← A Shot in the Arm Podcast
A Shot in the Arm Podcast
Emily Bass on PEPFAR’s Data Spin, What South Africa’s Oral Histories Reveal & the future w/ AIDS2060
01:26:08
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- [00:01]
A
Welcome to A Shot in the Arm podcast. I'm Ben Plumley and this is the podcast about innovation and equity in global health. Because let's face it, without equity, what is the point of innovation? Well, we're in. Surprise, surprise. Yet another wild time in the field of global health, which has really been the case, and we shouldn't be so surprised about that, since Mr. Trump and his administration decided to upturn the table of the global health infrastructure last year. And to help us make sense of what on earth is going on here, I'm delighted to say that we are joined by friend of the pod. She is a public health expert, an investigative journalist and author, and, yeah, Emily Bass, welcome back to the show.
- [00:52]
B
So happy to be here.
- [00:53]
A
How are you doing?
- [00:54]
B
You know, I'm just marveling at the weather in Sacramento and the state of the world.
- [01:00]
A
The state of the world and the weather in Sacramento have a significant bearing on each other because we've been surprised at how much rain. I'm delighted for the garden, but I'm a bit surprised at how much rain we've been having, which is, in a sense, is the least of our problems today. So, you know, we expected the field of global health to go through massive changes after everything that happened last year with the U.S. government closing USAID defunding, then partially refunding PEPFAR, the president's emergency plan for AIDS relief. And we're also seeing major reductions in funding coming from European donors to countries hardest hit hit by HIV and AIDS. But what say the 38,000foot level is your sense of what is going on here and how we should read what's actually happening?
- [02:06]
B
Well, we're just gonna stick with the rainy weather for a minute. And what I was commenting on is we've had three seasons in one day, which is a little bit what it feels like to be grappling with the changes that are coming at us and the. And the unexpected and the unnatural, as well as some of the organic evol with HIV aids. So in a normal time, without the intervention of the last year, we were expecting to be in a place where countries were beginning to think about how to take over, really run and manage HIV services in the context of epidemics that had reached a level of epidemic control. So you had the majority of people, the vast majority of people with HIV on treatment, virologically suppressed. People know their status, people are getting access to services, and then you can really say, okay, we're ready to transition. So that's where we wanted to be this time of Course, last year made that impossible. And so now where we are is this really. We've gotta be vigilant. Ben, we're in a moment where just in the last week, the US government has started for the first time to give us its story about what happened in the last year with the programs that it funded with HIV AIDS through the PEPFAR program. Just one quarter of data that it's very busy spinning to tell a story that makes it sound like we are where we wanted to be had nothing else happened, that we are just continuing with a level of progress. We're seeing all the right things happen. The funny thing with numbers is you can make them look a lot of different ways. And so what we're doing right now, I would say, as a field, is really trying to separate fact from fabulation, from what we don't even know yet, because we don't have clarity. And if you take those things and you go, okay, what does it look like through the clouds right now? There's a lot to be worried about.
- [04:07]
A
And we'll come back to the data in a bit. But the first piece of good trouble that you've been involved in is a report from Physicians for Human Rights on the impact of these changes in South Africa. Right. Can you tell us a bit about that?
- [04:23]
B
I'm so excited, too. So the report came out today, and it's a partnership with Physicians for human rights, mPhone Jenny, counseling and training and advocates for the prevention of HIV in Africa. So, Nono Eland, Yvette Raphael, some fantastic South African collaborators.
- [04:42]
A
Yvette Raphael makes yet another appearance on Shelton.
- [04:45]
B
Exactly. And the report draws on oral histories from 40 individuals who shared their lived experience of at the time that they were collected. So this was in September, eight months. In a country where the US has not only disrupted foreign aid, which is done in other places, but also canceled research funding, completely disrupted a research infrastructure built over years with billions of dollars of investment and tremendous benefits to the US as well as to South Africa and the world, and then ended cooperative diplomatic relations. So this report literally speaks through the voices of these narrators back to the US narrative that what happened last year was a necessary corrective to waste, fraud and abuse and foreign aid. What we find unequivocally is that those actions led to waste. That is, frankly, breathtaking, particularly and specifically in the realm of the destruction of overnight of a platform for delivering primary prevention and other primary health services. So that's primary prevention is for people who aren't sick. I don't have hiv. I want to remain HIV free. It's different from what I need if I have HIV and I need to have my meds to stay healthy and safe. Primary prevention is for people who don't have HIV and don't want to get it. And it often involves or can involve prep, pre exposure prophylaxis, right at the moment, just months, even weeks before the Trump took the office and the things happened, right? We had Lena Capavir, a twice yearly injection come online. That is a huge, huge game changer potentially in primary prevention. Not because it is the only thing people should use, but because it is something that may get people to come into conversations, talk about different methods. If you haven't read the choice manifesto by Yvette and her comrades from the African Women's Prevention Community Advisory Board, Accountability Board, please do that. Choice is central, right? But if you have a shot in the arm, as it were.
- [07:01]
A
It's not in the arm, it's not in the arm.
- [07:02]
B
But you know, there's other places, there's other well padded places to get shots. You have a shot twice a year. For some people that's gonna be extraordinary. But those people, often young people, and in South Africa, it's a thousand adolescent girls and young women that get HIV. 10% of the population, 25% of the.
- [07:19]
A
Just say that again. How many people being infected?
- [07:22]
B
1,000 adolescent girls and young women. Just that population per week in South Africa. In South Africa, 10% of the population, 25% of new infections. And I'll tell you something, if you've had a teenager or been a teenager, they don't want to spend their whole day waiting at a clinic. They don't want to be told that anything bad is going to happen to them. They're invincible. They're beautiful, they're strong, they're powerful, they're busy, they're distracted, they're on their screens or they're thinking about how to survive. It depends where you live. But this is not a population that is going to go, you know what, let me wait all day at a busy clinic to tell a nurse who might or might not, you know, be sympathetic to me that I'd like to have an injection for hiv. It's not going to happen. And the US knew it and South Africa knew it and South African communities knew it. And so for the past many years we've invested in a prevention platform that met not just agyw, not just girls and women, but men who have sex with men, transgender people, sex workers, so called key populations, where they are and Said, hey, what matters to you? What can we bring to you, close to you in your community, with people who look like you, who understand what you're going through, what information, what services, what do you need so that we could begin to get you into a conversation about HIV prevention that eventually leads to potentially using prep, whichever option is right for you, or condoms, by the way, or other choices. Okay. So we built this platform. The US really put money into it. And right when we had Lena Capavir to introduce into this platform to see what happens if you have yet another option, we destroyed the platform. So when we say we have evidence of waste, that's what we're talking about. When you build something and all that you have to do basically is unlock the door and put the furniture in or whatever the metaphor is there, and instead you just knock it all down. That is wasted investments. And this report finds it in ways that I frankly still find shocking.
- [09:28]
A
Give us an example, I mean, from some of the 40 folks that you spoke with.
