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A Shot in the Arm Podcast
Why We Need a World AIDS Day More Than Ever - with Emily Bass and Ben Plumley
01:16:00
In this special World AIDS Day episode, Emily Bass and Ben Plumley delve into the current and future state of the global AIDS response.
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- [00:01]
A
So welcome to A Shot in the Arm. I'm Emily Bass. And I'm Ben Plumley. And then I'll just take it from there.
- [00:05]
B
We just used that footage. That was perfect.
- [00:08]
A
Yeah, I think that's an outcut we can use.
- [00:13]
B
Welcome to A Shot in the Arm. I'm Emily Bass.
- [00:16]
A
And I'm Ben Plumblege. Emily, it's great to see you.
- [00:20]
B
Great to see you, too.
- [00:22]
A
So, look, this is our pre and celebratory, if that's the right word, World AIDS Day podcast, where the podcast is also going to do a domestic World AIDS Day podcast, because the state of the AIDS response in 2025 is perhaps nothing that we would have expected when the year started. But before getting into that, one of the things that's been most exciting to me this year is the rise of the Emily Bass substack and the way in which you are covering particularly things from a US perspective in terms of the US Administration's activity and what it means for the rest of us around the world. And I think it's become hugely influential. The link, of course, is in the show notes, and I thoroughly encourage everyone to go there. But how has it been? What are you covering and how are you finding the medium?
- [01:26]
B
Well, first of all, Ben, I don't know that I'd be doing any of it if it wasn't for you. And our ongoing conversations and collaboration around doing responsible storytelling in this moment. And so, tip of the hat, or of the shot, as it were, to you in particular. This is going to come up again as we talk about World AIDS Day, which is traditionally a moment when the US Government, every year for over two decades, has given a. A detailed, reliable state of impact, state of the impact, state of the investment. What have we paid for and how many lives have we saved? With the President's Emergency Plan for AIDS Relief, or pepfar, and Global Fund Investments, it's been a moment to take stock and to really both hold the gravity of what it meant to respond to a pandemic, but also to see what we've done. We're not doing that this year. And in many ways, the substack has been filling a gap. It actually started the first post in August was about the absence of data from pepfar, and essentially what I've been doing and what it seems the mandate is, or what the need is that this stack is filling is providing information that in any other time would have been provided by the US Government. That's what's kind of extraordinary about this, is that the stories that I am covering are what are the plans, what are the strategic documents structuring those plans, what are the proposed agreements? Who is doing the negotiating? All of this information in any other year and in any other moment was publicly, officially and systematically shared. And it's part of what made our impact possible. The substack. What's interesting about it is the extent to which for the folks that are reading it, it feels like it's providing information that's urgently needed. And we should also just take a step back and go, this information is not extraordinary. It's not classified. It is absolutely needed. What is extraordinary is that I have to be the one to put it out there.
- [03:33]
A
I mean, it begs the question and tell me to back off, but where do you get that information? I mean, is it in the public domain? It's just not being structured and organized in the way that we used to know? Or are you having to do just a little bit of digging to pull it out.
- [03:54]
B
Back off?
- [03:57]
A
You know, there's, there's indie
- [04:01]
B
British rich
- [04:02]
A
in the original house of cards that was British. The evil Prime Minister, when faced with questions like that, would say, well, my dear, you might think that I couldn't possibly comment, so we'll leave it at that.
- [04:21]
B
No, is that the information I don't want to create? More certainly we're not in house of cards zone. The information that I'm able to share is unclassified. And there are people working on this issue who care very much about the extent to which impact to date has been tied to everybody who needs it knowing what was planned. So that's what I would say, hear
- [04:49]
A
you loud and clear of the substacks that you've released, which are the ones that really you're most happy about and ones that are, let's say, frustrating you in terms of reach.
- [05:02]
B
The ones that I like the most are uniformly the ones that are the performing least well. And so that's just, that's a learning for me. But let's, let's be clear. I didn't get into this to sort of compete in the information economy or to have a substack presence, quite honestly. You know, I have another book I was working on. I was very happy doing that. And I hate reporting this story more than I hate anything, any story I've ever covered. The stack I'm most concerned about is the stack I posted on Friday which contains the full text of the proposed specimen sharing agreement that countries that are also signing the memorandum of understanding with the US Government for additional funding in global health through the State Department, will be asked to sign a specimen sharing agreement with terms that are so non reciprocal and so non respectful and responsible in terms of what a country that shares information can expect to receive in return if a vaccine or test or treatment is developed based on that information. That I'd really hope that this specific language would, and I do hope that this specific language will catch people's attention. The independent working group that is negotiating language on this issue for the pandemic agreement, which starts to meet this week and goes into formal sessions next week, and that's called the Pathogen Pathogen Access and Benefit Sharing or PABS text. So this is really a moment to bring what we know based on the copy I've seen, and maybe others have it, what we know about what the US Is proposing into those discussions. And even before I shared that language, both the elders and the independent board led by Michelle Kazachkin released statements saying more broadly, don't sign bilateral agreements. But little did we know what was in these bilateral agreements. So that's the stack I'm thinking about the most right now.
- [07:12]
A
Well, we'll definitely come back to the pathogen specimen agreements, both at the international level and the American bilateral level. But I mean, it does just speak to the priorities of this administration, which are America first, go it alone, we'll do it our own way and we won't get involved in the multilateral system. And again, I think that's going to have a critical underpinning to our conversation. But if we then think about the state of The AIDS response 2025, how do you think we're doing? Loaded question there. But it feels to me that we've been hammered on all sides. It's not just the US it's major European donors because of what's happening and continues to happen with this crazy US Monolateral, if you can have such a thing, proposed peace plan for the Ukrainian and Russian war, how do you think we're. We're doing?
