A Shot in the Arm Podcast

The Future of the Global HIV Response: A Post-World AIDS Day Reflection

Date: December 9, 2024
Host: Ben Plumley
Guest/Co-host: Dr. Eric Goosby

Episode Overview

In this reflective episode, host Ben Plumley and renowned HIV expert Dr. Eric Goosby assess the current state and future trajectory of the global HIV response, just days after World AIDS Day. Looking beyond ceremonial events and existing targets, they tackle the big questions: Is the world really on track to end AIDS as a public health crisis by 2030? What comes next for prevention, treatment, funding, rights, and the integration with broader health systems? The conversation delves deep into the shifting geopolitical landscape, the risks to rights-based approaches, the need for sustainable funding, and the evolution of HIV into a manageable chronic condition. Both articulate an urgent call for transformation and partnership, offering sober analysis and guarded optimism.

Key Discussion Points & Insights

1. Where Are We in the HIV Response? (00:58–04:18)

• Achievements:
  • Tremendous infrastructure has been built over 25–30 years.
  • Effective treatment models and monitoring systems now exist.
• The Unmet Goal:
  • Despite progress, “we have fallen short of what’s needed to get across the finish line in 2030.”
    — Eric Goosby, 02:06
• The 2030 Target:
  • Five years out from the UN high-level political commitment, skepticism exists about “mission accomplished.”
  • Goosby openly states: “I don’t think that there’s really any way that we can reach it...” (03:00), but stresses that current advances form a critical foundation for future work.

2. Rethinking the Use of Targets (04:18–06:56)

• Historical Function:
  • Targets have mobilized political and financial support but may not keep pace with on-the-ground realities.
  • “We have used [targets] to our advantage...to give leverage...to argue to political leadership who make allocation decisions for delivery systems to make that investment and expand.” — Goosby, 05:08
• Evolving Need:
  • High-risk group targeting remains essential.
  • Expansion to rural and non-capital settings is now crucial.

3. Populations Left Behind & Rising Challenges (09:03–14:42)

• Key Populations Identified:
  • Men who have sex with men, people who inject drugs, sex workers, and in some settings, women and girls.
• Access Gaps:
  • 9 million people globally remain untreated.
  • Rights-based approaches are “under threat and being chipped away at...in Uganda, Ghana...not just restricted to HIV.” — Plumley, 10:26
• Socio-Political Backlash:
  • Rising anti-rights and exclusionary policies threaten progress, making it harder for marginalized groups to access care and prevention.

4. Integrating HIV Care with Primary Health (11:25–14:42)

• The Case for Integration:
  • “As a physician, you see the needs of that HIV positive patient turn into issues around coronary artery disease, hypertension, diabetes, early cancer detection...” — Goosby, 07:47
• Systemic Pivot:
  • Systems must “pivot toward what is causing the morbidity and mortality in our patients that we've already captured and committed to” rather than focusing exclusively on HIV.

5. Geopolitics, Funding, & Sustainability (15:41–36:49)

• Geopolitical Headwinds:
  • “Are [geopolitical changes] going to make it harder...to bring whoever from whatever setting and population into care?...Without a doubt.” — Goosby, 16:02
• Funding Evolution:
  • Reliance on multilateral/bilateral (Global Fund, PEPFAR) is unsustainable.
  • “Over the course of the next few years beyond 2030 [we need] sustainability of access to treatment for the people that we have made the commitment to keep alive.” — Plumley, 28:00
  • Emphasis on increasing domestic resources, innovative approaches (e.g., private sector, national health insurance), and smarter, more accountable international mechanisms.
• Role of International Banks:
  • Discussion of low-interest loans and debt restructuring with entities like the World Bank/IMF to retain resources domestically for health.

6. Biomedical Innovation: Where Do We Stand? (17:57–23:43)

• Chronic Disease Status:
  • HIV is now a manageable chronic illness in most well-resourced settings, thanks to long-acting antiretrovirals.
  • Integration of HIV care with treatment for NCDs is both necessary and possible.
• R&D Agenda:
  • “Do we need an R&D agenda anymore?”
  • Goosby emphasizes that R&D should now focus less on “blockbuster” new drugs and more on integrating existing therapies into broader chronic care, making them more accessible and usable in resource-limited settings.

7. Access, Equity, and the Role of Industry (23:43–27:42)

• Global Access Imperative:
  • Industry, donors, and governments have a duty to ensure innovations reach all who need them, not just high-income countries.
  • Goosby recalls the activism around access disparities in the 90s, urging a similar moral reckoning now.
  • “[We] need to prioritize the ability to benefit from [innovation] as the measure of our success in developing this innovation and our ability to apply it.” — Goosby, 23:56

8. Transitioning from Donor Dependence (28:00–36:49)

• Ownership & Transition:
  • Multilateral aid should drive capacity and “country-owned” responses, not create perpetual dependency.
  • A graduated, data-driven transition with baseline service guarantees is needed.
• Accountability & Partnership:
  • Patient populations and civil society must hold governments to account as international resources shrink.