- [09:32]
B
So we talked to one young woman who was both a prep user herself and a former mentor and ambassador for a program called Dreams that mentored and provided information and life skills and economic empowerment to young women and was a major investment for, major, major investment made, by the way, under the first Trump administration. The first time that there had been a layered evidence based intervention package for adolescent girls and young women that looked at their economic, cultural, bio, behavioral factors, all of it. And so this woman was a DREAMS ambassador, was also a prep user. And she described going to the clinic. Fairly recently, she'd stopped prep. She thought that she'd had an exposure. And that's often why people go get back on prep, is they? Oh, that, you know, that was scary. You know, let me restart my prep. So totally normal. A good primary prevention program. That's super easy. Welcome back. You know, let me, I'm so glad you're here. Let me give you your prep. Do you want to try something different? Great. See you in, you know, X period. You know, let me know if you want to change. Let me know if you have questions. She goes to the clinic, she knows how it's supposed to run, and she walks in and she told us all of this. This is in the report, the place that you normally get your HIV test because you have to be HIV negative to start. Prep isn't there. The tents aren't there, the nurses aren't there, the counselors aren't there. She arrived at 7am, by the way. She finally sees a nurse who's hustling her through the protocol. She's a busy government nurse who's probably had several staff members, several colleagues whose salaries were paid by the US government disappear overnight. And the prep user who's also informed says, aren't you gonna give me a confirmatory test? I think I was exposed. So in addition to a rapid test, you really should be giving me an ELISA test. You should be confirming that I don't have hiv. The nurse says, I wasn't gonna test you at all if you didn't ask. Cause we're just busy here, we're just super overwhelmed. And she's saying, I don't wanna make people feel bad about not doing their job, but if I didn't know what she was supposed to do, she wasn't gonna do it. And by the way, she got there at 7 and she left with her prep refill at 4pm Wow.
- [11:52]
A
I mean it is such fundamental bad practice to offer pre exposure prophylaxis prevention tools to a person who has not been tested for hiv.
- [12:04]
B
It's bad practice and we are not going to have the benefit from this intervention if we're not bringing it to. So this woman had stick to itiveness and she knew what she needed and she got her refill and so she walks out with her drugs and she's.
- [12:21]
A
But she's wasted a full day.
- [12:22]
B
She's wasted a full day and she's not in school anymore. Girls that are in school environment, young women in school environments cannot do that. Right? The extended clinic hours, the school based clinics, the peer counselors, that's all gone, Ben. And so South Africa has an incredibly robust public health system. They actually pay for the majority, 80% of their HIV program, more than 80%. And so the percentage of funding that the US was providing was quite small.
- [12:51]
A
Now here's the thing, what I thought was so fascinating in the report and which is the cause of much confusion, so I'm really glad you guys are bringing this out. The South Africans being able to provide 80% or so of the resources for the overall national epidemic response does not give you a sense of what's actually happening on the ground and in different places. What did the report find in that regard?
- [13:24]
B
So the report says, look, overall proportions are not going to tell you the full story. It's not 82% and 18% that matters. It's that within that 18% of the U.S. resources, those covered 50, 60, 70, 80, sometimes all of the funding for specific elements of the program. And so when you pull the 18, you didn't leave the majority of services in place, but stretched. You did a little bit of that, but you also eliminated things overnight. And you eliminated community based testing. You eliminated often services that are also providing hypertension, diabetes, gender based violence, counseling, a range of other things, which is. Let's just, let's remember HIV exceptionalism is used to batter hiv. It's not how most services operate in the world. On the ground. Communities know what communities need and they want a range of things. TB testing. So we paid for a lot of those services. And it's important to note also South Africa has the resources both financially and in communities to do that themselves. So it's not even a question of like, should we have been paying for it forever? But you really. There was no transition, Perlan. There was no transition process. And to be asking eight months later or even now, why didn't they pick that up overnight? You have a country that's in the middle of its own budget cycle. It's got its own own plans that it's implementing and they have a very large budget. So 18% is in the millions of dollars. It is not fair, it's not ethical, and it's not proper to be saying, you know what, we're gonna destroy this system. But look, you guys have the money, so can you just, can you pick up where we left off without any gaps?
- [15:09]
A
I mean, it was quite a smart move on Physicians for Human Rights to look at South Africa precisely because that it's, you know, relatively well developed compared to other countries. And that 18% in South Africa in budget terms will be huge overall. But in other countries that don't have the kind of resources that South Africa has, the effects, I mean, it's sort of hard to imagine what those effects will be. But it's really smart to look at South Africa as it is also experiencing difficulties coming from such a. Well, you can't call it a transition, can you? It's. No, it's not a transition termination.
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B
Yep.
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A
No, but then the US comes back with bits and pieces and we're opening this and it's. We're going to provide services for pregnant women and girls or what have you. What have you? That's an interesting one. Definitely not what have you. Unfortunately, fortunately not as a proud.
- [16:15]
B
What have you. I can tell you, I'm not on their list.
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A
Yes, exactly. So how have these folks been able to provide or have they been able to get hold of services that have some sense of continuity, some sense of security?
- [16:33]
B
Yeah, it's a great question. And one of the things that I think we need to look for and be sure to lift up in every sort of narrative collection anytime we tell the stories. Particularly when you're doing a story about Africa or another, another region of the world where there are stereotypes about suffering and, you know, squalor and disease. Is the incredible resilience and ingenuity in South Africa, particularly because it has a general health system where if you could get people to those services, they were still there. And that's not always the case. Right. But South Africa has a robust public health service. So we spoke to sex worker advocates who literally had driven up a clinic that closed overnight and just put the folders, put the client folders into the trunk of a car and then mobilized themselves. They weren't dependent on US funding, so they were continued to be active track and trace efforts to get to every single person that they could, who was supposed to show up at that clinic to say, we need to move you to a different clinic, we need you to be referred. And we also spoke to sex workers who'd done referrals, these are in different geographies, and said, yeah, I walked into a clinic with a referral letter and the nurse said, oh, you're from, you must be a sex worker, you're from a PEPFAR clinic. So we, the transitions are not easy, but the groups just went into gear because they knew there was some place for people to go.
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A
Now, were these groups being paid, these sex workers that you referred to, collecting all the information about patients, how were they managing this and putting food on the table?
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B
So these groups are not USAID and not US dependent. And I think that's really important to also part of, part of where the resilience. South Africa is a country whose history is intertwined with community mobilization, autonomy, independence, civil society activism and advocacy, and mutual aid. And so some of these groups, especially given the US's history relating to sex worker groups in particular, they were independent. They are independent. And I think as we sort of go through different topics, we're going to keep coming back to this question of, or this issue of the incredible value of a resourced, autonomous, continuous civil society that can do accountability work, but that can also do these rapid response kinds of things.
- [18:54]
A
And more broadly, what really shocks and surprises me about all of this is that South Africa should be a natural ally of the United States. And I mean really right across the continent, but particularly Nigeria and South Africa, so important for American interests in the region. I mean, beggars belief. It really does. Anything else in the report? What about treatment?
