released our annual report on donor government funding, which just the main top line that I think is the biggest takeaway is what we’ve seen over multiple years now that, just is affirmed from the data, is that donors other than the U.S. are really pulling back from HIV. They have definitely reduced their bilateral support in favor of multilateral Global Fund support, which is – I think – I don’t have any judgment of that. I think that’s – there’s different ways donors approach addressing HIV.
However, their shift to the Global Fund has not fully offset their declines. So the pot is shrinking, and it’s below the high-water mark that we’ve seen. And the U.S. therefore is shouldering much of the financing burden. And so it creates even more sort of vulnerability or just delicacy around what that means – whether we’re talking about sustainability, or country ownership, or sustained attention to all of the issues that we’re – that we care about.
Other things that were highlighted at the conference – and I thought the conference did a really good job of pulling this through, was the emphasis on, as you mentioned, equity and structural challenges. And all of those really hard things that are not just about, you know, we have the science, or how many programs we have, but all of the really often intractable challenges embedded in different countries and different societies that are – and are in the U.S., that are preventing people with HIV from getting the services they need and putting people at risk for HIV.
So this was a huge theme that came up in many sessions. Equity was a huge theme. And it’s not that equity hasn’t been talked about before, but I felt like there was more attention to equity in a substantive way. It wasn’t just a term. People tried to define it. People tried to demonstrate where it made a difference and what it meant. We were – as you mentioned, we were involved in a report that UNAIDS and PEPFAR really pushed out looking at a range of issues around equity and HIV. And there were some really positive things that were found and some challenging ones.
So on the positive side, data show that where HIV programs exist in low- and middle-income countries, they are more equitable than the general healthcare system. That’s great. That’s a really – that’s an important finding. And it shows that some of the things that PEPFAR and others have been doing have really created a more equitable rollout of interventions than the health system. The flip side of that is what happens if HIV is fully integrated, or more integrated into those health systems? And that was an issue.
And another analysis in our report looked at that and said, well, where is – how is integration playing out with HIV? And found really positive results, except where there were structural barriers. And whether it was homophobia or other structural barriers, integration was not as successful. So these are things I think a lot of us have been talking about, but there were data to sort of back it up. We also worked out a report – part of this equity analysis looking at key populations. And one of the main takeaways was among – there are several things in there, but one was that addressing HIV among key populations has really suffered from not having durable funding and not having a durable focus.
And, lo and behold, right as we were putting this out there, PEPFAR announced, I think – which I think is the first intervention that will be a sustained – attempt to sustain funding embedded in budgets to address key populations that has existed. I mean, there’s little – there’s some semblance of that with the Global Fund, but it’s a little bit different. So that’s, like, a major step, I believe, in addressing this challenge.
So I’d just, you know, conclude by saying there’s no easy answers, but the fact that the conversation has shifted – and everyone, I think, recognizes this. I think there was resistance two years ago at Montreal to admit that things were changing. And I feel like as a global community working on HIV, there’s consensus or near consensus that that has happened. So the next step is really to try to figure out what does that mean, who defines it, and what are the implications for HIV. Thanks.
Dr. Morrison: Thanks so much, Jen.
Katherine.
Katherine E. Bliss: All right. Well, thank you very much for the opportunity to join this conversation today. I think I’ve done some variation of these since 2008, so it’s good to have a chance to compare and think about the conferences really over a 15-or-more-year period.
You know, over the period – looking at the history of the conferences and really attending a number of them since 2012 – it seems that the factors that really kind of make for a successful conference, in a lot of ways, include many of the factors Becky and Jen have already talked about. The major scientific breakthroughs, a focus on the immediate region, high-level political engagement and commitment, and meaningful civil society engagement.
And, you know, looking back over the history, particularly kind of the more recent history, some of the conferences that really stood out included Vancouver in 1996, when, you know, there was big news about the potential for antiretroviral therapies. Durban in 2000, with very significant continental civil society engagement and a real demand for access to those treatments that had been discussed four years before in Vancouver but still hadn’t really made their way to basic programs. And then Washington in 2012, really centered around the return of the conference here to the U.S., and the removal of visa restrictions that really allowed people from country – people living with HIV from countries around the world to attend the conference here.
So, you know, that’s how – a lot of things have changed since 2012, and especially since the pandemic, and even since the Montreal conference in 2022. You know, I think one is that the recent – or relatively recent concentration of the conference in host cities in Europe and North America has made it expensive for people to travel and participate in the conferences, particularly people from civil society or nonprofit organizations that aren’t able to kind of access sponsorship to participate.
Second, and I think Jen mentioned this, you know, the era of online publishing and pre-prints kind of steals some of the thunder from the sessions announcing the big scientific breakthroughs. So there is the conference every other year that is specifically focused on the science. And, you know, but yet, you know, that doesn’t mean – I mean, certainly the sessions focused on PURPOSE 1 and others really had a lot of energy and attention. But it does kind of steal the news from those. And at the same time, you know, the hybrid engagement is kind of a double-edged sword. At their peak, the conferences, I think, attracted more than 20,000 people. I think the one in Toronto in 2006 had something like 26,000. And the number for Munich was closer to 11,000.