- [08:24]
B
Well, I think that, I think that this has been a huge week. So we, we came to the end of this week with, with a number. It's, it's not the final number, but a provisional number for global fund replenishment that included a larger than expected US government contribution, providing that the US also pays the money that it committed last year. So the 4 point X billion, I'm, I'm losing the number whether it's 6 or 8. But if that number includes 2 billion, 2 billion in pledges that hadn't been paid out, then the new money is is is 2 and change, that's very little. If it's 4 plus the 2, that's much more than people expected. The overall total is lower than what folks were aiming for, but there's a possibility to see it bumped up. So what we have between the global fund pledges and potential full replenishment and the ongoing information about the US government bilateral negotiations is the first sketches to me of a map of what the future is going to look like. The future of US investments in global health may very well be in this kind of global fund space. These MOUs are really designed to off ramp countries from US bilateral aid and from any kind of ambition around co partnering or pushing towards service delivery approaches that lead to epidemic control. So we're really not, we have to begin to, and perhaps folks who are already there, and I'm catching up, move out of a mindset where the US has any ambition about, for other people or for saving lives embedded in the way that it's spending money. That's not it.
- [10:20]
A
Yeah, I mean I think we, we were going to come back to the US in more detail but I think it makes sense for us to just dive in. But before doing so, I mean so much of the response that I've seen coming out of civil society, out of the east coast, even the west coast of the United States has been, you know, Chicken Little. The sky's falling, the sky's falling. The one thing that I think, I mean you say we're beginning to see a roadmap. I'm thinking we're beginning to see truly that it's a shit show. But the one thing to me that stands out is this emergent Pan African particularly sense of this is our problem, we're in control, we need to take the reins. And I was listening to a Chatham House conversation, very British, a couple of weeks ago with the head of the Africa CDC who was very clear that so much of the responsibility both has to be taken by African American countries themselves and by their regional institutions. But also there's a real willingness to do so. Now whether that willingness translates into action is another matter altogether. And the one thing that I've worked on this year, despite all my health issues, has been the release of the HIV Leadership Forum's transition report and the way that it has said, look, we do not need these international NGOs coming into our country reporting directly to the US or the Europeans or they need to be fully part of our national response and also the salaries that they pay, which are way above what we can pay need to be rationalized and then we need to hire local folks. And then the other thing, and this comes to your point about data, is that we gotta stop submitting data for donors and really focus on providing data for ourselves that help us inform our epidemic responses. And that to me feels like, yeah, go on, let's do this, let's do this. This is a really concrete set of actions that makes this generic call for bold leadership from the African continent something that's real and can make a difference.
- [12:59]
B
Yeah. So a few things come to mind. I mean, one is, speaking of substacks nobody loved, I'm a little obsessed with monster movies and disaster movies and went down that rabbit hole early on in my, in my stacking and casting life with you, I don't think I see a pathway, but I do think it's after impact, when the dust starts to settle, we can see the landscape. And what I would say right now is that there's the voids or the vacuums are clearer. There is not going to be the US bilateral strategic micromanagement of an HIV response that has defined the HIV response for better and worse for, for years. And I think again, where, where there's plenty of things that we can say in the, in the back casting or looking back over what's happened, what I always want to come back to is, is what were the, what, what was the impact that was achieved in a given country under the conditions that we're now saying were suboptimal? And if things were going in the right direction in some way, what was driving those things so that we don't throw them out? And I think, I think the, the issue here is going to be different country by country by country. Just as one example in, in Kenya, when they negotiated their Memorandum of Understanding recently, the, the county governments which had been receiving at that point, 75% of the government to government funding from PEPFAR, were not included in the negotiation. Right. And it went straight to central government. So that's an instance where you go, what do we expect? Or what would be ideal from that sovereign nation? Would it be to say, hold on, we have a decentralized health system. In fact, we have sort of decentralized devolved government. And so you can't really leave out the provinces or the subnational units, the counties from this, because they're going to be the ones that have to deliver impact. And if a central government doesn't do that and instead says, hey, we'd love to have the money, that doesn't mean it won't happen later. But I, but I do think we have ways that we can. And when I say we, it's an uncomfortable we. It's not, it's not my job as someone in the global north, but I think that there are ways, very, very concrete ways to begin to look at whether African countries and other countries that are navigating the void that's going to be left by US Government leadership or ambition tied to public health impact in their investments, stepping into it. We can certainly say, what, what has that looked like? How are, how are African countries, this is an opportunity right now to say what, what is happening if, if the US Government is coming in and saying, you know what, here, use these off the shelf metrics that are very hard to, to interpret. And that's something we could talk about later if you want to. But the metrics that the US Is tying its investments to are, are really, really basic and quite hard to, to necessarily even say what direction they're supposed to go in. So if you're, if you're looking at diagnosing infants living with hiv, should the number go up or down? Well, it depends on how well you were doing to begin with. Right. And if it's supposed to go down the, you know what, you could just test fewer babies and the number will go down. So how do we tie our investment to impact? Well, the US isn't going to answer that question. I'm interested in how countries are going to answer that question and how they're going to, for example, look at the data sharing agreement and say, this is all well and good, but everything we share with you has to be transparently presented to our public because we believe in accountability. You see what I'm saying? There's a void, but there's also what sovereign nations do in that void, how they step into it is something is knowable and will give us a real sense of the degree to which there is substance behind this very important shift in posture around who's leading.