- [19:23]
B
Well, before we do treatment, I just want to talk a little bit about one of the other reasons it's important to look at South Africa. And I would certainly say on. There are multiple levels on which we all benefit through any program where we understand that our survival is intertwined. So if we're doing an HIV program in Lesotho or Malawi or Niger, there, there is, I would say, a benefit to a program that is really based in understanding how to make things work, that those benefits come back to all of us, right? Not everybody feels that way. And in South Africa it's important to look at it because this was a place where we had invested again, billions of dollars in research. Collabor had a direct and material benefit to us. So not the sort of, not a softer, more nebulous benefit of sort of how do we learn to be humans and global community, but literally a research infrastructure that is pumping out insights and innovations that the US cannot get on its own, but that we need because we do not have the rates of certain diseases, hiv, tuberculosis, needed to trust to test strategies ethically, quickly and affordably, but we need those strategies. Right? And so just as one example, the US put resources into a trial conducted by South Africans that identified the treatment for drug resistant tuberculosis that is now the WHO gold standard, right? So South Africa does the research, who adopts it. It's a clinical guidance. If somebody coughs on me on a subway train in New York and I get drug resistant tuberculosis, my doctor will know how to treat me because of a trial that happened in South Africa. That is material benefit, right? That is clinical trial, research infrastructure that produces insights, innovations that everybody needs in one of the only places that can do it.
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A
Sure.
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B
And we pulled the plug on that too, Ben. And that's a level of waste. Not only waste of resources, but also the other trio, the other troika of words that we have to have at the tip of our tongues is safer, stronger and more prosperous. So all of the America first global health strategy is against waste, fraud and abuse and it's pro. Safer, stronger and more prosperous. I'm telling you something. Losing our research partnerships, losing our access to clinical trial sites and collaborations where we are able to say, can we ask this question? Can we learn more about this? That doesn't make us safer. Literally doesn't make us safer.
- [22:01]
A
And we're pulling the plug on stuff that we've invested in and what a waste.
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B
Yeah, it's a huge waste. It's a huge waste. It's literally. That is what it is.
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A
Okay, so Tug going Back to treatment. What did you hear from folks who were on treatment?
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B
So we used an oral history approach, which can mean different things for different people. Some people want to just tell the history, their lived experience of a moment in history that is otherwise going to be recorded by the people with visible power. And some people want to do an oral history that starts with their birth. Basically, the beauty of oral history is people get to do a little bit of both. So I had a two hour long conversation with an extraordinary, an extraordinary gentleman, a beautiful human who really told me his whole life story. Probably 15 minutes before the end of the interview, he says to me, you know, I didn't get my refill three weeks ago. I couldn't bring myself to do it. I just couldn't. I know I'm stupid. I feel terrible. I feel so ashamed. But I couldn't, I couldn't go. You know, he'd been going to a clinic that saw gay men and other men who have sex with men and transgender people. And that clinic had closed. And he said, you know, the government workers are trying so hard, but it's not the same. They're not friendly. I don't feel welcome there. And it, in a way it felt first of all like the whole interview had sort of been leading up to that, but also the level of shame that he had about the fact that he just wanted to go to a clinic where he felt comfortable. And I say this because a lot of stories about what's happened in the last couple of years or the last year or so have focused on extreme examples, and that's proper to some extent. We have people who have died, we have children who have died, we have needless suffering, but the human dignity of being able to get healthcare that is acceptable, affordable, accessible and quality. Right. The idea that, and this is not the only person I spoke to like this, that, yeah, it's there. We know it's there. We can't bring ourselves to go.
- [24:25]
A
You can't underestimate how difficult it is for someone who feels they will be judged and stigmatized to go to a clinic. You know, the old venereal disease clinics were hidden away and, you know, the walk of shame to reach them. But in the context of a major epidemic, certainly we gotta think about how to do these services more effectively. So you don't have a separate train, a separate program for, say, for example, men who have sex with men or sex workers. But it can't be underestimated what a challenge it is to go into these very busy clinics, say, I'm here to pick up my refill of HIV medicines. Not only am I HIV positive, but I could be judged for being gay, for being whatever. And that's really heartbreaking.
- [25:26]
B
Yeah. And I think it also, again, comes to this question of what were we supposed to be doing at this time in the HIV response in South Africa and other places? There was no perfect roadmap, but we were supposed to be, I think, beginning to figure out how to integrate systems, integrate clinics, integrate services that might be standalone, that might not be feasible for the long term into a general policy population, or into take various approaches and figure out, okay, this proportion of clients, you know, at a gay men, MSM or transgender clinic can really can go to the general population. And what they really want is, you know, one dedicated counselor. Well, that's. That's different from. From an entire standalone clinic. This portion, you know, wants to just go into the private sector and see a doctor and, you know, they actually will spend the money if the free service isn't available. You know, in this other portion, you know, for whatever reason, we're going to have continue to try to figure out maybe some additional wraparound services. That's not just for keypal relations. That's for everybody. When you make a transition, you have a Runway and you go, okay, who needs what? What's feasible? And how are we going to know that we did this safely for everybody? And then you change. You change over time. I think that this man that I talked to, who was tormented by not having gone for his refill, if he had had six months or three months or whatever it was with the people he knew at that clinic, to say, look, this is how it's going. You know, you're gonna have an appointment there and you'll meet the doctors. All of these things make change possible. But what happened wasn't change. It was traumatic. So there's trauma. And I think that we have to figure out how to turn trauma into
- [27:14]
A
transition, because this was. We were moving from termination. And the termination of these HIV programs overnight across Africa, for me, is a crime. And it is a question now of how the countries, with everybody's help, rebuild or build differently programs, secure services that can help them get back on track.
- [27:45]
B
Yeah. And we can't do it without data. I think that's the other thing.
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A
Well, this was the other thing I was going to come onto. I mean, we've spoken about this report. As, you know, you're doing their PR for them. Anything that we've missed on that, Anything else you'd like to say, about the Physicians for Human Rights.
- [28:03]
B
I'll just say one more thing, which is that because of the way that we do our release forms and approach the narrators, people have a lot of confidence that their confidentiality isn't going to be disclosed. Which means that in both this report and one that we did in the first, based on oral histories from the first hundred days after the foreign aid freeze in Uganda and Tanzania, we were able to speak to government health workers who cannot give interviews to media, and I'm not sure yet, are participating in qualitative studies. We haven't really seen those come out yet of their experiences. So I was able to speak to a sister in charge at a township clinic and the data quality officer who happened to be there that day. And they were among the most terrified people that I spoke to, to be perfectly honest.
- [28:53]
A
Terrified of what.
- [28:54]
B
What they can't see, but they think is coming. So we were sitting there in a room and I had a pile of folders behind me, probably above my head, you know, and that's unlogged client files. So in those files are probably people that came back for their refills, came back for their tb, came back for the hiv. And so they're recorded right now as disengaged from care or lost to follow up. And there's probably also files missing of people who should have maybe got the diagnosis but didn't start treatment that day or didn't come back for their refills. And they don't know. And it's really important to sort of say that most people with HIV are going and getting their refills and they're stable on treatment, that this is not an unreliable population. This is not a population that has to be corralled into. So we're not talking about the majority, but to do epidemic control, to keep bending the curves of the HIV epidemic towards reduced infections, reduced deaths from advanced HIV disease, and reduced transmission during pregnancy and breastfeeding. You can't lose anybody. You can't lose anybody. So thousands of people, four digits or tens of thousands of people who are now going on and off treatment, didn't start their treatment, didn't finish their TB treatment. You know, it's a relatively small number of people. South Africa has a total number of people living with hiv, with HIV in the millions. Small numbers are gonna have a huge impact on your epidemic control. And so when this data quality officer says, I'm waiting for a bomb to blow up in our face, she's not saying, I think that the population of people Living with HIV is gonna default from care. But she's saying, I think that there's something going on here and I'm not gonna be able to see it until I see it in sick people admitted in the wards.
