← A Shot in the Arm Podcast
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- [00:04]
A
Welcome to A Shot in the Arm podcast. We're on Thursday, the penultimate day of the conference, and I'm absolutely delighted to have tracked down two leaders of one of our favourite organizations, the International Treatment Preparedness Coalition. And joining us are its executive director, Solange Baptiste Simon. Solange, welcome back to A Shot in the Arm.
- [00:32]
B
Thank you very much.
- [00:33]
A
Ben, how are your earrings? Because on our last. They're on. On our last outing with Solange, one decided to go walkies.
- [00:40]
B
They're secure.
- [00:42]
A
And I'm also really thrilled. And this is his first time on the show to welcome Otman Malook from itpc, but based in Morocco. Ottman, welcome to A Shot in the Arm podcast.
- [00:55]
C
Thank you. Hi, Ben.
- [00:57]
A
What title should we be calling you this Juncture?
- [01:02]
C
I am the Access to Medicines and Health Technologies need at icbc.
- [01:07]
A
Brilliant. Now, at the start of this conference, you all held one of the pre conference sessions, which I presume was about treatment. You'd assume. So how did that go and has it helped set a tone for what came afterwards during the course of this conference?
- [01:30]
B
Yes, absolutely. I mean, we held a treatment pre conference. It was half day, it was incredibly well attended. In fact, we had people spilling over into the overflow room. We had over 60 different countries represented, about 33 different speakers because Othman and I and the team made it. It was a little bit like what we're calling a Moroccan wedding. So a little bit of crazy. There are too many speakers, too limited time. But it was excellent and we could talk through some of the themes that came out from it there.
- [02:05]
C
Yeah, no, yes, it was a great success, actually. The room capacity was 120 and we had more than 360 people, so different people attending, people who are queuing outside. So it was great success. But anyway, I don't measure success with the number of people, the quality of discussion, to be frank, we had this pre conference because we were a little bit too worried that treatment issues are going to be neglected from the conference. And it was all about prep. The idea is not to oppose prevention to treatments, but we really wanted to make sure to remind people that, you know, treatment is not done and that there is a lot of challenges, especially given the current context that we may talk about later.
- [02:58]
A
So one slightly facetious remark, your numbers sound like our wedding, where we had virtually double the people that. So I can imagine the chaos and mayhem that went with that. But you talk about the tension between prevention and treatment. Can you talk a bit more about it? It's always been there in some way, particularly since the emergence of oral prep. But how is it playing out now in 2026?
- [03:33]
B
Look, I was also involved in setting up the prevention pre conference. So I kind of saw the themes of choice and, and you know, how that played out. But I think just overall at the AIDS conference this year, there's a, it's about a particular product, it's very much a lot of prevention conversation. And we wanted to make sure that people weren't getting back into this weird danger zone where you feel like there's a choice or quitting prevention versus treatment like we did back in the day. There's still a huge treatment gap in many countries. The biggest, the best form of prevention is treatment. Treatment is prevention. That's still actual science. And I think the things that are playing out at a country level are important to think about. And we had many countries speak to their issues on treatment across different kinds of contexts. War situations, middle income countries, the kind of regulatory environments. But the thing I would say is this question of you have limited resources at a country level, are you going to put it towards one particular product that requires a lot of uptake in its rollout to have the impact that's necessary when there are many other things in the pipeline in terms of long acting technologies. And then what about long acting technologies for treatment as well? It's not just for prevention.
- [04:59]
C
There are two ways to look at it. So either we look from public health perspective and in this case we lose the people. Like we are more into statistics and data and you know, behind each number there is a person, or we look at it from the individual person. And in this case, I think the debate of prevention, treatment is just a fake debate because people have needs and throughout the continuum, you know, people should get access to testing, to services. Sometimes prep is the entry, the demand for prep is actually the entry point to treatment because people go, and I have a lot of friends around me who actually got on treatments by going to see prep and they just discovered that it's too late for prep and that, that they, they were positive and, and same thing, people were maybe on prep and on treatment later because something happened. People may enter to treatment through prep or whatever. So I think for us as activists, what is important is really the people and the continuum of care and the services. And it's not about, you know, there is no strict limit between prevention and treatment. And let's not forget the best prevention is actually if people know their HIV status and get treatment, we may even not need crap. You see, I mean it's one way to stop the new infections. So yeah, for us there is no limit. But unfortunately when we get to public health debates and creating conferences like this and we have two cluster sessions and we say, you know, prevention or treatment or sometimes, you know, prisons or roof treatments, where actually where in prisons there are people who need breath and in prison and there are people who use drugs or who are in prison and sex workers or whatever. But very often we cluster this session by teams. But when you speak at the individual level, you know, everything is mixed. And we cannot like cluster this like we, we do in the conference like this, where you have thematic sessions or tracks.