- [17:14]
A
Yeah, I think that was a very, it was a very brave intervention and very well articulated because that's a British euphemism for. Yeah, because it's tough. Because we're not saying, look, you know, Africans need us to report their data, which, let's face it, has been a underlying component of much of our international HIV solidarity. You and I have been arguing for a while, but particularly this year, that that era is absolutely over. And so it's a question of being told by countries what support they need. And that's the way that we really make the era of the AIDS response being this next era being truly led by Africans with our support rather than them doing what we consider best, whether it's coming from policy, think tanks or academic institutions. But we keep talking about America. So let's do that. Let's talk about the actions of the US administration. It's been a wild ride from the start of the year. Those executive orders, the closing of usaid, the cancellation of so much pepfar, and then suddenly that's reversed. Or is it reversed and now we're only treating the innocent victims in inverted commas. The pregnant mums, the mums with kids, and okay, we'll keep treating the people who are already on treatment. You know, that's us. You want to do anything else, countries, other donors, that's your business. But it's nothing to do with us. So talk us through what really, really matters. And again, I think this America, Global Health first, whatever it's called, policy that was announced in September is, is really crucial to this.
- [19:20]
B
The very brief answer I'm going to, I'm going to try this out, Ben, I'm going to try to be super brief is that there's, there's much in the global America First Global health strategy and in the, and in the rhetoric around what the US is trying to do, that first of all is not new. We were on a pathway to sustainability and country ownership prior to January20,20,25. And that if executed properly, and by properly I mean in alignment with the data, in alignment with the epidemiology and in alignment with an analysis of the gaps in programs, including ones created by the abrupt closure of usaid, the two week stop work order that left even programs with that later got their funding back. Scrambling to rebuild trust with communities. The very short answer is that the strategy is okay. The operationalization is dangerously breakneck in its speed. And that's the thing I think we need to really again dig into. That's where African leadership has potentially a role to play. There is no reason why these strategies, these memorandum of understanding that are supposed to structure the next two or five years of American global health investment and overseeing massive shifts in how we spend that money, who gets it, what it's spent on. Everybody has been aiming for those massive shifts and frankly going too slowly. But now we have a situation where we're supposed to have all of this executed in three weeks, all of these decisions made in three weeks with Mouse, I'm afraid, signed as early as World AIDS Day and in the high burden, high investment countries in sub Saharan Africa gunning to tie them up by December 12th. And when you look at the scope of the ambition, I know you want me to stop talking, but now I'm on a roll. The scope of the ambition versus the brevity of the timeline which included a government shutdown. You really have to wonder if it's sincere.
- [21:30]
A
Yeah, let's talk about these mouse. I mean they sort of come from Brad Smith's most excellent visits to Africa in the space of, I don't know, 15 minutes in total. I joke, but it was a very rapid set of visits that were supposed to conclude these MOUs. Were the MOUs directly referred to in the Africa First, Africa First, America first global plan or did they come out as something that took us a bit by surprise but could be argued, could be a part of that?
- [22:12]
B
So in the strategy we have compacts and a compact is a binding agreement in the vein of the Millennium Challenge Corporation. The McCarthy compacts, which, and the MCC was, was, was sort of came to life at the same time as pepfar. You know, George W. Bush, President George W. Bush was a huge innovator in the foreign aid space. And MCC was supposed to do for broader development aid what PEPFAR did for HIV aids. And for various reasons it didn't. And MCC compact is a legally binding, fairly complex agreement. And I went back and looked at the time to signing for, for those compacts and it was, it was, you know, one to one and a half to sometimes two years, I think, occasionally a matter of months. But the timeframe to get a legal agreement like that in place simply didn't fit with the realities of an administration that wants these done by December. And keep in mind America first strategy came out before the shutdown. So we didn't even know how little time we had. So that's an mou, that's the modification and it's not a legally binding agreement. And I think there are real questions about after this is signed, will there be some kind of shift or some kind of additional piece that's, that's, that's utilized to give it a little bit more teeth?
- [23:44]
A
And, and these MOUs are broader than HIV, aren't they? And the conversations that are happening with Brad and his team of merry men are happening primarily with ministries of finance bringing in health and agriculture and others as it's needed. But you know, in that immortal joke of the American tourists stuck in Ireland trying to find a way to, to Dublin, if you were to try and develop a country led effective program that truly, truly has impact, well, you wouldn't start from here.
- [24:27]
B
I mean, so there are three teams that have been out and about. Right. Brad is, Brad is on. Mr. Smith is on one of them with Dr. Rebecca Bunnell, who is the principal deputy assistant secretary who's been in charge of pepfar. We have one that has Mamadou Yillah, who is a longtime leader and keeper of institutional knowledge and wisdom and strategy, and then Jeff Graham. So we have actually three different teams that have been out, and bless their hearts, I hope they get home for Thanksgiving because this has been a long trip for them. But it's a very, you know, Jeff Graham made a stop in Kigali at a, at a global supply chain conference and took the podium and basically said, we want, you know, we want it. We want to get into sort of a customer client relationship with, with Africa through our, through our, you know, what are they going to pay for that? We have and invoked a drone company, you know, an American drone company that's going to be brought in to deliver medication.
- [25:31]
A
So it's a very zipline, I'm happy to mention them.