- [30:55]
A
Well, that's right. And that's the big issue with hiv. You get infected and it can take even up to a number of years before you start seeing symptoms. And it's that gap that makes this epidemic so pernicious and difficult. But let's talk about some other things. Let's talk about the U.S. government. I mean, a lot happening. We've you spoke about the data and I want to come back to that, that measly quarter of data that we've got. We've got issues with the supply chain
- [31:27]
B
which we sure do.
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A
We really need to talk about. And there have been some, you know, some significant high level staffing changes. And maybe that's the place to start because literally, I guess hot off the press is that friend of the pod, Dr. Mike Reid, who was the Chief Scientific Officer of PEPFAR, is the Chief scientific officer of PEPFAR no more. He resigned in a way that I think was absolutely remarkable via a substack. And we'll include the link in the show notes to this. But your sense of what Mike had to do and what this means for other members of staff who are still there, still trying to carry on the
- [32:11]
B
fight, I think this is huge. I think it's really, really huge. If we look at the whole course of the last 15 months, the Bureau of Global Health, Security and Diplomacy, which is where PEPFAR is run, has not had a single high level, what they call career, meaning they were there before the administration change. Not a single high level career has publicly left and said, I can't do this anymore. We've had it with cdc. We had it as USAID was shutting down. We've had it with fema, we've had it with the Department of Education. No other federal agency that has withstood the kinds of changes that have happened. I can't think of another one where the careers have been so stalwart. So let's applaud them. And Mike says in his substack, these are tremendous people working under immense, often immense strain right now. So we haven't had a departure. And Mike said in a substack, I can't do this. I can't be sure that I can keep doing my job without being essentially warped or implicated in things that I can't stand by. It's very specifically talking about Global Health as being inherently anti fascist. Right. Inherently about solidarity, equity, human rights. And that he can't reconcile implementing a program that should be based on anti fascist principles for this administration, which he doesn't call fascist. Although I'll tell you, if you're not antifascist, I can tell you what you are. But he does call them authoritarian. And I really, really hope that folks sit up and take notice, because it's not. He didn't walk out to meet Dr. Demetri and Deb Khoury and the CDC. He didn't get clapped out. But this is a moment where you have somebody stepping out and saying, I can't do this and everybody should be concerned. And it's generous that he did it. It's generous that he stayed. It's generous that people are still on post. I mean, this doesn't mean we don't want all the careers to walk off. But he's saying to people, especially in Congress, who are starting to pay closer attention, you are right to be concerned.
- [34:34]
A
Right. I mean, it was a very, very brave thing to do. I think he has really worked over the last however many months to keep the train running, keep the elements of pepfar that matter. But it has been a challenge. And I think the way that he has done this will undoubtedly cause personal cost and we all have to stand by him. But as I said, we'll include his substack, as indeed, as always, yours, in the show notes, and I'm sure we'll be seeing much more of Mike on the podcast. Okay, let's talk data. The US released a report, you said, at the start of the podcast, identifying how well and how marvelous the data was, showing how well they were doing. Doing.
- [35:35]
B
Yes, they did, Ben. We will put the link to this maybe in the, in the, in the show notes as well. It's not funny. It is. But some of this, at some points, you have to maintain a sense of humor. So, in fact, my substack started on August 8, a year, you know, not a year ago, but at August 8, 2025, when I noticed that, that PEPFAR, a program defined by its data use and data and transpar, removed the planned release date for a quarter's worth of PEPFAR program data, which by the way, was routine, transparent, you know, discussed at the country level, discussed at the regional level, helped everybody to understand what was happening, including Congress. That date was taken out of the calendar to go, oh, hey, you know, it's August. So you guys, you know, came in and fired up your wood chipper in January, you know, it's eight months later. We could see some data. Nope, no data. And we've been in a data blackout ever since, ever since the Trump administration took office. And what I would say is I consider us still to be in something of a data blackout. So I'm not. I want to be very measured. And I was surprised by this, actually, that the release on Friday of one quarter's worth of data didn't really feel like a victory. It felt like confirmation that we are, at the moment, our global health programs are being led by people who are actively disinterested in aligning investments with impact on people's lives and health and absence of suffering.
- [37:18]
A
Let me ask you, can we trust the data that they release?
- [37:24]
B
That's a really good question. I think we can trust the data that they released. The data were collected by the same, you know, the same sites, the same systems, the same staff. There's a lot of talk about heroic people still on post, you know, country level staff and then headquarters level staff doing data collection. So I trust the data and I urge everybody to look at what AMFAR and collaborators have done with the same data set, which is to look at it and to come up with very different conclusions than what the State Department has come to. And I would not trust their press releases at all.
- [38:04]
A
Right. So it's their analysis and their interpretation. But I asked that question because Marco Rubio, Secretary of State and National Security Advisor, Chief bottle washer, whatever else to Mr. Trump, has indicated that PEPFAR is now only concerned with pregnant women and young girls. So am I right in thinking that the data they are collecting is from the pool of people they want to have the PEPFAR program work for or are they still looking at the broader population and, and you know, the populations like men who have sex with men and sex workers are still in there. That, I guess, is why I was asking the trust question.
- [38:57]
B
So you just opened up a can of worms there. So let's just take. There's all of these different things that are. So they're a little bit in the weeds, but we really have to be,
- [39:07]
A
get into the weeds vigilant.
- [39:08]
B
As I said, this is a moment for vigilance, right? You know, whether it's sunny or rainy when we step outside or the sky is clear, we gotta be keeping an eye. The visibility is very, is very obscured in this realm. So just on the pregnant and breastfeeding women, it's a really, really interesting thing. The press releases, the self praise, the self congratulatory press releases and Then what I kind of call the fabulation that is going on, you know, in other spaces, including a recent public appearance by, you know, Rubio henchperson Jeremy Lewin. They just could not be more pleased with themselves about what they are saying is an increase in the number of pregnant and breastfeeding women on PrEP. Here's the thing, Ben, is that up until January 2025, or whenever the waiver went into effect, recording whether your PREP user was a pregnant or breastfeeding woman was optional. It's what's called an optional disaggregate. Or if you're, you know, you roll like that, an optional disag. So you have a clinic that is serving people and they may or may not be recording that this is a pregnant breastfeeding woman. Okay. They may just, you know, this is a woman, she came in who knows right when you have. And in this case also called an indicator when you have something like that, you're measuring. Right. In this case, how many pregnant and breastfeeding women are taking prep. You have to compare apples to apples.