- [07:09]
A
But what we're really seeing is a sort of a continuum flow between testing, prevention and treatment. As you say, some of the people that you know come in thinking they want prep, but they discover that they are living with HIV and so they move, maybe the same drugs, maybe different, into a treatment cascade. How difficult do you think keeping those various options going in the minds of healthcare workers supporting folks who this may be one of their only times, their first times coming into a treatment clinic or sorry, an HIV clinic. To what extent do you feel that they are prepared to deal with this ambiguity? Is it both a training but a capacity issue that we have to address and deal with?
- [08:11]
B
I think this becomes even more complicated when you think about integration, which I think many countries are actually doing now. So it's. I don't know if the question is still, I think your question is still valid, but it's not only exclusively about this HIV clinic. There are many places where they're actively doing the integration, where now you are chronic disease, so you have hypertension, diabetes, maybe some asthma, sick people, but then also HIV services. So now one healthcare worker now has to be able to manage all of these different things. And if you're also including prep options and sort of just. It's chaos, it's chaos on the ground. I don't know how else to put it. I mean, I don't want to name specific countries, but places I know vary from, you know, second hand, from the people who are literally doing it or trying to seek those services. You don't know where to go. And there's a curtain because there's no actual facility that can now merge both really well. You just shut down HIV and you've put it into chronic care management. And now you have a curtain between the diabetic, the one who's just checking the hypertensive, and now somebody who's going through the full continuum of care to be tested, who might now be receiving a positive result and now figure out what is the next step. So I think there's a lot of support that needs to go to healthcare workers because this is a very difficult time for them because in terms of capacity skills, understanding how to now do all the things well when they're already under pressure. I mean, I do speak from a community perspective, but I do truly empathize with healthcare workers and the amount of enormous pressure that's on them to not only provide quality services, but now there's so much going on between the AI, the digitization, the interoperability, writing the record and now needing to learn to make sure that you're giving quality services across a continuum of diseases. It's a lot.
- [10:06]
A
Yeah, it is. And has. Has that sense of barely manageable chaos made its way into the program of the conference here or like many other things, including the rapid decline in PEPFAR funding, we're still hoping it'll go away overnight.
- [10:31]
B
I don't think it has fully entered into the main conversation. I, you know, I think if we had a strange moment, that's the best word that I could come up. I feel strange on one hand I feel like conversations like this that are real, where we're actually talking about what it takes to integrate what is the context, what are the true. I don't think we're having their honest, real conversations. We are still, still talking a little bit on surface level about self care and AI and integration and prevention over here and oh yes, let's do about IP and whatever else, but we are not really getting to those harder conversations and making those difficult conversations come to solutions. I don't feel like it's bubbled up in the conference, but I don't so sure what is the solution. I don't know if it is necessarily tweaking a session, if you know what I mean, or making a better title and inviting different people. I don't think we collectively are truly ready or are having those kinds of conversations.
- [11:41]
C
I heard some discussions in the conference on that. More from the funding crisis aspects. As Solange says, there's a lot of pressure on healthcare workers and in the majority of countries we have less and less healthcare workers, but also community. I think we should not forget about community health services or whatever. So yeah, at this moment where like the burden, the capacities, the issues people have to deal with are getting bigger and bigger and at the same time we have less and less human capacities and resources to do that. Now what we need, what we shouldn't forget is that There is no one size fits all. And I think each country and even within a country like each setting will require to find its own model. And this can only happen if communities, local communities are involved. In my parts of the world, in the Middle east and North Africa, integration will not work because of we. For years we have built, yes, it's vertical programs, yes, it's HIV only clinics, but whether you are in Cairo, in Casablanca or in Beirut, you can be a gay man who sells sex using drugs, but you still get good quality services in these clinics. Because there had been a lot of efforts on addressing stigma, discrimination, training healthcare workers and whatever.