So, on the one hand, certainly livestreaming the sessions makes them simultaneously available to people who have the digital registration. And so people can really kind of follow the conversation and participate. On the other, you know, given the pressures on civic space in so many countries around the world, around freedom of expression, freedom of assembly, the conference, you know, really does serve, as, you know, if not, like, right there in the plenary sessions, at least it’s kind of a – you know, a hub for people coming together either before the meetings, or on the sidelines of the meetings, or, you know, in and around the sessions to meet, and share information, and strategize and think about, you know, kind of how to build alliances and move forward policy goals. And so, you know, the hybrid engagement, I think, has pluses and minuses over time.
I think this conference, you know, to me stood out for several things. You know, one was, you know, really, the overarching theme was, put people first. And I thought that, you know, the plenaries, the satellite sessions, the workshops, the side events, everything really did a very good job of weaving that focus and that sentiment into, you know, many different aspects of the conversation itself. Certainly, there was considerable excitement generated by the results of the PURPOSE 1 trial around the long-acting lenacapavir for PrEP. But, of course, tempered by the recognition that products have to be acceptable and accessible in order to really change the trajectory of the pandemic.
We did see some high-level political engagement, notably the in-person participation of German Chancellor Olaf Scholz at the opening session, and his commitment to the Global Fund, and his call for, you know, engagement with other donors, for other donors to maintain their commitments, and step up as well. There was the announcement of the Barbara Lee Political Leadership Award that featured Congresswoman Barbara Lee as the first award recipient at the closing session. And that’s something that will continue over time.
And then on regional issues, as Becky and Jen have mentioned, I mean, there was certainly a high, high focus throughout many different sessions on the negative impacts of the conflict – of the war – or the conflict and war in Ukraine on access to HIV prevention, diagnostics, and treatment. But at the same time, because, you know, the focus really was on Eastern Europe and Central Asia, there was considerable discussion about how the greatest number of people in Europe living with HIV are in Russia, but there’s so little information about what’s actually happening in the country. So quite a bit of focus there.
And it seemed to me that the conversation around political and legal issues has really deepened at the conference over time. Certainly, from the last time the focus was on Eastern Europe, which was in Vienna in 2010, when the theme was human rights right now. At this session, I attended a number of panels and other conversations really focused on the decriminalization agenda and the role of structural barriers in the transmission and treatment of HIV. And these sessions included, you know, not just academic researchers, but judges, lawyers, sex workers, and activists. You know, people really bringing a depth and, you know, cross – you know, many different kinds of experience to the conversation.
And I thought, you know, they did a really exemplary job of not only sharing research and experience on the ways that the criminalization of HIV transmission, sex work, migration, drug use, and many other aspects, you know, of just daily life negatively affect everything about HIV – from prevention and access, to treatment, to really data acquisition and analysis. And so you know, over the period of the conferences, you know, it seems to me that that track focused on the political and legal issues has really deepened over time, to complement both the science and the policy and behavioral work.
So I’ll stop there and look forward to the conversation.
Dr. Morrison: Thank you. Thank you. Well, this – you’ve covered an enormous amount of ground here. I want to get back to the bigger question around if the ground has changed so significantly, and there’s a consensus emerging around those realities and an awareness of what’s driving it. And those factors that are – that are making it more difficult to sustain political and financial support are not going to ease. They’re not going to go away. They’re not temporary.
It has raised the question of, well, then what is the strategy going to be? And how is that strategy going to reach powers outside of the community that was represented in Munich to change the thinking and choices? Having Chancellor Scholz show up was, to my mind, monumentally important. And Birgit Poniatowski deserves an enormous amount of credit for being insistent that the high-level political leadership be there to register the support, because the high-level leadership has been missing for so many years. It’s been years since we’ve had any significant African high-level leadership at these – at these conferences. And it’s – and it’s a problem.
So the question of what is the strategy, and how would that strategy reach the most important decisionmakers – whether they’re the White House, or members of Congress, or leadership in other countries, that strategy, it seems to me, can focus on the technological changes, but there it’s, how do you accelerate – the questions around the PrEP and treatment changes, the long-term injectables, there’s a long wait there for this to come into force. And there’s a lot of uncertainty.
But if it comes into force, it can change the – change the equation of new infections to some degree, it’s hoped. Are there things to – that can be done now to capitalize on what we saw in Munich that would deepen the awareness of what this means among those outside of this expert group, but also things that can be done to accelerate the process? I don’t – maybe it doesn’t lend itself to that because of the way regulations and licensing and other things are done. Is there more that can happen at the level of diplomacy? I know there’s been discussion around a summit that Dr. Nkengasong has talked about. Is there a way for – to take this to the next level in terms of our diplomacy? Because we haven’t – this argument needs to be carried to another place around the threats to sustaining HIV, and the opportunities that are still there, and the values.
So maybe, Jen, you can say a few words, and then Katherine and Becky can say a few words. What is your thinking on what the strategy for this moment needs to cover or be in this period? Because we haven’t really answered that question. We’ve had a shift of consciousness. Denialism has given way to awareness and acknowledgement of what’s happening. But we don’t yet have a clear strategy.