- [25:36]
B
Yes, exactly. Which, of course I, for a minute was like, oh, am I going to get to go through the trees? And like, you know, so what do we want to say about all of this? If you're trying to get into a transactional relationship with a, with a government with whom you want access to their markets or their minerals or their resources or their airfields, if you want to be positioned for whatever reason, you will not go to the county health official who designed the HIV response. Right. Because that's not. If your motivation is to be in a transactional relationship and to have a customer, you want the customer who has the most money, and that is central government. And we've been saying for years that we need to be bringing in ministers of finance. Where do we actually need something that is, that is already originated as our strategy? And just going back to something you were saying earlier around, we are not going to be gathering data anymore. I think we have to continue what we being at this point, global HIV stakeholders. There's going to be countries where that works brilliantly. There's going to be countries where the epidemic is growing in marginalized and criminalized populations whose existence is denied and repudiated and actually, you know, in jeopardy, jeopardized by the government. Gay men and other men who have sex with men, transgender people, sex workers, people who use drugs, refugees, sometimes people in prison. Those populations, if, if they are in countries where the government denies their existence, we cannot simply say it's Time for governments to lead. We being people who care about health as a human right. And so I do think that a tiered country approach or a sense of where additional external resources and attention to data. How is HIV doing in transgender people? How's Prep doing in those populations? So I think we have to be careful about the words that sound right because sometimes they're going to leave people behind. Country leadership is going to leave people in those countries behind in some places.
- [27:59]
A
See, here's what worries me. We are talking, if we're not careful, in a neo colonial manner that we've been really critical of certainly for the last 15, 20 years of the AIDS response. And it comes from our own domestic experience, which is that for the most part, national governments, very centralized national governments, where ministries of finances are in the lead, can't organize a piss up in a brewery, that you really need to have content as well as finance as well as dollars to be able to drive the agenda. And in a way, the statement that, you know, it'll depend very much on the country, but the skepticism that leading with central government and leading with the budget holder, the big purse string holder, who will then make decisions about how much health and how much social services get is an experience that we've had in the US and the UK that has been bad and we somehow have to, if not raise the alarm, at least share our experience to say this is what happened and to civil society in these countries, watch out and make sure you are able to take what you can from the experiences that we've had.
- [29:37]
B
Well, I think, I mean, it's always good, it's always an invitation to consider, you know, where, where, you know, transnational racism, which is the same as colonialism, and I mean, I'm going to be bringing it in, you know, consciously or unconsciously. By virtue of who I am. I mean, I, I think that, you know, I think there's a few things, I think there's, there's, For me, it continually comes back to the process and the time that national governments have to develop their responses. And it's not necessarily that it's not net bad or net good to go to central government. In fact, I think it's totally understandable and it's what we've been driving towards. But if you are going to central government, including ministries of health, which devolved health systems, are doing policy and guidance while the actual service delivery is happening, is managed at the, at the county or province or district level, and you're saying effectively, you know, over the next five years, or sometimes over the next two years you're going to have to take over a bunch of stuff that in the past was done bilaterally. And you know, we want to see your plans for that. The central function has not been delivering those services and the devolved governance has. And you could do a serviceable plan that, that mapped those two and that brought in community, community led and embedded services and that looked at things like what do we want to put in. In. There's a section in the MoU where you can list the policies that would be crucial to continue to implement under, you know, for example, your PREP guidelines. Right. If your national PREP guidelines list all the people that need PREP and not just the ones that are covered under the US Government waiver, that's a great thing to list. But that, and that is a, that is a direction we need to go in. But we're, we're racing there. And the corners that may get cut in that process are not necessarily even corners that, that are the, That are not necessarily, they will be cut not because of a bad intent in all cases, but, but they will be cut and we will end up with, with agreements including signing of the data sharing and specimen sharing agreements that aren't necessarily pro equity. You know.
- [32:15]
A
Well, I think good place to, good place to get into the, the pathogen sharing components here. I mean, I mean from a very simplistic perspective, this looks like good old 19th century British gunship diplomacy in which the US is saying, you will give us these pathogens. We'll do our scientific magic, assuming it exists at all, after what's happening from the Department of Health and Human Services. And then we will have a transactional relationship with you to make sure that you pay either what is being paid in the US or if necessary, a little lower. And this is a relationship that is purely between us and you won't go in any other directions. And that just seems so 19th century, so absurd, so out of date, and yet so clearly the foreign affairs component of MAGA of America first.
- [33:41]
B
I mean, you know, it raises questions about the quality of early childhood education in the US because certainly that's where I learned what the word share means. Right? So these are data sharing and pathogen sharing agreements in which the US Is not reciprocal in any way. In any way. And that has a level of disrespect in a way that I hope that and a sovereign African agenda will, will sort of push back on very, very specifically. What that means, let's just take a couple of examples, is that if the U.S. you know, look at what's happening with our immunization rates, look at what's happening with circulation of disease. You know, what if we have a new strain of measles or something that emerges here, right? And these are countries where they really care, you know, pediatric immunization, lots of childhood deaths from vaccine, preventable diseases. Hey, the U.S. can we have access to your measles strain? Right, because we have regional manufacturing capacity to make a vaccine and boy would we like to do that under these agreements. The answer is no. We don't have to give anything to African governments. And I think one thing to start to do to move out of this sort of colonized kind of conversation is to understand that everybody needs things for global health security and global health. Everybody needs things, we need things, but so do the other countries and that the exchange has to be multifaceted and multilateral. But the, the, the what is in the specimen sharing agreements right now is as you said, if you give us the information from a virus that's circulating, the genetics, a sample, specimens, and we make a test or a vaccine or treatment out of it, we will only give it to you after all of America's needs have been met. And we're not saying we're going to give it to you. It says we will prioritize your request, which I just imagine like a stack of papers this high, you know what I mean? And who's, you know, what does prioritize even mean? And we'll prioritize your request and assuming that financing is available, assuming adequate financial resources are available, we will give it to you at or below the cost that we paid for it. Now the US pays top dollar for everything. Our price for a course of cap of ear for prevention is 28,000 price in low and middle income countries covered by the voluntary licenses is 55. And we're not saying we will give you the technology transfer, we will help you with the ip, we will make sure that you can make this and those kinds of that is totally different from what's going to be without knowing what's going to be. That's different from the spirit of the, the pathetic access and benefit sharing agreement that's being negotiated now for the pandemic agreement.