- [13:23]
B
So you get friendly service.
- [13:25]
C
Yes.
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B
Okay. Not specific to your.
- [13:27]
C
Yeah, but then if you send people everywhere, like in a public hospital and you know, a trans person or whatever coming, it's not going to work. So I think we need to be careful on these models that are sometimes imposed, like global strategies that we are going to roll out. Even we speak about adaptation. You know, there are limits to adaptation sometimes. So I think we should. If communities are involved, if communities are monitoring what is happening and doing the advocacy and engaging in the dialogue with policymakers, with people who are sitting programs, with donors or whatever, we can, we can make it. The problem now is that. Well, this strange moment you were speaking about is a kind of blocking a lot of things and people are completely lost. I think this conference for me is really a strange one.
- [14:33]
A
Yeah, yeah.
- [14:34]
C
And I don't know, but in two years, where we will be and if things were different, I, I totally agree with you. Between Kigali and the kind of. And Rio, we were thinking, okay, by Rio we'll have a kind of clear idea and vision where we are going. I think it's still blurry, not to say even worse. So.
- [14:57]
A
Yeah, yeah, sorry. I mean, I'm feeling that the creativity, the innovations that one expects to see bubbling up from countries simply isn't being presented here. And I don't know if that is because it's not ready for prime time or if it's because people are still trying to get used to the fact that budgets have been slashed. I think the one thing that is pretty clear is that people have come to terms with the fact that there will be no going back to the kind of PEPFAR that we had in the past and how shall I put it, that that's actually a good thing. It's quite shocking to see across so many countries how much influence PEPFAR has had. And it's also really flip of the coin, but also very interesting to see how countries are like, yeah, well, we're not going back to that. We don't want to go back to that because we live in a political environment where one of the two US parties frankly stands for this. Yeah, delay, collapse, whatever you want to call it. And there's no guarantee that there will be political incentive to come back. It's very nerve wracking, but it is very exciting because this is. You no longer have to pay international salaries to the international NGOs working in countries that PEPFAR has required you to do. You don't have to pay for the US data collection models that PEPFAR have insisted the ball is in your core and the conversation you can have with fellow travelers, fellow countries. That sounds interesting, but again, you're just not seeing it emerge here. One of the things that does seem interesting is the emergence of data into new compounds, new therapeutic approaches, mostly some form of long acting. And I don't know if that's the enthusiasm for that is something that you've picked up on or how you read that situation.
- [17:28]
B
Maybe Othman can speak to that because we have supported some studies on that. But I just wanted to pick up before maybe respond. I was talking to GNP yesterday and it was interesting about how we talk about the cuts of the US and what the US is not doing, but maybe the narrative needs to be what it is. The African governments or governments across the globe have stepped up. Many of them are failing. We know the situation, debt colonization, the whole story. But some of them are stepping up and I mean, it's not bubbling up. I fully agree, but there are stories that I have seen in specific sessions that are very strong, but those don't get prime time. What we are getting is what did PEPFAR do? What did they do wrong? Why are they not there? So I think it's also on us to try. It's our responsibility also to promote those things. But yeah, the map.