Dr. Kates: I’ll give it a try.
Dr. Morrison: OK.
Dr. Kates: Some things I’ve been thinking about that, in my mind, are steps that should happen, but also, I think, are part of a strategy to remind or renew or change the direction. Everyone is talking about sustainability. That is – you know that is another shift that has – it’s solidified. Everyone talks about sustainability. There’s been a lot of work done to define sustainability, talk about what it’s going to look like. And it’s interesting to me that there’s such an emphasis on it coming from Congress now, coming from outside of the U.S. But if you – if you look broadly at all of the U.S. programs, not just PEPFAR, no U.S. development or global health program has figured out necessarily what sustainability is.
So I think there’s a real opportunity for PEPFAR to lead on this and to be the program – the U.S. program that could be a model for how this is done in lots of different contexts. That in some contexts that model is the U.S. government’s going to be there for a very long time because of these reasons, and other contexts it’s here’s how the off ramp is going to go. But I think PEPFAR has a real opportunity to do that and play that role. That would not only show that it’s putting – you know, it’s not just talking about, it’s actually walking the talk. But then becomes a model for other U.S. global health and development programs and other non-U.S. programs. Global Fund too could do this, although Global Fund model is so different that its approach to sustainability has to be different. So I think one is that.
Two, I think there – we lose in this – the conversation that’s shifting and the discussion of all the issues that are out there and all the multiple challenges, forgets one thing. Which is ignore infectious diseases at your peril. We have to remind people what we’re talking about, and that this is not just – if we ignore HIV or any virus for which there’s no cure, there’s a huge risk there. And so we have to remember, I think, that argument.
Dr. Morrison: And that’s a strategy for bringing the threat back. Because the threat has disappeared.
Dr. Kates: It’s not – the threat has disappeared. And it’s – and I don’t – I don’t think it’s an easy – always an easy argument to make, but it’s truly the case from history and from just the way the viruses interact with humans that if you ignore them when they’re not – even when they’re getting to low levels, once you pull back we will have increasing cases. It just that’s the dynamic. And you can see that playing out in different places in the world at times, and with different viruses as well. So I think just reiterating that and reminding different stakeholders of what that looks like. It doesn’t mean the programs that we have have to be exactly the same or look the same in five years, but it does mean that that has to be a part of this – you know, top of mind in thinking about the future.
One of the key messages that came out at the conference, but one that I think many have been emphasizing, is real – this is increasingly going to be – HIV is increasingly going to be something that’s affecting those remote – or, the people that are hardest to reach. And this is not – I’m not saying everyone knows this. But that, I think, has to be a focus going forward. And who’s hardest to reach might be different in different places – I’m looking at Katherine and thinking kids, in many places. But who is hardest to reach has to be front of mind in thinking about the future.
In terms of accelerating the innovation rollout, it’s true that there was a lot of, you know, concern. What’s going to happen? Are we going to get len out to women who need it? And it’s also important to remember that the accelerate – the pace that it’s operating on now, in terms of the thinking that, I know, Gilead is involved, and others, around what has to be done on the regulatory side and all, is so much faster than has ever happened before. So that’s really a testament, I think, to the movement in the past. And that becomes also a model not just for HIV, but for how to roll out interventions and innovations outside of HIV. So those are just some initial thoughts.
Dr. Morrison: Thanks. I mean, it seems that because of this emphasis on the threat to other regions – Eastern Europe, Central Asia, Middle East – that was at the forefront of the UNAIDS analysis and the forefront of talking points, that that creates a different context in which to put this on a global stage beyond the public health community or the HIV community, to others to engage and to put it into other contexts.
I also think that we’re going to – you know, we’re going to have – we can foresee other bumps in the road, right? We’re going to be – we’re going to be back at the reauthorization for PEPFAR in March. The replenishment for the Global Fund and the other replenishments are going to begin to unfold and are likely to be rocky. So there’s going to be turbulence that should be anticipated, but also be part of the strategy of trying to get people to take another look, right, because it will only intensify the sense that things are at risk.
Katherine, your thoughts.
Dr. Bliss: Yeah, just thinking about the rollout of new innovative tools. You know, I’ve been thinking about this with respect to the news that came out around the PURPOSE 1 trials, but also in comparison with what we saw during COVID with new technologies and the COVID-19 vaccines. And, you know, I do think there’s an important and urgent need to really pay attention to the trust and confidence environment, and the potential for misinformation around new technologies. I mean, we’ve seen this any time there’s a new technology rolled out and vulnerable populations are being asked to, you know, take this on, that, you know, immediately there are social media campaigns and others that that raise questions and doubts.
And so I think, you know, there is an opportunity to – you know, as the regulatory process is unfolding – to raise awareness and to provide education, and really, you know, work with vulnerable populations and community providers to, you know, help create awareness and understanding, you know, about the potential and what different options people may have around prevention.
Dr. Morrison: Becky, what’s in the works in terms of your plan to take advantage of what was learned and said, and carry it internally and externally to the Hill, to other parts of the administration, most importantly, the White House? How do you see the opportunities here? We’re in the midst of, obviously, a big national election. That complicates things. But all of these challenges are fast upon us.