- [36:38]
A
And that's something that the US has pulled out of, hasn't it?
- [36:42]
B
Correct.
- [36:44]
A
So that's going to be really interesting. You have a classic multilateral model that builds on the understanding of sharing that you were brought up with versus a sparkly. I don't even know how to describe it really, but this Monolateral imposition from the United States, the world's largest superpower for the moment. And how do you see this won't connect, but how do you see it not becoming an area of controversy and concern?
- [37:30]
B
Well, you know, one of the things that I was hearing before I before in the app, knowing that a bilateral specimen sharing agreement was, was in the works and not knowing what it said, the main concern among the folks that I was talking to was is it going to preclude countries from also participating in the agreements and arrangements structured by the pandemic agreement? And the answer is no. It specifically does not preclude countries from participating in the multilateral system. So it does not take countries out of a multilateral, hopefully, equity grounded access space. And, and that means that if you have genetic information in a publicly available database, which the U.S. says it will accept as, as a form of sharing, that other players could make the vaccine or make the test or make the treatment, and that the terms of access would be governed by the pathogen. Access, benefit sharing, where the PABSS agreement, not by the US Bilateral.
- [38:40]
A
So let me push you on this as you're much closer to this than I am, but looking at really the sloppy way the Trump administration thinks about things and makes changes as it goes along. Do the MoUs explicitly state you can be part of multilateral agreements or does it simply not make any reference to them?
- [39:07]
B
No, it does. It does. The specimen sharing says you can be part of multilateral agreements. But again, I want to turn this around and not to make, you know, a deliciously international podcast, super US focused, but to the US Audiences. Okay? Our scientific infrastructure and research infrastructure is being gutted. So we are not going to have the next vaccine. What we are doing forget. Well, don't forget. But yes, it's bad for African countries or signatories. It's bad for America. Bad for America. If we are in a situation where the next effective vaccine test or treatment is developed by a country that is not the US and we want access to it, we have taken ourselves out of that completely by not participating in the pandemic agreement. So this is not just about being extractive, it's about being putting American lives.
- [39:59]
A
I paused there because I'm just, you know, who would have thunk this 18 months ago that this is where we are? No, but I want to try a thought experiment with you, Emily. Let's see if we can have two conversations about things that don't involve the U.S. let's do it. Let's do it. The Global Fund Replenishment God damn it. There we are straight away into the United States. But as you said at the top, we've got around 11 billion committed. Whether that is seen in the final end of the three year period, we'll see a good chunk coming from the United States with some form of a commitment to pay the money they already owe. Though how that plays out is anyone's guess. I have to say. Although they were asking for 18 billion, which was clearly a ridiculous amount to be asking for in these current environments, I still think that the 18 billion number is a really serious, significant achievement. And again, as you said, there's still more to come in France and the European Commission particularly have not been able yet to put their numbers on the table. And besides the US we've got really good commitments from Canada, from Germany and it's small fry. But I don't want to exclude Ireland because they play such a critical role in continuing to forge a human rights agenda. So I'm feeling upbeat about that. How are you feeling?
- [41:45]
B
I share that, I really do. I think that, you know, we have 11 billion, maybe with a decimal figure now, and, and we are with uncommitted pledges. The, the folks that I know who, who follow this closely, we really could get to with. The magic number is one that's, that's allows a two to one match with, with the US Government, which is the last thing I'm going to say about that. We would, would we like more money? Absolutely. But if we can, if we can hit that, that's, that's fantastic. I mean to me that's potential in a multilateral space that really, as I've been saying with the just settling that is going to be where we look for global health leadership strategy and a continued focus on impact and any stability in that funding is going to be crucial to countries who actually want to execute this transition to leadership in a rational, sensible, phased manner. You need resources to be able to do that. Domestic financing isn't going to happen overnight. So the fact that there are resources there to do that is really exciting. It's going to mean efficiencies and squeezing blood from stones. And I think it means we miss opportunities to really seize innovation like Linda Capavere and potentially like long acting treatment agents, you know, once weekly pills and things which are, which are soon to be in the offing. But it is, it is. After the year that we've had, it is, it is. What is the Churchill, you know, so the best, worst, you know, it's, you know, it's it's, it's the, it's the best solution because it's so whatever, you know, it's, it's better than anything else, you know, we've seen.
- [43:35]
A
Yeah, yeah, yeah. And I think all credit to the Global Fund's very cautious and under the radar advocacy and their partners for getting us there. Although it's still going to require radical change from the Global Fund in the way that it does business. I think you could call it mission creep or you could call it sensibly responding to country needs as things like Covid and other pathogens emerge. But it's still nonetheless a major top heavy institution. And I think Peter Sands, the executive director says there's got to be radical change. I think he's absolutely right. But you mentioned the biomedical advances, particularly of Lena Caprevir, which is again one of the really good news stories of this year. But the Global Fund entered into an agreement with the manufacturer Gilead, and guess who? The United States government. And we have the first of the agreements out, which basically says yes to Zambia but no South Africa. You're on your own. And I noticed that our friend Mitch Warren from AVAC had put out a very tactful message of support for this announcement. But the best that I could come up with was that, you know, this truly is like the curate's egg. It's good in parts, which means that it's bad in parts and nowhere us, Gilead, the Global Fund can say that a country hit really hard by HIV should be excluded from this. I think we need to call bullshit on this.