- [40:49]
A
Yes.
- [40:49]
B
So they're saying they're calling an increase. It was this many women to this many women. And that's a sign that literally this is their press release. We're progressing towards control of mother child transmission, which is also confusing to me because PREP is for people that don't have hiv. But. But there's many things in their press releases that suggest they don't really know how to drive the car they're driving. But just with the pregnant and breastfeeding women thing, they're celebrating an increase, but it's not necessarily an increase in the number of humans taking PrEP. It's an increase that is, we weren't asking before and now we're asking. So we're counting people that weren't pregnant and breastfeeding or may not have identified where. We don't know whether we increased or not. Do you see what I'm saying? We don't know because we're not doing apples to apples. You can take a year where everybody was doing a pregnant and breastfeeding disaggregate that was routinely collected at all clinics and compare it to the next year and say that that's an actual increase. Or it could be the same number, but you just started to report it more.
- [41:57]
A
Yeah. And the challenge is continuing data recording approaches that you started with. You can't make claims about whether things are improving or getting worse. Now, there was also data around kids with HIV on treatment. What were they saying?
- [42:16]
B
There this is another. And this press note that we're talking about came out yesterday. It came out on Monday after a weekend where the media coverage didn't go maybe in the direction they expected it to, and after congressional briefings where Hill staffers weren't buying what they were selling. So a media note comes out yesterday that is, I think I'm ready to go on the record saying it is the most bizarre document I've ever seen come out of PEPFAR about its data. I think I'm ready to just go there, say it. I'm just saying it. It's truly bizarre. Somewhat stream of consciousness, but not in a Joycean way, you know what I mean? And it says, look, the number of children on antiretroviral therapy went down year after year after year. And that's a really good thing because it shows that we're making progress against mother to child transmission. So here's the thing, Ben, again, it is not clear to me that the people that are speaking into a Dictaphone and then having that turned into a press release understand how HIV works. If you have people with hiv, adults living with hiv, you want that population of people on treatment to grow and to stay stable at a certain point, because some people are gonna die. You don't want it to go down because it means people are dying. With children, there's gonna be a certain number of kids that age out into adults, so lose it. And there are gonna be a certain number of kids. Okay? But the only time you would say, celebrate the pool shrinking because you know it's kids aging out into adulthood and minimal levels of death, you can't celebrate that until you have closed the gap between children on treatment and adults on treatment. Right now, across the world, only about 55% of children living with HIV are on treatment. Okay. Compared to much higher figures in adults. In some regions where PEPFAR operates, particularly in Southern Africa, south and South Africa, it's a bit higher. In East Africa, 2/3 of kids with HIV are on treatment. Not 100%, not 90%. So if you're celebrating that you have a reduced number of kids on treatment against a backdrop where, where a third or even a quarter of the kids who need treatment are not on treatment, you should not be celebrating.
- [44:52]
A
You have a problem, you have a
- [44:54]
B
problem, and we have a problem. If the people in charge of giving away billions of dollars for further health aid don't understand how to measure impact, and frankly, don't even seem to really care about what happens to children with HIV because they have removed the age disaggregate. There's that word again. You could say disagree. Right. They've removed the age disaggregate. So going forward, countries that have funding under the America First Global Health Strategy will report on two age groups, Ben. 0 to 12 and 12 months and up. Which is great for those of us like you and me who are sort of, you know, forever young. You know, we can just count ourselves in the, you know, you know, that, that big bucket category. But for kids that 50% of kids with HIV who are not on treatment die before this, their second birthday, 12 months and up. We'll never see it. We won't see it. We're not asking the question, so we won't see it.
- [45:50]
A
And this is, I think, what is so terrifying about this absurd lack of responsibility at the highest levels of the US Government. This is an example where you take a declining figure totally out of context. And given that we are reducing the spread and availability of these services,
- [46:19]
B
we
- [46:19]
A
don't know who isn't coming into the clinic, by definition, we don't know how many kids are being born with hiv. Well, that's a bit of an extreme assertion. Places like South Africa, places where PEPFAR is still functioning with the governments, yes, there are mechanisms for, for counting those, but given the disruption, we're not having the same kind of comprehensive data oversight that we had, that it gives us the confidence to say we're making improvements here.
- [46:58]
B
Yep.
- [46:59]
A
I mean, it's a grand shit show.
- [47:02]
B
It is. But I will say that between Mike's public departure and the most bizarre data document in PEPFAR history, This is affirmative of, and I hope catalytic towards a crisis of confidence in aspects of this program on the part of Congress, who has the power to do things, to make sure that different things happen. And so the fact that, that the folks in charge are publicly celebrating declines in children on antiretrovirals, there are people in Congress, there are leaders of faith communities who know very, very well that that is not something to be celebrated because they knew what the treatment gap was for children before the woodchipper got. Excuse me, got fired up.
- [47:54]
A
So what you're saying is success at this point in time is that we're closer to recognizing that this has created a crisis.
- [48:04]
B
Yeah, we're closer to recognizing, and it's really overdue, in my view, that the same people that brought us the Straits of Hormuz are running the America First Global Health Strategy. There's no difference. There's no plan for what to do with a crisis. And if I can be totally frank here. There has been too much accommodation, too much benefit of the doubt for the America First Global health strategy. Perhaps because historically HIV has been buffered from the political. Buffered from the foreign policy agenda of the. Of the administration in charge. We haven't had to see the HIV resources as of a piece with the broader foreign policy agenda. And PEPFAR is a perfect example of that because it is a genuinely effective program that saved millions of lives that was created by the person who also brought us Abu Ghraib and waterboarding and extraordinary rendition. Right, Right. So we know of what we speak.
- [49:04]
A
President George Bush. Second George Bush.
- [49:07]
B
Yes, exactly. So people have been pulling their punches, I'm sorry to say. People have been acting like we can look at the America First Global health strategy and say, you know, it's got strengths and weaknesses, there are opportunities, there are ways to work with it. Mike Reed did us all such a huge favor by leaving and insisting on a unity of analysis. You can't look at this strategy and not think about Iraq, Venezuela, ice in our own cities, Greenland. You can't do it is what Mike is saying. And I think we have. I hope he gives everybody permission to understand that that's the case. And you can't read the press release with the fabulations about what the declining trends say and not make connections to some of the truly bizarre things that are said about why we're doing what we're doing geopolitically in the world.
- [50:01]
A
Right. We need to accept that there is a continuity of crass stupidity, corruption right across everything that the administration is doing. There was a bizarre interaction that Secretary Rubio had with a senator in a recent hearing where Rubio said, if there's one thing I'm really proud of is that we've stopped male circumcision in Mozambique. And I'm not the world's greatest fan of male circumcision as an HIV prevention tool. May I call Per Kate Hankins. But that's just the way it is. But nonetheless, this was an intervention that had particular relevance in a group of people, by the way, in a state called Gaza that as we've noted on the podcast before, the brilliant Elon Musk assumed had to be in the Middle East. But it speaks to a sort of a cress, even a really don't care if, you know, I don't care about this.