Dr. Bunnell: Yeah. Let me start with just picking up on what Katherine said, before going up to that bigger picture. I mean, I think if we could look specifically at lenacapavir as an example of a new innovation, what are the kinds of things we can do to get that out and get it into action as quickly as possible? And, like you, I was impressed that I think there’s a real intention across the board – all the players, pharma, civil society – everybody kind of coming together to figure out, how can we do that.
So on the PEPFAR side, I mean, some of the things we’re looking at and leaning in to support that constellation of players to do include, you know, some of the nuts and bolts around how can we accelerate, you know, licensing and transfer to generics? How can we ensure that there’s accelerated filing in priority countries, that the WHO guidelines get moving? I think thinking very carefully about who is going to benefit most in an epidemiological and programmatic and equity sense, and making sure we get the limited product to those people, is going to be very important because, you know, if I can speak in epidemiological terms, the number needed to treat for any prevention intervention is much bigger than using treatment as prevention and preventing an infection through that. So, you know, we’re going to need to be careful about that equation, and how we really focus on those who need the benefits of this most.
Obviously, volume and price are going to be big barriers or facilitators of a rollout. But I think, you know, on the PEPFAR side, we’re all in and trying to start thinking about, as I mentioned, we’re doing a two-year planning process. So what can we do now or in the very near future in collaboration with others to figure out some of the implementation and operational issues, so that, you know, we’re innovative. Is this going to be a community outreach campaign approach? Is it going to be a facility? What are the various models, and how can we get those to the people who need them the most? So I think all of that is stuff that we’re absolutely in conversation about and thinking about, and will be part of our conversations as we work with countries to do their next two-year plans. Because now is the time – if things move at the accelerated pace we all hope – now is the time that countries need to plan in their budgets to be ready to roll with this. So there’s a lot to do in that space.
Bumping up to the sort of broader space that you alluded to, Steve, you know, in terms of, you know, how do we talk about this to – on the Hill and other places? I mean, I think, as I mentioned, I was fortified by what I heard at Munich around sustainability, that I think there is a real interest and desire in our partner countries to be partners in that process. So I think we need to really build out that narrative, get it clear, and be able to communicate that we are working on it. But that ultimately, sustainability is not all about financial sustainability, because, you know, a country like Botswana, yeah, we can probably get there, and we’re working with a cohort of countries to get there. But Malawi and other examples of countries that are, you know, really in that lower-income status financially are not going to be able to pick up the tab.
So educating folks about what the future role is going to be, there’s always going to be a need both for some financial commitment but also help to translate these new innovations, help to ensure that there’s equity, and that civil society and key populations aren’t left behind. There are going to be important roles. They’re going to evolve from some of the things PEPFAR has done at the time when we were just focused on an emergency response to what can we do now as we’re evolving to this future state? But making that narrative clear.
You know, and we would take advice from others about to what extent is it important to bring in some of the other real factors, like the role of China or other players, the security dimensions of what PEPFAR and the global response provides. You know, there are other ways to kind of discuss the benefits and needs as we go forward.
Mr. Morrison: Thank you. I want to encourage – I’m going to ask one other question, and I want to encourage anyone in the audience who’d like to offer a quick intervention. We have a microphone over here. We have a half hour remaining in our program here. So please, please, do take that up. We’d love to hear from the audience.
The sustainability argument you hear all the time, what we don’t – that sustainability drive is suffused with tensions, right? I mean, people don’t – people are reluctant to talk about 2030 as a major pivot point. People are reluctant to talk about the what-ifs. What if these countries aren’t prepared to take on the burden of responsibility and ownership that would be implied by making 2030 a pivot? And we do have, you know, on the Hill increasingly not just Republicans, but we’re hearing – you know, we’re hearing more pressure around what’s the – what’s the vision and plan? This shouldn’t be open ended.
And, yes, the key populations have to be – have to – there has to be a strategy that takes that all into account and doesn’t abruptly get ruptured somewhere along the way. But we’re heading pretty fast towards 2030, and this – the critique is taking form. And it seems to me that conferences like this one show you that there’s still a lot of ambivalence about really taking that on with what is the narrative and the strategy, but it also gives you new ammunition in your argument.
Like Jen, if you were to go to the Hill to face those who are concerned but skeptical or want to see more evidence, what would you say came out of Munich that would equip you to make a case for – to address those concerns about what’s the value for money? What’s the long-term vision here? How is sustainability going to be translated into some sort of pivot?
Dr. Kates: Well, I’ll answer quickly because there are people who are going to ask more questions. You know, there was such – the discussion on sustainability at this conference was so much more substantive than it has been in the past. So I think one of the messages is there’s a real conversation about sustainability. And what – Becky, what you said about so many of the panels I was part of that had African leaders, in particular, on them talking about sustainability in a serious way, from – what it meant from their perspective, how much they were very focused on country ownership and all the things that we – so it really wasn’t just coming from the Global North. And so that was a reality. So I think getting that reality to the Hill and other stakeholders who might not be aware, I think, is really important.