- [18:23]
A
There's just one thing I wanted to say. That's the map that the State Department presented in their own special event prior to the conference that had an extraordinary reworking of the geography of the continent. But
- [18:40]
C
I feel a little bit uncomfortable like basing strategies on products. And I think the trend we have seen during the past three years is signs by press release, big announcements. Now we have no clue if Alimatra is effective or not. So we have a big hope. We hope that it's gonna work, but we are already speculating and you know, prep for me is an intervention. It's not about a pill you see what I mean? So it comes with the services testing with, you know, hep B vaccination with the STI screening and whatever. But now actually, yeah, we are just looking after products and brand and people are even speaking about company on Gilead's prep, Merck's prep. So what is the difference between, you know, it remains still, still, still prep. What is clear from this conference is actually, and maybe this is one of the strong messages that I heard that we don't have any more problem with science or innovation now the problem is going to be a manufacturing, a financing and a kind of delivery stuff. Yeah, the pipeline is for prevention is rich. There is some interesting pipeline in terms of simplifying treatment for people living with hiv, but at the same time it's completely passed. Nobody, nobody even paid attention to. And I went to some sessions where there was almost nobody there in the, in the session. And so yeah, so the problem now is a problem of leadership. This is the first international AIDS conference when I haven't seen ministers of health from key African countries or key donor countries. So usually you have the minister of health of France, of Malawi, of. You see what I mean? And many I haven't seen leaderships from. Sometimes, you know, you have artists, you have whatever showing up and celebrities and whatever. So like clear there is a crisis of leadership. Science is not anymore, or at least now is not an issue now the issue is going to be who's going to access what is available or not. And this is for me the key takeaway. And now we had this show of companies like oh, it's going to be the LAN thing. And then few days before, like Merck stole part of the show of Gilead, you know, it's like a telenovela. You see what I mean? Like two days before you get to the conference and you have the suspense and, oh, and completely. And actually the discussion now I feel really pissed off. Like we are speaking names of drugs and brands and companies or whatever. While the real problem is really the problem of who's going to fund this, who's going to access it, who's going to manufacture it and are we going to do things differently this time or not? All of this is not being discussed. You see what I mean? And we are speculating on products on.
- [22:20]
B
We need a conversation, a serious conversation about sustainability. Because if Global Fund and all these other philanthropies decide the next magic bullet is the thing, that it will be subsidized, who is going to pay for this at the country level when they move on we're back to the dependency problem, which we have not fixed. So where our energy needs to be is at the country level finding fiscal space. That's the conversation that we're not having. And when we start talking about financing and fiscal space, everybody, here goes. There's a wall.
- [22:56]
A
Yeah.
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B
We don't know what to do.
- [22:59]
A
Do you have thoughts about how room in the fiscal space can be set aside for prep or is it, is it still too early?
- [23:13]
B
I don't know about still too early, but I do think that we need to have a conversation about debt. We need to have a conversation about the taxation issues that we're seeing. You know, everyone talks about debt swaps, but countries are not prepared for debt swaps. That's a very big sort of machinery that you can't just do. Yeah, there's a whole issue of corruption in countries.
- [23:40]
C
Sure.
- [23:40]
B
But there are efficiencies that can be made. And you know, people like Brooke Nichols have gone and they've done the modeling on the financing. There's a tier plus tool that can help you with prioritization based on what you can see. And there is fiscal space with some of this. If we can have those more difficult conversations. I found one person was able from the, from a ministry that was able to say something true. He said if. Because we talked about self care and the importance of things and they talked about the importance of literacy for communities like, you know, self care, the idea that you can take care of yourself and find the doctor or the nurse if you need and when you need them, but you need literacy, you need to know what the choices, you need to know what you're asking, etc. And he said, if you asked me to choose between literacy and products or ARVs, I would choose the ARVs. So that is a choice. Now you go and you look at the prioritization.
- [24:35]
A
Now why would they pick the ARVs?
- [24:37]
B
Because there's a more, that's more immediate need. People need ARVs to live. It's a, it's a, you need them daily. Right. And maybe you can get philanthropy to pay for the literacy, but they're not interested in that because it's not sexy. So then you, you need a strong government that can stand up to donors and say, this is what I need you to fund. I am managing my response. And here is where you can help as opposed to what the current dynamic is. We are paying for this product. Take it.
- [25:08]
C
Right.
- [25:09]
B
They're not going to say no and
- [25:10]
A
implement it the way and implement it and.
- [25:12]
B
Yeah, exactly.