- [45:28]
B
Well, to me the most underreported story and I really, I maybe you can explain to me why nobody's reacted to this. But is, is the announcement that China is making a huge investment in, in South Africa via UN aids. Right. That, that were so. And that, that's not directly answering your question, but I think it's, you know, what is happening in South Africa is incredibly important to watch because of the geopolitics around the health space. Right. So we've seen the US retreat because of absurd racialized mis and disinformation. Various things are happening that make our continued investment in South Africa as well as an assessment of the size of its economy, which Jeremy Lewin mentioned in this press conference they did about the Lena Cap of the year. So they don't need our help. So again, really not looking at where we were spending money before and why and just going, you know, we're out of this. China going great, I'm going to. We're going to step in, you know, in, under, in COVID 19, the first country that knew about the Omicron variant which emerged in South Africa was the United States. That is not going to happen again, is 100% not going to happen again for many, many reasons. But just again to bring this back to this is a 360° web of relationships and we are, we are missing the boat on why the US needs to be a partner.
- [47:09]
A
Well, to answer your question, if, if, if the role of the America first strategy is to bring a more commercial transactional approach that will partly compete with China, then it's going to be a rabid failure. South Africa is part of the BRICs, those emerging markets, as is China. Why wouldn't President Cyril Ramaphosa, why wouldn't he talk to other people in that group? And I say all credit to him for talking to the Chinese. I mean the Chinese have got big problems with their investments, let's not call it aid across the continent, both in terms of delivery of infrastructure products, but also the loans that they made and frankly the monies that they based there investments on. But the same could also be said for Brazil, which again back to unaids. It's now the chair of the Program Coordinating Board, the board of unaids. You have a history of Brazil supporting countries in ways that the US does not like. And I think rather than preventing these other initiatives from going ahead and you know, I'm the big bully in the school schoolyard, you'll only do what I say. I think it weakens American leadership really significantly. Weakens therefore, in the way that you've described, Emily, our security in terms of biomedical pathogens that could affect us, but also our soft power. Well, they don't believe in soft power, do they? But our ability to influence, but also the whole global security of the world, this is really unstabling.
- [49:09]
B
Yeah, and it is. And I think, you know, just wanting to return because I have, having worked with Mitchell Warren for 15 years, I can hear him in my head sometimes. We blew past Lena Capavir and let's go back there. This is a potentially extraordinary intervention, but there's no magic intervention. This strategy, like every other, needs to be put into programs that are responsive to people that are choice based, that say, hey, if you liked your oral prep, try this injection. Oh, you want to switch back? We're happy to have you switch back. Oh, by the way, we can meet you where you are. We can meet. You know, you don't have to come into a clinic and you certainly don't have to sit for 12 hours and many, many aspects of this to realize the benefit. Why do we want to realize the benefit? Well, in part because to prevent waste and abuse of resources that we have already invested in the HIV response. We, the US Domestic governments, global Fund, you name it. We also want to expand the market for it. We want to have more people want it, which means we have to get it to people. And there will be a private sector, there will be private health care, there will be people that want it just on their insurance roles, including in South Africa. So many, many, many reasons why you want to have South Africa in the mix and leading the way for what is possible, for what is ambitious and innovative and possible. And I have been spending the weekend and we'll go back to this when we finish listening to oral histories that I recorded in South Africa in September that, that very often tell incredible describe incredible ways that shuttered programs collaborated with the national government to try to restore some services. You know what didn't pick up is prep the community based prep for adolescent girls and young women. The ability to talk to young women who cannot control whether or not they are subject to sexual violence, gender based violence, rape, who desperately need education, information about prevention. Among many groups that really got hit hard by the foreign aid transition. And the, the idea that we don't have a responsibility, let alone an interest in, in seeing Lena Capavir rollout everywhere that it's needed is, is truly painful.
- [51:36]
A
It's going to rely on local manufacture or regional manufacture and that's going to take a while but it still has to be a priority. And I think that announcement from Gilead, the global fund in the US make the need for regional manufacture all the more important. And of course who pays the bulk of healthcare costs across many most countries in Africa? Well, clients, it's out of pocket expenses. So if we're looking at affordability of a groundbreaking innovation, then it's got to come from the countries themselves. Well, let's try one other subject that isn't necessarily going to bring us back to the US Although I'm not sure we'll be able to do it. Unaids, UNAIDS has had a bit of a drama this year. It's perhaps been the subject of one of those Brazilian novellas that go from cliffhanger to cliffhanger. And so we've got, you know, we've got as we know, a board, UNAIDS board approved plan probably to wind up, wind down by 2030 when of course we end the AIDS epidemic as a public health Crisis another matter altogether. On that we then have UN 80, the Secretary General's plan for the United nations family, released in September at the United Nations General Assembly. And there, right at the bottom, is a commitment to sunset UNAIDS by the end of 2026, which is a shock and takes I think pretty much everybody by surprise. But it does beg the question whether there is a continued role for UN AIDS in all of this. Poor little UNAIDS dealing with having to herd cats on heat that are its co sponsors. It's a joint UN program, so all the major UN agencies are part of it. Was this just a sideshow or is there anything you think we should be concerned about for the future of UN aids?