9. The Prevention Conundrum (37:28–44:42)

• Stagnating Prevention:
  • Despite advances in treatment, prevention successes have been limited and uneven.
  • “We have done a pretty lousy job... getting rates down...increased epidemics [in] Eastern Europe and Central Asia...extraordinary rates...in young people in the Philippines.” — Plumley, 38:00–39:26
  • Biomedical prevention tools like PrEP are underutilized.
• Mixing, Agency, and Behavior Change:
  • Limitations of biomedical approaches due to social, gender, and cultural barriers.
  • Agency, especially for women and girls, remains a severe challenge.
  • “It's difficult to get behavior changes. It's one of the last things that seems to happen. It only happens when it has to happen.” — Goosby, 44:42

10. The Future of Global HIV Leadership and Architecture (45:05–47:57)

• UN AIDS After 2030:
  • Reflection on ongoing reviews of UNAIDS and whether its role remains vital post-2030.
  • Both hosts suggest that dedicated advocacy and coordination remain as relevant as ever given persistent funding and rights challenges.

11. Optimism vs Fatigue—Are We at Mission Accomplished? (48:01–51:21)

• Fatigue in the Field:
  • Some in the community are exhausted but “I’m on the optimistic side...I see the opportunities that have been created by this 30 year sprint [which] have the elements of the end game that's needed for us to preserve the drop [in] morbidity and...mortality.” — Goosby, 48:40, 49:00
  • A clear warning: “It would be tragic if [funding] drops started immediately...We are smart enough to do this so nobody gets hurt.” — Goosby, 50:20
• Transformation for Sustainability:
  • The donor role must evolve, with a clear destination of country ownership and longer-term, integrated planning.

12. The Role of Targets Moving Forward (51:26–52:47)

• Implementation vs Political Targets:
  • Goosby supports “public health implementation targets,” not arbitrary political markers:
    “That yearly bite is important to know...We’re good at [surveillance]; we have no excuse not to be iterative.” — Goosby, 51:44–52:35

Notable Quotes & Memorable Moments

• On Missing the 2030 Goal:
  “I don’t think there’s really any way that we can reach it, but the advances that have been made…should be looked at as the necessary structure on which to build…”
  — Eric Goosby, 03:00

• On Political Will and Accountability:
  “The population that needs and uses and depends on these services is not holding [governments] accountable…We need to reinvigorate that understanding and be part of the message to the person that we've been treating for 20 years: that you've got to have an agenda that holds your political leadership accountable…”
  — Eric Goosby, 27:41

• On Future Direction:
  “It to me is a moment where the needs coming out of pandemic in the background and in the future with primary care needs with that population we've already committed to, this is winning more for that group than we were in our original vision with just an HIV TB approach. This is what they really need and we're part of delivering that to them.”
  — Eric Goosby, 50:20

• On the Challenge of Behavior Change:
  "It's difficult to get behavior changes. It's one of the last things that seems to happen. It only happens when it has to happen…”
  — Eric Goosby, 44:42

• On Optimism:
  “I see the opportunities that have been created by this 30 year sprint have the elements of the end game that's needed…Our commitment to that population would be inappropriately inappropriate if we decided now to recede our investment…”
  — Eric Goosby, 49:00–49:27

Timestamps for Key Segments

• 01:00 – Setting the scene: Where are we in the response?
• 03:00 – Are we likely to end AIDS by 2030? Hard truths.
• 05:08 – Value and evolution of global targets
• 09:03 – High-risk and marginalized groups; barriers to care
• 11:25–14:42 – Integrating HIV and primary care; new risk profiles
• 15:41 – Geopolitical challenges for access and retention
• 18:38–21:34 – Do we need more HIV R&D? Treatment integration and the chronic disease paradigm
• 23:43 – Ensuring innovation reaches all who need it
• 27:42–36:49 – Funding dilemmas and transition to country ownership
• 37:28–44:42 – Prevention, mixing, behavior change, and agency challenges
• 45:05–47:57 – Relevance of UNAIDS/global institutions post-2030
• 48:01–51:21 – Fatigue vs optimism: Have we run out of steam?
• 51:26–52:47 – Role of public health vs political targets

Tone and Takeaways

The conversation is candid, urgent, and driven by decades of experience. Both hosts acknowledge the exhaustion and frustration in the field but remain convinced that with structural transformation, new partnerships, and explicit government responsibility, the world can preserve—and even expand—hard-won gains in HIV. The time to begin that next phase is now.

For listeners and stakeholders, this episode serves as both a sobering reality check and a roadmap for what must come next if the legacy of World AIDS Day is to be more than just rhetoric.