- [51:04]
B
Right. Yeah, true. And again, I wanted to me, there's an opportunity. There's opportunities. So I think when Mike walks away from the program and says, don't be fooled, guys. This is the same administration. There's a unity. You know, Rubio's going to go and say this and that, that senator can turn around and say, okay, you know, duly noted. You know, Secretary review. Can you, can you please show me the data, the incident, the HIV incidence data from quarter one of the bridge plan, which is the three months, you know, we're going to have two quarters soon, but three months from October through, what is that, January, the first quarter of. And, and so I don't, I think that when we stop equivocating about who's running the show and what the quality of the program is, it doesn't mean we walk away from it. And I sincerely hope that I don't think Mike, oh, no, we turn right back around and we start asking for incremental changes. And I do think that we can get those. We can get improvements. We can get an age disaggregate back so we can see what's happening to children.
- [52:02]
A
So our third area on what's going on with the US Government has been an issue with the way the supply chain has been working. And is that an area where we can see some good news?
- [52:15]
B
I have no good news. No good news for you yet in that area. I mean, it depends what you call good news. Right. So I think that what we're seeing, what I'm seeing as a pattern is
- [52:29]
A
that
- [52:32]
B
sustained public attention and outcry and pointed questions from Congress do get a response. The Bureau and the administration are not impervious to critique. So we had a recent example where there was sustained public outcry, pointed congressional questions, media attention about how exactly the Department of Defense and the Centers for Disease Control and Prevention were supposed to continue implementing programs in countries that don't yet have additional money under the America First. How are they supposed to do that given that they'd been given permission to operate but no new funds? And the answer well, just use the money you have in the bank wasn't good enough. And I think that the, I don't know this, but certainly the fact that the Bureau asked these and the agencies to continue with no new funding and then several weeks later send a notification to Congress that they'd like to give them more money suggests to me that the critique got through. Right. So for the last couple of weeks, people, including myself, have been sending up flares about a situation that is so complex, I can't totally tell you what has caused it and what yet may resolve it. But it basically, it appears that the supply chain contract that manages everything. When PEP first started, it was the largest peacetime contract in US History, right?
- [53:57]
A
That went to a nonprofit agency called Chemonix in. Is it nonprofit? I don't know that it is.
- [54:03]
B
No. Chemonix is for profit and it didn't originally go to Chemonix, but it's a contract that's held by an entity called Chemonix. And something real weird started happening a few weeks ago, maybe even longer. Suppliers weren't getting paid, right? Their invoices weren't getting paid. And there started to be concern about whether additional orders could be placed. And then emails went out from Chemonix to its country programs, basically saying we gotta shut down because we haven't received additional funds.
- [54:36]
A
Now, as you say, this help us understand supply chain. What are they supplying? I mean, is this medicine?
- [54:42]
B
They're supplying medicines, antiretrovirals, antimalarials, bed nets, diagnostic tests, TB medications, laboratory commodities, you name it. But they're not just. It's not Amazon, it's not an online ordering system. It's not even Wombo, which you might hear about, which is the global funds sort of procurement system. It's a way to order commodities online. It's that, that. But it's also what happens once you get to the port or once the plane lands. The supply chain contract also covers things like distribution from the port to the warehouse, from the warehouse out into the field, all the way down to what's called last mile distribution, which is really making it what it sounds like, getting it to the most remote terminal place that the supplies are needed. It supports forecasting, right? It supports stock tracking, it supports ordering, it supports all of these different things that go into making sure you have the stuff that you need them. I just learned today, Ben, we are. I didn't know this. Bed nets have a really long lead time. So you can't Amazon Prime 2 million bed nets if that's what you need for your country. It's not going to come in 24 hours if you click buy within the next 11 minutes. In fact, we needed to have been placing those orders now or before now for 20, 27, right? So when you start to disrupt a supply chain contract and people can't place orders that need to be placed for things that need to be there a year from now, and you shorten that lead time, you're looking at a world of suffering, right?
- [56:21]
A
Why is this happening? I mean, how did this come to pass? What did the government do to Chemonix?
- [56:30]
B
So I don't know. I don't Know, I mean, that's really the honest answer. And nobody can entirely untangle what has happened and where the bottleneck is. And Chemonix is a for profit entity. It's got, you know, billions of dollars. I'm not telling anybody to move money from one place to another, but suppliers not getting paid. I mean, there's all sorts of ways, you know, Chemonics will not say what happened. So we also don't have a narrative from them. So it's immense confusion. But I'll go back to something we were talking about earlier. These are the same people that started a war in Iran with really not understanding what happens if you don't then get control over the Straits of Hormuz. Right. We have the ability to, or the propensity right now in our administration to break things, to destroy things, with no plan for what to do. So I don't know what happened, but I know what the consequences are. And what we've seen now is again this sort of fabulation piece which Jeremy Lewin said, it's all myths that there's anything wrong, that there's any disruption. Nobody that I've spoken to, and I've spoken to lots of people, people who know suppliers, people who are in country, people in headquarters, nobody has clarity on what's happening. So I don't feel relieved. But I do do feel, I feel that there's a possibility because we have now seen that this administration with this issue sometimes mitigates that. If we keep talking about it, I don't have to be able to tell you why it happened, to tell you it's a huge problem. And if we keep talking about it, maybe we can help. Maybe it's congressional oversight, maybe it's a special hearing, maybe it's saying, look, we don't just want you to run through the end of the contract, which is now what they're saying, saying that's November 2026. Right. We want you to run through the entire period of an orderly transition, which for most supply chain activities is about a year. Okay? October is not a year from now, November's not a year from now. So I don't know what the solution is, but I do think that we have opportunities to. And not even opportunities. We have a mandate, we have a necessity, an imperative, Ben. It's an imperative to avert this disaster. This is the worst thing, this is the worst thing that could possibly happen to this.
- [58:58]
A
Well, precisely, because if there is a disruption in the supply of HIV medications, then we have a serious problem.
- [59:07]
B
Then we have A serious problem.
- [59:08]
A
Yeah. And we don't know yet if HIV medications are going to be subject to the same kind of, of frantic ordering that we're seeing with bed nets.
- [59:23]
B
Well, HIV meds, a lot of first line is paid for by the Global Fund. So it's really, it's different with different commodities. You know, the example. I've been talking about this a bit in the last few weeks and people have said, you know, what does it look like? What do we need to worry about? And I keep coming back to this oral history, this conversation that I had in the first round in Uganda and Tanzania in the first hundred days, it was Good Friday and the clinic executive director, program executive director and her clinical officer came in and these are people of faith. So that was actually kind of a big deal. And. The drugs were in Uganda. They were in a warehouse in Uganda. But when the supply chain contract got turned off, the same contract got turned off when it got reactivated. Not all of the subcontracts, not all of the different, different components got turned on. So there was, it was possible to get drugs into the country and into the warehouse, but the last mile delivery to get them out of the warehouse and distributed, that didn't get turned back on. And so because of that, this clinic had not had enough medication, including for its pregnant women. And 25% of a recent cohort, a recent cohort of women living with HIV had given birth to babies who are PCR negative, who are positive, HIV positive at birth. And in a cohort with a regular drug supply, that would have been zero. And so when people say what happened, that's a wobble in the supply chain. That's a wobble. That's a minor disruption.