- [54:09]
B
You know, it's not a sideshow. It's not a sideshow for so many reasons. You know, one of them, which is, as you know, is a particular preoccupation of mine is, is having accurate, reliable data on the state of the global HIV response and the regional and the national response. Our ability to control a virus for which there is no vaccine and no cure has depended entirely and hasn't succeeded fully on knowing where to bring services and knowing how well we're doing that. And if we don't have that information, we can't do better, we can't finish the job, we can't repair what happened in the last year. UNAIDS is really essential to filling that gap. Right now. UNAIDS is still getting monthly updates from countries, it's still aggregating. Obviously the data collection systems are where they were funded by PEPFAR and where that didn't come back in, there's gaps, but that's a. Truly vital role. And it's like we cannot have any more lights go out in the pepfar, I mean in the HIV data response. So that's one piece of it. The other piece of it is that the wider landscape is seeing an array of conversations about the future of global health architecture writ large. How does financing work, how does governance work? There's unity, there are discussions, not WHO reform, but how does WHO want to position itself in terms of global health architecture? There's another high level meeting on pandemic preparedness. So we're in a, in a changing world where UNAIDS stands apart from almost every other governance structure in terms of engaging, meaningfully engaging communities that are impacted by the issue that it works on. We have a governance structure and a way of doing things within the HIV response that is embedded in UNAIDS and country coordinating mechanisms. We cannot afford to lose it, especially at a moment where we're moving to this idea of nationalism or national leadership or even populism that isn't always about the people in the country, especially those at higher risk of disease. So UNAIDS ripe for reform. Certainly we need to take a gimlet eyed look at it, but we also cannot. It's not a sideshow and it's not expendable.
- [56:55]
A
I mean I'm again completely agree. I know that when UNAIDS was established it was always, you know, Peter P. Always made it clear that this was not something that should become, you know, firmly institutionalized and we should be celebrating UN AIDS at 50 or UN AIDS at 60. Although I have to say I think the state of the AIDS response now may force us to have that bittersweet celebration. But I think there are two things. One, I think UNAIDS continues to play a crucial role in supporting countries the where they're good UNAIDS country directors help countries develop multidisciplinary. So that speaks to your point about civil society and marginalized communities helps countries develop these plans for submission to the Global Fund for Funding. And they play a crucial role in speaking truth to power, in making sure that civil society is heard and they play a crucial role in supporting ministries of health. I think the data side of it is particularly important, especially as countries and again you see this in the report of the HIV Leadership Forum as they move to creating data reporting for their own use. So it's for the country use, it's not for the donor's use which futures what we have been living with. But actually the US may be looking to make a major investment in UNAIDS as its data collector. And that fills me besides the fact that the US would breach its commitment to no multilateralism in the America first global health strategy. And it will be great for UNAIDS to get some more money. But what worries me, what really causes me concern is that whether formally or informally, UNAIDS is going to become a contractor of PEPFAR of the US Government if this funding is restricted to a quid pro quo transactional government data collection for the US government. And I don't see how UNAIDS can accept that money under those circumstances if that were to be the arrangement. That is not what multilaterals do. And if they do start going down that route, then I think we really have a big, big problem that is much broader than h.
- [59:48]
B
So a few things, I mean one is just historically, you know, I'll put my historian hat on is that the relationship between PEPFAR and UNAIDS has always been extremely cozy. Right. So at moments where, where the US wants to move to test and treat or fast track goals. Before there was the triple 95s, there was 90, 90, 90. There's an extremely close alignment between what PEPFAR wants to be driving its program to and what UNAID says the global strategy should be. It's the right thing to do, but it's also not a coincidence. Right? So, so let's just, let's let, let us be clear. For people that weren't maybe paying attention like we have always, the US has always had a, had a, has always made a contribution to UNAIDS and has often had, had things that were priorities that were reflected in what UN AIDS did. Okay, fine. Also, it's interesting I haven't heard that rumor. It's one of the reasons to cast with you so that I can get a little gossip. But you know, if, if where we are going, not necessarily the pathway, but if what we're seeing with the dust settling is the US operationalizing America first by divesting from bilateral arrangements and that put it in the business of delivering impact or self service delivery and writing a check to Global Fund and potentially to UN AIDS as a way that keeps it in, in the game as we've known it while also pursuing this transactional work that, that aligns with what we've seen with the Global Fund. So that's, you know, I like that in the sense that we're seeing some consistency. I think that what you're saying is exactly right, which is that the terms of the agreement are going to matter tremendously, not only in terms of sort of client, you know, or sort of contractor service delivery, but what is going to be in the fine print and will be an expanded version of the global gag rule be in the fine print? What kinds of terminology will be there that we know are going to be imposed on all of foreign aid and all recipients of US foreign aid funding? And how does signing on to, you know, attestations related to our, you know, gender language or edi, you know, how does that impact UNAIDS ability to play this role? That was one of the things, you know, we were just talking about in countries where human rights are violated by people who are most at risk of hiv, transgender people, gay men and other men who have sex with men, sex workers. UNAIDS plays an invaluable role in the local response, right? In securing people's safety. We can't lose that. We cannot lose that. So I think really what is the fine print? What are they signing away and what are they agreeing to and does this agreement, what does it look like vis a vis these, this MOU and the data sharing, the specimen sharing agreements, which are so incredibly transactional that. Anything that's going to be for the benefit of the countries or the communities impacted is going to have to be negotiated by the signatory. That'll be the same for unaids.
- [63:17]
A
Yeah, and you're right, certainly PEPFAR and UNAIDS have had a very, very close relationship in the past and I think it's sort of been one that has been coordinated with Global Fund, with one of the co sponsors who particularly. And it has made sense because forging a multisectoral response to the epidemic has needed these organizations again committed to the concept of sharing that you were brought up with.
- [63:54]
B
Three legged stool.