The other is sharing more details about what does sustainability look like. And I think finding a way to not just talk about the sustainability plans that PEPFAR is doing, but also underscore that sustainability is a dynamic concept. It’s not something – you don’t turn off a switch and then never turn it on again. You don’t – it’s not a – there shouldn’t be a cliff. It really is dynamic. And there’s reasons why it’s dynamic. So there has to be – that conversation has to happen.
And I think the last, which I believe was on one of your slides, Becky, that you showed, it has to be a differentiated approach to really convey that there’s – we’re talking about many different contexts and many different populations. So sustainability – real sustainability is going to look different and has to take on a very unique character in different contexts. Those are some of the things that came out at the conference that I think, I guess, stakeholders outside of our community aren’t as aware of.
Dr. Morrison: Katherine, what did you think? What came out of the conference that could be brought to the Hill today to answer critics or skeptics?
Dr. Bliss: I mean, I was really encouraged to hear the conversation about integration of HIV services with primary health care. And I know health systems is not a selling point on the Hill necessarily. (Laughs.) It’s hard to describe. It can be a little murky. But, you know, maybe primary health care is an easier concept to digest. But there was a lot of discussion about, again, you know, also the importance of tailoring that kind of integration. Some places where there’s a really high burden of HIV still, maybe it does make sense to still have services that are somewhat, you know, focused on that. But in in districts or subdistricts, where cases are very dispersed, I mean, integrating health personnel and services into the primary health care system benefits both systems, and really, you know, can pave the way forward for a sustainable approach. So I felt very encouraged by what I heard there.
Dr. Morrison: OK. Becky, did you want to add anything?
Dr. Bunnell: Just picking up on, Jen, your point on how dynamic this is. Again, going back to Ukraine, you know, it’s an example of a country that was sustaining their own and funding – fully funding their own antiretroviral treatment needs, et cetera. And when war hit, suddenly all that fell apart. And had PEPFAR not been there – I mean, we were able, with USAID’s implementation, within five weeks to provide antiretroviral treatment for all of the Ukrainians who, honestly, would have all fallen out of care had we not been there. So, you know, thinking about the fact that these shocks – until we have a vaccine or a cure, these shocks to the system mean that you’ve got to have some backup system. So just on that – on that front, adding that.
Dr. Morrison: OK. Thank you.
Let’s turn to our questions. Please identify yourself and please be brief.
Catherine Connor: Oh, a struggle there, but thank you. I’m Catherine Connor with the Elizabeth Glaser Pediatric AIDS Foundation. Thank you for providing your reflections and thoughts today. I was in Munich, and I learned a lot. So very much appreciate it.
I have sort of two questions. One, predictable. One, a little more provocative. One of the inequities you did not address was the data that was revealed on pediatric treatment, the fact that the pediatric treatment gap between adults and children is actually growing, not shrinking. And, of course, the impact on that is the mortality rate. Children are still only 3 percent of the people living with HIV but 12 percent of mortality. But this isn’t something that came up. I’m curious if there was anything at the conference you saw or heard that made you think a little bit differently about this problem and how we can address it better.
My second one is about the reflections you gave on the conference itself. I think all of you sort of touched on the fact that the real alchemy of the conference is it’s one of the few forums where science, implementation, and community come together and really bring those conversations to life. And I think we saw that in particular with the PROMISE (sic; PURPOSE) study results, how that impacted the room. But also with the smaller sessions on integration, or even digital health and AI, how that could change the rate of the epidemic. I’m curious, though, as this becomes more complicated, as we’re bringing in things like sustainability, operational models, fiscal budgets, even primary health, is this conference still the right place to have these big discussions about HIV and the direction it’s going? Or are we now kind of losing the momentum that that conference usually brings, it brings focus and energy to a topic we all really care about? Thank you.
Dr. Morrison: Shall we respond to those, and we’ll come back to our next question? Who would like to jump in on this?
Dr. Bunnell: I’ll jump in for a second, because I was – you know, I was mentioning some of the data from the UNAIDS report. I mean, I almost had tears reading about 120,000 pediatric infections in the last year, you know, because that came out as well in the data. And that is a winnable battle that we should be able to reach. And I know there are people in the room – my colleagues, I’ll ask Hilary or Michelle, if they want to jump in – who can speak to this more.
But I think I personally probably would share your observation. I didn’t hear enough about that, even though – we had some sidebars on that. I just may have missed those sessions. But I agree with you that this is something we need to make sure we’re mobilized to do, because we should. It’s – anyway, don’t get me going on that. I agree with you. And I would invite Michelle and Hilary to jump in, because they may have seen things I missed.
In terms of your other comment, which I think was also really good, part of what I was thinking is, you know, as we’re moving into this space where it has to be more multisectoral, are we gathering the right constellation of people to have that dialogue? We did have some sidebars at Munich to think about, OK, based on this, what do we need to do at UNGA, at the U.N. General Assembly? Who do we need to convene? What do those conversations need to be? So I think, yes, you are – you are on to something that we also felt.