- [61:05]
A
Look at the impact that has.
- [61:06]
B
Look at the impact that has. But I also, people with HIV and people who get people to do, we want to sort of manage concerns because Global Fund procures a lot of antiretrovirals. I'm frankly, I'm very worried about bed nets. I'm very worried about, about malaria, pediatric malaria, you know, no bed nets in the rainy season, you know, super high mortality rates. I mean, there are things that we just.
- [61:31]
A
You haven't mentioned TB procurement. How much at risk is that, do you think? In this.
- [61:37]
B
Well, there's, what is it? Global drug facility is another. So procurement is. Its whole, is a whole complicated world. And I don't. You can't speak in generalizations. It goes country by country, commodity by commodity and disease by disease. But I think so. So I would say that it is which my friend Jeremy Lewin is using as an explanation. We're going to go country by country. We're going to go context by context. You can't do that unless the entire system is humming along in the background. You can't shut down the system and then meet individual country needs. So we just keep coming back to this issue of orderly transition, people. Orderly transition. You know, there's, it's, it's been reported, though I haven't quite nailed this down, that the original plan was to keep this Chemanas contract running through 2027. The clearest proof that I see is in the Memorandum of Understanding where several countries implicitly say we're, they say we're going to use the US supply chain contract, which is Chemonix. And then Uganda had an implementation document that listed by name this contract GHSCPSM for the entire five years of the MoU. So people were expecting this to be around. And so we really need State Department leadership to revert to what appears to have been their original plan. I don't know who got upset, I don't know who stole whose toys or who, somebody didn't share their cookies or something. I don't know why we got into this mess. But let's go back to what we were gonna do and not do this engineered emergency of having people uncertain about whether we have a US supply chain and procurement contract.
- [63:21]
A
I mean this is really crucial. It's central to the effectiveness of any infectious disease response. And I'm just grateful that through your sub stack you're keeping a close eye on this and will keep us informed as we get news. You said earlier that you were firing up flares and this seems to be one of those flares.
- [63:46]
B
Yeah, well, and I think, you know, one of the things that we, we're in the business of telling fact based narratives. We're in the, in, in the business of being clear about what's going on. And we're in a kind of, for me, covering HIV and doing HIV related work in a time of unprecedented obscurity about what's happening and, and we cannot report, I think with the same level of certainty and clarity that we used to be able to because the information is so incredibly hard to get. But we can say this is an area of concern. Something here doesn't look right. And so with the email and the piece that I wrote that shared that countries had been told you're gonna have to shut down by the end of April in some cases, I can't tell you why that email gets Sent. I can't tell you where the funding bottleneck is or who's to blame. And I' like to be able to do that because that helps us figure out the solution. But I can say what I know and if I'm wrong about some part of it, the correction can help us figure out where to go. So I do think that there's a imperative for people now who have information to put it out there, validate it and put it out there before you have the full explanation. If you think that telling what you do know can help us all figure out what to do next. And in this instance, we don't know what happened, but we know that we need a stable, orderly transition with supply chain procurement contract.
- [65:12]
A
Yeah. Which again, you can't do through a sudden termination.
- [65:15]
B
No. You also can't do it in. What are we in April, you can't do it in six months. Can't do it.
- [65:24]
A
And of course, the people making the decisions are not familiar with the subject, putting it politely, are not listening to the experts who do know how these systems work.
- [65:37]
B
No, they're busy celebrating that we have declining numbers of children on hiv. HIV treatment.
- [65:44]
A
Well, I'm having a hard time finding anything to be cheerful about here. I mean, is there anything happening that we should be.
- [65:52]
B
Well, you know, look, I think that this is. I think it's good. I think it's good that we have the data, we have the stories that the, this administration's leadership wants to tell about the data. We have Mike Reed saying, don't be fooled, it's the same people. And I'm coming out and I'm going to work with you on the other side. And we have something that I'm kind of curious about, Ben, which is I know you have a project in the works that I'm.
- [66:19]
A
Oh, I have a fiendish global plan. Yeah. Just coming is a new initiative from a shot in the arm media which is called AIDS 2060. And it's thoroughly irreverent. And I think everybody knows how much I loathe and detest targets, not least the one that the UN General assembly imposed upon us, ending HIV as a public health crisis by 2030. I mean, what on earth does that mean? Anyone's guess. I don't think we were ever going to achieve that, that we're certainly not going to achieve it now. And so what I'm doing is starting to look at what are the long term things that we need to commit to and anticipate so that we recognize that HIV is going to be around. Hopefully we'll be in a situation where we can manage it at the individual level and that we can have a, a clear strategy about the long term investment that's needed, the long term investment, particularly in research and development. Because even with the grand news about Lena Capavir, that's not the complete picture. We still need the research. We don't have a cure for hiv, we don't have a vaccine. And I think the biggest challenge with HIV is the stigma, is the discrimination that goes with it. We talked about people not coming to clinics because they were fearful of being judged, fearful in some countries of being persecuted and identified where if you're gay it's illegal and facilities are required to report you. So I took the, the notional idea of the Global AIDS Conference taking place in 2060 and what would we expect there? What would we like to see? And so there are going to be a series of podcasts and thought pieces around some of the trends. We kick off with what's going on in San Francisco, which was one of the early epicenters. And looking at the San Francisco Community Health center, which of course I'm chair of the board of, but which I think gives a really interesting insight into how to manage things with, you know, as my sister would say, knit your own yogurt approach, which is if the resources are poor, you find ways of getting around it. I know our dear Yvette has other terms that she uses, but I also think that it's time for us really to consider some of the, the bigger 38,000 foot level challenges that we've not been able to accommodate. It is shocking that the HIV epidemic could be so disrupted so rapidly. And that's a US investment. But it's also because, and I confess this as a former partly still HIV exceptionalist myself, we haven't made links with other health priorities. And so I'm really going to be looking at how we fit into the global security conversations where disease spread has geopolitical effect on regions and political structures and stability, looking at how we link with the climate crisis because it won't just be hiv. That was the first of these new wave of zoonotic infections coming through, where we get closer to animals, where we expose ourselves to more pathogens that we, that we didn't know existed. And also to look at where the future of leadership is going to come from. We're going to be talking with established leaders in the HIV response now to get their thoughts, but I'm particularly interested in looking and meeting with people who have made a decision now to have their career in hiv and what are their expectations, what are their hopes? That I think is going to be the most interesting thing. And while you have given me the floor, I have to say that in my role as co chair of the other organization I'm involved with, we're embarking on a major strategic change that is the MTV Staying Alive foundation that has now been renamed at a formal launch in Nairobi, Kenya as Sugar Global. And of course, Sugar is the name of the TV programs that have been produced over the course of the last decade or so. And I'm really excited at what Wame Jalo is doing at Sugar Global now to make sure that content creation digitally as well as the traditional terrestrial TV series, what that can do to help drive behavior change, drive of greater understanding of what HIV is, how it fits into the broader structure of sexual reproductive health, growing up, getting through your teenage years and living a full and healthy life.