- [25:14]
C
And I think with this conference, or not necessarily linked to the conference, but this moment, I think we reach the kind of the summon, the extreme of the biomedicalization of the response. And if you look back what we have been discussing in previous conferences, criminalization, stigma, discrimination and whatever, how to make sure now, like for every problem you have the pill or the injections. Sometimes when I hear some people speak in sub Saharan Africa is just like your challenge is to make sure the young girl comes to the clinic to get her shots and just make sure she comes back in six months to get the other shot if she's raped in between, if she is, whatever, it's not a problem. We avoided like new infections and all the human rights program and same thing for the gay guy who is in Middle Eastern North Africa or in Senegal criminalized or whatever. The objective is really to either prevent new infections or either make sure people are tested and put on treatment. And what happens in terms of human rights or whatever, it's not a problem. Now we have like the pill or the injection or whatever. So I think we will not be successful if we do not address also these kind of things. And there are limits. We have indeed amazing and promising biomedical tools. But it is not enough to address the HIV epidemic because it's not just a disease. Maybe people should go back to Jonathan Mann and you know, I think people have forgot or maybe they are young and they don't know where we come from.
- [27:12]
B
But we need those young people though.
- [27:15]
A
We do. And I gotta say, I, I was able to get a partnership with the International Aid Society this time round to interview members of their Young Leaders program. And I've been pretty blown away at their enthusiasm and optimism, which, okay, we were all like that when we were kittens and bunnies at the start of our.
- [27:44]
B
Is he saying we're not kittens and bunnies anymore?
- [27:48]
A
Well, I know definitely that I'm the sort of the old, very respected Jack Russell sleeping all day and that's where I fit in. But what I meant seriously is they've got plans they want to do
- [28:11]
B
and
- [28:12]
A
they're really well thought out. They really are thinking that's probably the case because their presentations that they're doing here, you know, they won their young leadership membership by producing really strong presentations. But there's something else, and I think it speaks to a larger point, particularly the scientists, a lab scientist focusing on viral reservoirs, co infection of hepatitis B and HIV in Botswana. The way they are able to articulate and speak, I mean, I understood it, I understood what they Were saying, when does that ever happen?
- [29:01]
B
Oh yeah, exactly.
- [29:02]
A
You know, and so I feel really optimistic on, on that side of things. Where I feel deeply pessimistic is that, you know, we have never seen such a level of funding cuts and it's going to take us a good few years to get over that. We don't know how we're going to do it yet. And I don't know how many years it is setting back the HIV response. I've got a project called AIDS 2060 which I would love for ITPC to be interviewed of sort of a long form conversation about why we're not going to meet the goal of ending AIDS as a public health crisis by 2030, which is absurd, it's just a whole absurdity. But what are the trends that we need to take account of and start thinking about now so that we can pool our resources and our intellectual resources particularly to get to a point where we can think about bringing HIV to a close? And it's an interesting one, a difficult one. How do you reactivate to ending aids by 2030? How are you managing it? Because I know for some people, some organizations, you have to pay lip service to it even though you don't really believe it. But are you finding that it is something that is easier to Talk about? The Post2030 agenda?
- [30:46]
B
I don't think in any of these numbers, do you? You just reminded me that that was there. Honestly, I don't think about 2030. I think about generations and how we need to equip them for succession. When, you know, I just realize I am in, I'm a young person in the old people's club. This is where I've arrived. One day you wake up and you realize you're not that person anymore. And your children age you, they say you have references, they have no clue what you're talking about. I think in generations I kind of breathe in 10 years and breathe out 10 years trying to see what the young people now are talking about and making sure that they're equipped with whatever I can pass on so that they can take the next phase of whatever this looks like. I genuinely don't think in the2030s and I know that's helpful for target setting and having something to aim for. But as we approach the reality of life, you know that that's not a real thing, right? And even. What did you say, 2060?
- [31:54]
A
Yes, but I picked 2060 as a joke because let's pluck, let's pluck a number from the air.
- [32:02]
B
Pick an Apple. Yeah.
- [32:03]
A
Put it towards the United Nations General assembly and they will instruct the virus that it will adhere to this UN General assembly declaration. It's nonsense.
- [32:18]
B
Yeah, no, I agreed.
- [32:22]
A
Well, we're coming up to the top of the hour. What have you got left for the conference? What else are you up to?