Dr. Kates: Yeah, I’ll jump in on that. I think it’s a great question. I’ve been asking myself that as well. And I was thinking about it and putting it in the larger context of what – our conferences have really changed. And not just this conference. I mean, the role of the conference has changed after COVID. And so I think every gathering is grappling with what does it mean to come together in person? How necessary or not necessary is it? As well as the composition. I don’t have a good answer for it. I think there’s still a demand for this gathering. But I agree that if the – something that both of you said, if the conversation remains in one lane – not that it’s – I’m oversimplifying it – we really risk not being – not really moving forward. So and that is probably a good question to take to the new governing council of the IAS, what is the vision of the conference in this new point?
Dr. Morrison: Katherine, you’ve looked at the evolution of the conference over the years. What are your thoughts on the direction the conference would move, given this – the emergence of all of these other dimensions?
Dr. Bliss: Right, I mean, yeah, the conference has changed a lot since 1985, when it was very focused on research. And then by the late ’80s, you had, you know, activist groups really being very disruptive and, you know, demanding a voice at the table. And, you know, conferences were very different in the late 1980s than they were by the late ’90s or into the early 2000s. And, you know, early 2000s, you know, we kind of saw the politics of plenty. And there was lots of funding going towards HIV. And it was kind of a celebratory period. Then there was kind of austerity after 2010. And now I think we’re in this post-pandemic moment where there are a lot of questions.
But it’s always kind of moved through phases. And so, you know, the point is, really, I think, to come back to the people it serves and ask, what is the vision, you know, going forward? And how to make it most responsive to the people in need.
Dr. Morrison: But the call for it to be less self-contained, less insular, and more outward, and more – and bringing in new interests and new dimensions of the response, whether those are AI, or whether they’re high-level political leadership, or whether they’re, you know, other constituencies that are now seen as having a greater stake in finding solutions. What I was – what I think Catherine was suggesting is a rethink along those lines about the evolution in the post-COVID moment, but it’s the moment of AI, it’s the moment of shifting ground and greater threat.
Dr. Kates: I’m going to – this is going to be a radical statement. And I’m just going to put it out there. So I guess a question is, is it – how long is it the AIDS Conference or the global health conference, right? Is it – that may be one way to think about it. So do we reframe the conference itself and its focus, or not?
Dr. Morrison: Thank you.
Ms. Connor: Can I just clarify one thing? I mean, I do think I was kind of talking about we’re a little bit still siloed in who we bring in, what we talk about. And even something – and I’ve heard all of you kind of touch on – health ministers are much more critical to some parts of it. Finance ministers are more critical to certain conversations. If we’re talking about integrating with primary health but we’re not bringing the primary health community into the conference, it doesn’t feel like we’re going to have that kind of bringing everyone together that we’ve had in every shape and form of the conference.
There’s been a reason these communities have gotten together. There’s a reason they’ve had these dialogues, the sidebars. It feels like the amount of times that the sidebar conversations have been referenced as more important than what’s happening in the conference is a little troubling. Is that if you’re an average conference attendee, you go session to session but all these great sidebars happen. They’ve always had good sidebars. We’ve also had good community sessions. We’ve had a CONDOMIZE! zone. We’ve had those things. But I feel like may be less so as we move in this different direction around sustainability and those type of things. So just wanted to clarify a little bit.
Dr. Morrison: Thank you. Thanks, Catherine.
Hilary Wolf: I’ll be brief. Hi, everyone. I’m Hilary Wolf. I lead the Care and Treatment Team within GHSD at PEPFAR.
So, yeah, I mean, I think it was such a huge conference. And impossible to be everywhere at once. But I did get the – have the opportunity to be in all the pediatric sessions. And there were many of them, much more than I’ve ever seen at this conference before. And I mean, we presented at the EGPAF session at 7:30 in the morning and it was almost a full house. So there was a huge – I felt the energy and the momentum, really looking to address the issues for children. And that was really, really exciting.
There was a wonderful session on the Global Alliance that UNAIDS brought all the partners together. And really – we heard from the countries about holding them accountable for their action plans and what successes they’ve had so far. And then we also really heard from the community about what they need and their request, actually to our ambassador, for more support for the community, for women – breastfeeding and pregnant women. And so I really do think that dialogue was there, and it was great to see.
Dr. Morrison: Thank you.
Chris Collins: Hi. My name is Chris Collins, and I’m with Friends of the Global Fight. And this has been a great conversation. Thank you, everybody. And I was in Munich. And it was – it was a great conference.
Three things real quick. For a long time, I went through a period of being down on these conferences. I asked myself, what’s the point? And I’ve just circled back and realized how important they are. And I think part of the reason is because if you go to this conference, you realize you’re part of a movement. And this movement is unique in health. And so looking forward – in other words, everyone gets treatment. It’s not absurd to say, we should get the most marginalized people everything they need, and every poor person what they need, community should be involved, et cetera, et cetera. Those things that HIV has spearheaded are part of this conference and they’re part of the movement of HIV.
And the conference reaffirms that you’re a member of that movement. And we need that movement going forward. And it’s going to change, and it already has changed many times, the HIV movement. I hope that future IAS conferences, yes, do bring in primary health care and the integration piece more, and in a more deliberate way, to have those conversations. You know, because there are a bunch of integration conversations here and there and scattered. Can we bring them together in a way that there’s kind of a series where we have a more serious, ongoing discussion? I think that’s really true.