- [71:47]
B
I'm wondering if you can connect the two things because I think there's something in your AIDS 2060 vision or your sense of where the world needs to be going, right? And this evolution, the launch of Sugar Global, taking something that's been around for 10 years, really continuing to ground in community leadership and having it be launched out of Kenya and out of Africa, is there something in that development that also feels like a seed crystal or something that we need to take and nurture and make sure is part of whatever the best possible outcome is as we move towards 2060?
- [72:23]
A
That's a really tough question. I think why I'm so excited about Sugar Global is that this is a vision that we've had for a long time, a good few years. And I even go back to the former executive director, good friend Georgia Arnold, who I think is one of the most important figures in the communication side of HIV prevention over the last few decades. And this has always been where we wanted to go, that the stories and the narratives were created by the folks themselves, not outsiders coming in and thinking we can make something interesting out of this. But there is a strong connection in that we have to build really strong alliances and collaborations with areas of the AIDS response that we've, we've let go. I mean, I think of content creators, and right now Africa's the place to be. I mean, this is a continent that is seeing a rapid rise in the numbers of young people who are immensely creative, who have high demands and expectations of what their governments are going to do for them in the course of their lives. And I think it's not a wild claim to say that Africa probably leads in content creation in both the creativity, but also the. The way in which the hustling and the using of digital technologies has actually proven to be a very effective mechanism to reach people in ways that we frankly in the north hadn't understood. So I'm really excited about this.
- [74:25]
B
25% of that is Yvette in the back of a car. I just. That's facts, that's science. Abina what I hear you say, where I see a connection also is who's telling the story stories, right? Not to go all Hamilton on us, but who lives, who dies, who tells your story? And I think with AIDS 2060 and with Suga Global, it really success, the outcome we want and need is one where the narratives and the storylines and the content creation are rooted in the communities that are also the focus. And so to me, there's a really interesting pairing of those two elements. Updates and of course a lot of other stuff has to fall online for countries to be leading and driving and autonomous. And I'm wondering if you have any wish lists or previews of things you want to see countries doing to sort of step into that narrative control moment.
- [75:21]
A
So you're right, and you and I have been really focused on this in recent years. The AIDS response and frankly, global solidarity and global economic stability has to be rooted in not excluding any particular region and in fact taking the continent as an area of great opportunity. And that is in the kind of mutually beneficial commercial political relationships. And so during the course of, of this next phase, this next 30 years, you want to see institutions like the Africa CDC, like the African Union, really grow and flourish. You want to see the emergence of biotech and health service delivery models coming out of the continent. It's happening. It's happening right now. And you want the leadership of this new generation with the challenges that it faces driving the agenda. So that means that us oldies in the north play a supportive role. We're still there. We still have an important role to play. But ours is one of support, it is not one of driving. And that I think will be one of the most important things we try and get out of AIDS 2060. The only thing I think that worries me is that in that process we may find ourselves losing how to reach, losing how we connect with key populations. Don't like that phrase, but there we are. Men who have sex with men, sex workers, drug users particularly. Although in the context of Africa, you could also say girls and women as part of that. But these are people who may well get excluded from the exciting general population growth and development. And yet these populations are key to making sure that the epidemic is controlled and then reversed. And I don't see us doing that by 2060.
- [77:48]
B
There's also. So there's really interesting data that I'll find and we can put in more detail in the show notes. But when you have an LGBT population, just as an example, that's safe and flourishing and has the right to health and human dignity, often your governance is better, your accountability is better. I mean, when your girls and women are healthy and strong, your economy is stronger. So really, I think that the kinds of progress you're talking about are gonna be hand in hand whether we measure it or not. And I would hope that we do measure it with a health and wellbe of all of the segments of the population, including those that are often excluded or asked to wait at the back of the queue.
- [78:29]
A
Well, it's gonna be connected with population redistribution as a result of the climate crisis, as whatever other pathogens are going to face us. For me, HIV is the canary in the coal mine. And it is that. It's something that we said earlier about the importance of recognizing that this is a dis. That you can get infected with some difficulty, but nonetheless. And it won't appear if you're not connected to any services until you start seeing your immune system being affected. And that means that an infectious disease can spread quickly but appear slowly. That's the worst place you want to. To be in.
- [79:21]
B
Yeah. Well, one of the things I like about AIDS 2060 is that you're sort of going, you know what? Can we get rid of this idea that it's going to be over? You know, can we get rid of this idea that the thing we need to do is to start having a different conversation, but rather, let's figure out what it looks like to have a conversation about HIV AIDS that extends that far into the future. Because this is a disease that if you just follow it, it tells you a lot of. About everything else. And if you address it, it tells you if you address hiv, you address so many other things. And I think that there's something in that. Your proposal that we actually extend the timeline, not because we're going to fail, but because keeping our attention is beneficial.
- [80:02]
A
That's right, yeah. And much, I think, of the early targets. No, not the early targets. I'd say the targets of around the middle of the last decade, the 20. We're about trying to save money. We're about ultimately reducing the investment. And you know that's bullshit.
- [80:22]
B
Yeah.
- [80:23]
A
We need the resources as. And that takes us right back to the start of our conversation, which is why if you are going to disrupt the flow of resources, you have to have a transition in place to make sure that they can be picked up, adapted, whatever, by the people who are going to be running them.
- [80:41]
B
Yeah. Yep.
- [80:43]
A
Well, my gosh, Emily, we have covered so much in the space of just over an hour. And there are a load of other things I'm sure that we could talk about. I'm particularly interested in us coming back to talk about maybe the philosophy of these. Let's break it and not bother about how it gets rebuilt, builds.
- [81:08]
B
But I feel like that was an abuse of the word philosophy, Ben. But that's. If you must dignify it. As you were.
- [81:17]
A
I wonder if there isn't a philosophy. We're getting into this conversation. We're not going to do this now, but this is a really good hook for our listeners and viewers to keep an eye out for the episode in which we will discuss this. So
- [81:34]
B
do toddlers on ketamine have a philosophy? Stay tuned.
- [81:39]
A
Stay tuned. Any final thoughts, things that we haven't covered, besides whether or not we have a philosophy or not of the second Trump administration? Anything we haven't covered?
- [81:53]
B
I think you look fabulous. And I think that your podcasting that you're doing, including colon meat cancer, is extraordinary and a gift to. Really, a gift to the global community. And I just want to thank you for that.
- [82:06]
A
Well, thank you very much. Yeah. And I appreciate all the support that you and others are giving me as I go through this. Well, I guess that's it for this episode.
- [82:18]
B
I think we did it.
- [82:19]
A
I think we did. Now I'm going to close out. Or do you want to close out?
- [82:23]
B
Oh, I will never get it right.
- [82:25]
A
Okay. Well, I don't know how many takes it's going to take for me to do this, but anyway, that's it for this episode. Thank you to Emily Bass. Thank you to Eric Espera, our director and producer. A big thanks to you. Now, you know you can subscribe wherever you get your audio podcasts, but we're on a push to increase the subscriptions to our YouTube channel and our Spotify video channel as well. So please subscribe. Give us five stars with that. Have a great week and a safe week, everyone.