- [32:29]
C
We named our pre conference treatment as crossroads and we are as crossroads. And maybe as I say, like crossroad is not a destination, it's like a decision moment. And I think we are in a moment when we need to make decisions and do differently. As I said, there is no problem with science. Now we have enough. You know, maybe a cure will be perfect, but a vaccine. But with what we have now, we can ace. I think the funding crisis, if we can get something good out of it, is that we hope that many countries are going to wake up and for years they try to work within a system but now we knew as communication that the system was not working. But I think they realize when you have a big donor coming and telling you you should all go on this product because it is expensive or whatever and then tomorrow we stop funding and deal with it. So we know that most of these products are cheap to make. Why would we pay something thousand times? That's what it could be made in generic version with profit margins. So I think countries should wake up. There are policy options that they can take. You know, they can revoke patents, they can issue compulsory licenses or whatever. For me it is not normal. If we look at other health programs and especially in rich and developed countries, the cost of medicines is small even if they pay high prices. And actually it's the health services, you know, that are expensive. Now we are putting a model, imposing it to poor countries where the burden of the medicine they need to contract on the essential services, on the infrastructure or whatever to afford for the medicines. While it is not happening in rich countries with extra extremely high prices. Yeah. So I think decisions should be made at this time. I don't know, maybe the fact that we had no leadership like in this conference from minister or whatever is that. I hope I will interpret it like this, that they don't want to play that game anymore and come as a muppets and we show them and say we are committed that we make whatever. If this is why the atmosphere, it's a kind of good news. Now if they just don't care or they have no hope or they abandoned or there is no, then it's another discussion. But yes, we are in a moment when decisions need to be made by everyone, including us. Should we continue to do things like we have been doing for almost 30 or 40 years or the world is changing and we have to do differently. So, yeah, so I'm leaving this conference with a lot of questions, not too many answers, unfortunately. But it's a good moment of reflections and also, you know, introspections. And that was one of the objectives of our pre conference actually is really to gather together and to say, okay, what did we did, what we can do differently and how do we react to what is happening today?
- [36:12]
A
Yeah, thank you.
- [36:13]
B
The human. Touch the human. Because one of the questions we asked at the end of the treatment pre conference was what gives you hope? And it was actually a quite emotional moment where everybody had to kind of truly reflect. And the through line was community and the through line was people. And I think where I would land is also just to kind of round that off because everyone is talking about the promise of AI and I think the promise is scaling more than the evidence of scaling. And we are rushing to scale things that have no evidence, that meet standards on equity and, you know, real actual impact. So I would want us to remember that intelligence in that form also includes community intelligence. And no matter what the topic, if it's IP issues, if it is funding crisis, if it's the new medicine, whatever it is, communities are still the answer, communities are still the solution. And so I think we need to make sure that communities are supported and well funded and resourced and no matter what, they'll still show up. They showed up in a protest. We show up in the pharma prevey booth, in the treatment networking zone. We're still showing up in the most difficult circumstances because of the audacity of hope, as President Obama has said.
- [37:40]
A
Yeah, yeah, thank you. I think for me, coming out of this conference is an underlying sense of, of strength out of that audacity to hope. We've got a long way to go to put that into practice, but I don't doubt that we will do that. And I think certainly the members of Trump's State Department who think we are easily handled by a map that puts Mozambique above Uganda, well, they're in for quite a shock, I think. So, Solange Altman, thank you so much for giving up some time here at the conference for the really important work. Of course, I should declare transparently that I also have a relationship with itpc because again, you're a bit like the Catholic Church. Once you're part of it, you never leave it. I was on the board of itpc. And it was one of the most insightful and rewarding things I've ever done. So thank you very much.
- [38:56]
B
Thank you very much, Ben.
- [38:58]
C
Thank you, Ben.
- [38:59]
B
Thank you.
- [39:00]
A
Well, that's it for this episode. Thank you to Solange. Solange. Solange. What on earth am I thinking about? Solange.
- [39:08]
B
Salami.
- [39:09]
A
And. Salami. And. And Ottman. Thanks also to our director and producer extraordinaire, Eric Aspar from A Shot in the Arm Media. And finally, a big thanks to you. Have a great day and a safe day, everybody.