But I would not lose the name “HIV” from this conference. HIV is unique. The people who rally around it are unique, the passion they bring. We need to bring that to broader health, not water it down and do just general global. We need to bring the HIV aspects to global health, to UHC, and to pandemic preparedness. So I say, stay with the conference and change it, but don’t move away from HIV.
Second, there are all these interesting, crazy strains right now, right? There’s Lusaka Agenda, which, in its earliest form said that there needed to be tradeoffs between disease specific programs and health system strengthening. A false choice, of course, but that’s the way it was positioned up until about November of last year. Most new infections are among key populations who many governments don’t want to talk about or think about. The money donors are leaving on a bilateral basis, not making it up through Global Fund. And the U.S. Congress remains focused on HIV deliverables and outcomes. How do you bring all that together in a politically astute way to keep the U.S. money flowing?
I think the endgame sustainability analysis is the thing, because, as we, in a detailed and credible way look forward to where we’re going and show that there’s been huge progress in some places, challenges others, but we understand them and this is where it’s going. Within that analysis, we can talk about how you begin to end this epidemic and have in some places. And also bring in the synergies with other health, and the need to reach key populations, and how the financing works.
It’s a huge task, but I don’t think there’s anything more important than all of us working on sustainability and the endgame in a way that is credible and real and true and detailed, and also works politically. And I know my organization is very interested in doing that. I know PEPFAR is doing it. I know Kaiser is doing – KFF is doing it. That’s awesome. Let’s let 1,000 flowers bloom. Let’s keep the flowers in contact with each other as we bloom, because I think this is what we need to do next.
And finally, if I think – stand back and think, OK, here’s a great movement response that has got all these tectonic plates shifting underneath it, what does that kind of mean on a strategic level? To me, it says, this is the time for big bets. This is the time to lay down big money in the game changers, not just piddle along and see how we slowly change these – change this too slowly. Make a giant bet on long-acting PrEP. AVAC is a group that’s bringing together multiple different groups to look at how to do this. Make a big bet – the purchasers, Global Fund, PEPFAR. I know PEPFAR, you’ve already done this to some degree.
Make a big bet on long acting, and then show the – double down in three countries and show the results to Congress in two years. Show the power of a new technology and what new money can do. So think about a big bet there. I would say, make a big bet on pediatrics. If you can show that you make a big improvement on reaching kids with treatment, that also is huge for kids and for families and communities. It also helps us on the Hill. Thank you.
Dr. Morrison: Thanks, Chris.
Ron.
Ron MacInnis: Hi. My name is Ron MacInnis and I work with Palladium. And first of all, thank you for having this session. I think it’s important that CSIS and KFF continue to spotlight the importance of the conference. I agree with what Chris Collins just said, it’s important to keep this conference. The language is important. It’s important for diplomacy. It’s important for public health. It’s important for communities.
And I think a few things that came out, from my reflections at the conference, there was this great debate of whether AIDS is exceptional or should be integrated along with public health, global health broadly. And I think, you know, it’s a false argument. And we see that in our own country. We only need to look inward in the United States and see it’s exceptional and it needs to be integrated. And I think keeping the language on that is important.
This is the first conference where our top leadership from the U.S. government is representing an office that doesn’t have the word HIV/AIDS in it anymore. So there’s no office of the global AIDS coordinator. It’s the Office of Global Health Security and Diplomacy. And I think that’s a challenge. I think it’s a challenge globally to keep political commitment high on the agenda for HIV. I think it excuses those leaders in many countries we have to engage with in PEPFAR programming to not pay attention to HIV as a top critical issue in countries, especially in countries where there are millions of people living with HIV depending on us and other donor governments to support those programs. And I don’t think we need to feel animosity towards that, but I think it’s important that we keep the language of AIDS in our diplomatic language, in our engagement. Otherwise, it will be left by the wayside.
Sustainability, I don’t know if it’s going to maintain or if it will have resonance on the Hill. But I think the idea and the ability to transition HIV programs to a more country-led, government-led – government at national and sub-national level – is very important. But I think we need to make sure that our Office of Global Health Security and Diplomacy is ramping up its diplomatic agenda. There were very little discussions around financing. There’s a big challenge with debt burden in the countries that most need to put domestic financing into health and HIV programs. How does that play into our calculus? The great session I think that you mentioned, where the eight, I think, highest-burdened countries presented on their plans – their look towards sustainability, none of them mentioned domestic financing in those presentations. That was very telling to me. There’s still a big mystery on who’s going to finance this sustainable process.
One final point, many of us may think we’ve advanced beyond where we have in some countries. This was the first of the International AIDS Conferences that had a pre-conference devoted to key populations. For those of you who know this conference, there’s a myriad of pre-conferences that happen all the time to try to expose and distill and dig into particular issues. First time, 2024, there was a pre-conference focused on key populations. And sustainability doesn’t resonate with the key pops epidemics, because those programs haven’t been built. And I heard similar discussions around pediatric programs. Those programs haven’t been built in country to extent that we could talk about sustaining them.