- [63:56]
A
Yeah, yeah, yeah. Do you know, I don't know that I was brought up with the same idea of sharing, to be honest. That's worth reflecting on, on a British public school education designed to educate me for the 1930s. Anyway, I do think that there is, I mean there's so much that is a priority that as we have covered in any one year, these would be enough. These would be our individual top priorities. But altogether it's a challenge. But I do think there needs to be a serious conversation about the future of UN AIDS and if we are to accept the sun setting of unaids, where do these key roles go? Because they've got to continue. And I think particularly the human rights components of UNAIDS that have been developed over its history are a legacy that need to continue. And I don't know where else we do that. So. Yeah, so I. Oh no, please go ahead.
- [65:12]
B
I was just gonna say, I think I was just chatting with someone this morning, you know, and it is, you know, the sense of these multiple different issues. This was related to the, the MOUs cover not just HIV, AIDS, but malaria, maternal child health, polio and global health security and a little bit of TB thrown in there, if I didn't say that already. And you know, sort of how does one pull all of that together? And I do think that sovereignty is the unifying national health sovereignty, particularly in sub Saharan Africa, or national sovereignty period, not just for the elected government, but for the population. Self determination is very much at the fore of what we're talking about and it unites all these issues. And if we, you know, if you run UNAIDS status through there, I think, you know, hearing from countries, not just the governments but also the communities, what do they need it for? And we are hearing that is really important. If we are serious about sovereignty and, and, and sort of transferring leadership and ownership, and you have countries and communities saying this is an essential component, you know, to our ability to participate or we need this or that, then for me, increasingly that is the way to pull all of these disparate threads together.
- [66:35]
A
Yeah, I think those are very wise words, Emily, because we have to reclaim sovereignty. Reclaim it and build it in a very different way. Because at the moment, the only sovereignty that appears to matter is the sovereignty of the bully in the schoolyard, the United States. So. Yeah, absolutely.
- [66:57]
B
Well, and I think we have to, you know, being in solidarity with, with people in Palestine and in Gaza and the west bank, you know, has, has brought the phrase self determination very much to the fore of a lot of our lips. And I think as we oppose genocide anywhere, and in Palestine in particular, realizing that once again, we are learning as well as, as well as being in solidarity and the idea, if you really sink into the idea of self determination and what does that mean for it, that is another way for us to think about people who are allies, who are not. Well, let me be clear. I'm in the People's Republic of New York right now, where self determination, you know, based on our, our wonderful new mayor is going to be hugely important. But I think we're talking about survival strategies in a, in a really uncertain and dangerous world. And, and a self determination that's rooted in society plus, minus supportive government is, is absolutely crucial.
- [67:57]
A
I feel that is a really terrific place to end this podcast. But I also feel obliged to ask, is there anything we've missed? Is there anything we haven't covered that we should have done?
- [68:16]
B
I think we did okay, don't you, Ben? I think we did kind of okay.
- [68:21]
A
Yeah, I think so. I mean, for me, the message is there's a hell of a lot on that none of us would have expected. I just want to give a shout out to international development workers, whether they're at UNAIDS or USAID or PEPFAR or some of the international NGOs we've been slagging off, but who've lost their jobs this year. And, you know, a real shout out to them and how, again, we got to help them, whether it's through a pivot or finding opportunities. You know, we didn't necessarily get everything right, but I do think our hearts were in the right place.
- [69:11]
B
Yeah. And I'll, I'll join you with that. And we got to shout out the people that are still trying to do it. Some of these people, these people are heroes that are working within the terms of these MOUs that are working to get whatever they can get for Global Fund. I mean, people that are still in this fight. There is no one that I am speaking to that isn't feeling a level of pain really. And of course, you know, I don't want to say hopelessness because Grace Paley, who I've quoted before, the only recognizable feature of hope is action. We're talking about people that are still taking action and putting one foot in front of the other, even though this is feeling incredibly, really destructive to life's work. I appreciate the folks that are doing the work and I appreciate the people that did it and, and got asked to stop really summarily in very cruel and abrupt ways. You know, and I think the other thing since you gave me the opportunity is just we all love you, Ben. How are you doing? And what, what kinds of comments do you want from your readers in the chat to cheer you on in the next phase of your your health journey?
- [70:28]
A
Well, funny you should raise that because in a couple of weeks you and I are going to be together and doing a live podcast in person rather than through the joys of technology. And I would love there to be questions about how I'm doing physically at this stage of responding to cancer. There will be a Colon Meet cancer episode coming out very shortly, which brings all the updates. I'm on a maintenance therapy now, not the killer chemos that were making my life so strange. There's a lot of humor in it, a lot of fear, a lot of anxiety. But I'm looking forward to getting back into the swing of things in 2026 and joining you and others to make sure that the goals that we set to make HIV go away in our lifetimes, that we do everything we can to achieve that. So in the notes on Facebook, on Substack, wherever you see this podcast on YouTube, please put questions in on comments and we'll come back to you with some thoughts of those when we meet again in a couple of weeks for our Ding Dong, Ding Dong Christmas special.
- [71:51]
B
That sounds fantastic.
- [71:53]
A
And holiday special.
- [71:54]
B
Holiday indeed. Indeed. Well, it's marvelous to be as, as difficult as the topic is. It's marvelous to be to be doing the dialogue with you, Ben.
- [72:06]
A
Right back at you, Emily. Well, that's it for this episode. Thank you to the incomparable Emily Bass. Do not forget to go to her Substack. Subscribe and follow these really fascinating and gut punching articles. They also include some very interesting popular music and popular entertainment references that should not be missed should not be missed. Thanks also to our director, Erica Spera, from A Shot in the ARM Media. And finally, a big thanks to you, our subscribers, our listeners, our viewers. Viewers, we couldn't do this without you. And if you haven't already, I really urge you to visit our YouTube channel and subscribe there. You can find us at www.YouTube.com podcast. Well, with that, it just remains for me to wish you a great week and a safe week, everyone.