September 23, 2024
Comments by Chris Collins at National Academy of Medicine Workshop on HIV-AIDS Sustainability
The following are comments made by Friends President and CEO Chris Collins during the panel, Sustaining Political Commitment to Ending HIV as a Public Health Threat.
It is good we are having this dialogue as political leaders on the hill want to know the trajectory for our global HIV investments. In the PEPFAR reauthorization debate earlier in the year, we actually saw a great deal of bipartisan support for PEPFAR, but the debate called the question on the future of the program. We need to get in front of this and articulate the future of the effort to end the HIV epidemic.
For me, the first question is “what are we trying to sustain.” Absolutely we are trying to sustain a robust country by country response to the HIV epidemic, but I also hope we are working to preserve the unique aspects of the AIDS response. That includes a commitment to access for all, deep engagement of community, inclusion of multiple stakeholders in decision making, an appetite for innovation, and a focus on reaching the most vulnerable.
These values are part of why the AIDS response has been called “exceptional.” As we progressively integrate HIV into health systems, we also need to integrate many of these exceptional qualities into broader health.
Let me address working with Congress, and then some comments on the foundations of sustainability.
Working with Congress:
First, it is essential to maintain the bipartisan nature of support for PEPFAR and the Global Fund. A major factor in doing that is keeping the programs visibly results-oriented.
Second, we need an actual member education campaign tailored to tested themes that resonate today. For years we have talked about one, but a real effort worthy of a program this massive and lifesaving has never been funded or implemented.
Third, our overall communications need to be much more compelling. A couple times a year we highlight countries that have eliminated malaria – let’s make movement toward HIV epidemic control and 95-95-95 more visible.
We need concrete sustainability plans with countries and clear transition policies and incentives from PEPFAR and Global Fund. These sustainability plans can become a point of reference for all stakeholders and even rekindle engagement if they show how to achieve progress on access and equity in health services.
Civil society should be involved in the development of these plans and can use them to hold government to account.
Bottom line: we need a communications approach founded on greater specificity and sense of strategic direction.
Then I think we can get a lot smarter about putting PEPFAR and the Global Fund in the context of broader health and development. For example, there are many paths to Universal Health Coverage and pandemic preparedness, but there is no path to either if we don’t invest in PEPFAR and Global Fund given their extensive support for health systems.
The Bureau of Health Security and Diplomacy has a crucial role here as a communicator and convener to drive us towards finding synergies in global health programming.
There are also real communications challenges. Even as we talk about the pandemic preparedness and health systems contributions of PEPFAR and Global Fund, we can’t let Congress conclude this is “mission creep” – but rather an effort to maximize opportunity, efficiency and spill-over potential.
Then there are foundations of successful sustainability:
The first and foremost is: invest in and support community. Community engagement, activism, service delivery and monitoring are the foundation of our success. But we can’t just say the words, “put community at the center.” We need concrete investments now to build capacity and support community involvement.
And a next step for this process, and the sustainability plans, is to have much greater inclusion of civil society and others from the global South.
Second, most new infections are among key populations and continual underinvestment in reaching these groups is unfair and non-strategic. Whatever sustainability is it cannot be about abandoning people.
Addressing discriminatory laws and human rights issues related to HIV vulnerability and access is also essential. Global Fund data show their Breaking Down Barriers program had measurable impact on human rights markers – we can make progress here.
Third, a critical structural priority. PEPFAR needs to stay at the State Department with its close ties to diplomatic assets and its cross-budget authority. Moving PEPFAR or downgrading PEPFAR will kill sustainability.
Fourth, it is time for a big bet. An intensive effort to scale up long-acting PrEP could drive sustainability in multiple ways: by pushing down incidence but also by motivating improvements to multiple systems – regulatory, manufacturing, purchase capacity, demand generation.
Long-acting PrEP is also a giant opportunity for our work with key populations, providing a powerful new prevention tool, but also for supporting community and key population-led delivery systems.
But to make this big bet work, we need all stakeholders to take risks – donors, partner country leaders, international financing institutions, Global Fund, PEPFAR, pharmaceutical companies, civil society. Leaders should make a commitment and challenge others to join. AVAC leads the Coalition to Accelerate Access to Long-Acting PrEP that can help drive this effort.
I will close with my point on AIDS exceptionalism. Several years ago, a community provider in Rwanda spoke to me about working in AIDS, saying, “The important thing is the mindset. People who work in HIV learn to establish partnership, the importance of multisectoral work, of the community response, and of monitoring.”
The AIDS movement is ultimately a movement for health equity, and we need to bring that mindset to all of health.
An important new report from UNAIDS, GHSD and PEPFAR, with analytic support from KFF, argues that “there can be no sustainability in the HIV response without equity” and it points out that HIV programs bring an “equity advantage” to health. Integration is an essential pathway to sustainability, and there is evidence it can improve equity. But the report notes where stigma and discrimination are prevalent integration can harm key population groups.
And in some cases, building up and expanding out from HIV programs is needed, including community-based programs for key populations. Earlier this year we released a report with UNAIDS and Elton John AIDS Foundation documenting where countries have done that with great success.
There is an endgame for the HIV epidemic with adequate funding and good policy. The fiscal reality in many countries means it will take time for them to approach self-finance. Our sustainability work should serve to justify US investment, not diminish it in the near term.
We face challenges, but let’s not forget the power of the HIV response and the HIV movement. Done right, sustainability can be a mobilizer, a path to more lives saved, greater equity and better health for people globally.