So I think the language around sustainability might be something to consider as we move forward with Congress. Is that the right word? Is it the right term? As Jen pointed out, was it ever used in previous iterations when we’ve tried to sustain or graduate countries from family planning assistance, or from other types of foreign assistance? So those are my immediate thoughts. I thought the conference was very useful. I love the mix of science. I think communities showed the richness of their engagement in the global village component of the conference. And those of you who aren’t aware of that component of the conference, I urge you to dig into it because it really is a great barometer to see where the community voices are around the world, what they’re networking around, who they’re networking with, what alliances they’re building. Thank you.
Dr. Morrison: Thank you, Ron.
We’re getting towards the end of the hour. I want to add one comment, which is – on the sustainability debate. You know, we started the conversation reminding everyone that the global HIV response, in terms of external funding, is 75 percent dependent on decisions made by the United States. And the sustainability debate is like – the pace of the sustainability debate, and the pace of change, is going to be significantly determined by actions taken on the Hill, with respect to whether that 75 percent persists or not.
And we do have the emergence of a critique and the emergence of patterns of questioning that we did not have until this last year that are going to require some answers. So I think we’re going to have to move towards much greater specificity and concrete strategies, because the pace of change is not simply being driven from the executive branch. The pace of change is going to be driven, to a significant degree, by the Hill. And I just think that’s reality. And we are – and that’s part of the shifting ground that we’re – that we’re standing on here.
Just to close, if we could do a quick round starting with Katherine, and then Jen, and Becky around – just to close on a positive note. What is the – you know, what is giving you the greatest hope and optimism as we look forward here? Because we had – we did hear some very promising things in the course of this. And I think we need to remind everyone of what those are. So I’d like to ask Katherine to start with that question, and then Jen, and Becky. And then we’ll – then we’ll adjourn. Thank you.
Dr. Bliss: Well, looking ahead to the next conference in 2026, I’m excited to see Latin America and the Caribbean as a region be spotlighted. Beatriz Grinsztejn from FIOCRUZ in Rio de Janeiro is the new – or, I guess, now – she’s not incoming. She is the new president of the IAS. So, you know, this is a region that, you know, while the numbers of people living with HIV are not as high as in Sub-Saharan Africa, you know, racial and gender inequality, coupled with fiscal crises, political polarization, and a challenging legal landscape – particularly in the Caribbean – you know, are really driving transmission and putting up significant obstacles for people who need to access services.
So to put a spotlight on this region, particularly after the exceptionally negative experience during the COVID-19 pandemic, you know, I think is great. So, you know, in October, the Research for Prevention Conference is going to be in Lima. We don’t know where the AIDS 2026 is going to be, but presumably somewhere in the region. So I’m really looking forward to seeing how the agenda to innovate, advocate, and agitate evolves over the next two years.
Dr. Morrison: Thanks. Thanks, Katherine.
Jen.
Dr. Kates: So let’s see. Just to put it out there, I do think this conference is important. But the way you described it, Chris, in particular, really captured what I saw in Munich. And I think there was an energy around that that maybe we hadn’t seen in a while. We had a virtual conference in 2020, then we had a sort of hybrid-ish conference in 2022. So this was – I think this definitely showed the role.
I was – I was really excited – I continue to be so excited about the long-acting injectable PrEP. I mean, that is such a game changer. It’s unbelievable that it’s here. We have to seize on this opportunity and keep going with it. So that gives me a lot of optimism. I hope that in two years when we meet again, we’ll be talking about the successful rollout in many parts of the world.
And I also, Chris, who you could have been up here as well, I liked your big bets, your concept. And one of the things that I thought the conference really did a good job of is highlighting the challenges faced by keep populations in a really – whether it was the pre-conference, a lot of the discussions, PEPFAR announcement. But to end with something Catherine talked about, it is really horrible that we’re at this point and kids are so far behind. And if we can’t make that argument rise higher, I think we’ve really lost something. So we have to be optimistic and put that forward. But, again, in two years’ time, I hope we can come together and say that there’s been a lot of progress there.
Dr. Morrison: Thank you.
Becky, you get the last word.
Dr. Bunnell: I also feel like the energy of the conference gave me optimism and excitement about what we – you know, the potential of lenacapavir. And also looking beyond just that long-acting agent to others that may come on the prevention side, and on the treatment side. And those are going to be game changers, if we play our cards right. And very excited about that.
I also, you know, just stepping back to this bigger picture that you’ve brought up, Steve, I’m optimistic that given what we have done in the last 20-25 years in this HIV response, and how far we’ve come, I’m optimistic that we collectively can script the next chapter in a way that will show the world, and show our Congress, that an investment of $110 billion was worth it. That in fact it’s been worth it not only in lives saved but in myriad other ways. And it provides an example for future investment in public health, in global health. So I’m optimistic that we can get there. I know we have some work to do in getting the narrative together, but I’m optimistic that we can. And that we collectively can, not just script that chapter, but enact it.
Dr. Morrison: Thank you. I want to thank, again, Carolina Andrade, Corey Donnelly, Anna Russin for all their support. And Eric Ruditskiy and Qi Yu for their technical prowess in putting this whole program together. And thank Katherine, Jen, and Becky for your leadership, and your commitment, and your willingness to come here and share all of your thoughts today. And to our audience online and in person, for making the time to be here with us. Thank you. (Applause.)
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