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This Week in Global Development
Impact of HIV funding cuts, and the rise of digital public infrastructure
00:31:55
We dig into the details of a new report published by https://www.devex.com/organizations/united-nations-programme-on-hiv-aids-unaids-23691, which found that donor funding cuts to the HIV response could lead to...
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- [00:04]
A
My name is Adva Saldinger and you're listening to this Week in Global Development, hosted by myself, Rumby Chikamba and David Ainsworth. This week I'll be digging into the top global development stories of the week with Katherine Chaney, our senior editor for special coverage, and DEVEX senior reporter Jenny Lee Rivello. We're going to be talking about what we're learning on HIV AIDS as we mark World AIDS Day this week. New global rules for weight loss drugs. This is this Week in Global Development. Jenny, Catherine, thanks so much for being with me today. I'm looking forward to chatting with both of you. I know that Monday this week was World AIDS Day. And so I know we've had quite a few stories sort of looking at HIV aids. And Jenny, I wanted to turn to you because you had a piece sort of looking at where we're seeing some of the biggest impacts of sort of global aid cuts on HIV AIDS progress. And so maybe you could tell us a little bit about what we're seeing on that front to kick us off.
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B
Yeah. Thank you so much, Adva, and happy to join you on this week's podcast. Yes, this is a big year for hiv, good and bad. At the same time, we know there's been huge impacts because of the funding cuts, especially from the U.S. but the report from UNAIDS last week really shows us one of the areas that's been hit hardest is really HIV prevention services. So I've got some numbers I just want to mention for our audience. It's different depending on countries, but it gives us a picture of really how those cuts are affecting HIV prevention services. So in Burundi, the number of people receiving PREP has declined by 64% between December 2024 to August 2025. In Nigeria, male condoms distributed fell by 55% between December 2024 and March 2025. These are big, you know, large declines, really numbers. You've got male circumcision falling by 65% in Uganda between December 2024 and June 2025, and then 88% in Botswana from January to May 2025. So you've got really this big hits on HIV prevention services. And it's happening at the same time when there's a deteriorating human rights environment globally. UNAIDS was reporting that it's the first time since 2008 where they've seen an increase in countries criminalizing same sex sexual activity and gender expression. So, yeah, I guess we're starting off on something that's really not so good news on the HIV front. And I just want to add, it's interesting because the US this year announced support for rolling out of lineacapavir. Right. And so that's a good news part of it for the HIV front this year. But at the same time, when you see declines in other HIV prevention services, it just hits you something like, you know, when you talk to the HIV community, they'll tell you there's no one tool that can, you know, end AIDS or that can end this crisis. So for people who don't know what lenacapavir is, it's the long acting injectable HIV prevention drug that's really, you know, that everyone's been saying a really game changer if it is, you know, it reaches all the people who need it. So it's only can be given about just twice a year for people. And it's really a game changer because, you know, when compared to oral prep, that's taken, you know, every day.
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A
Yeah. And I think, you know, we have seen the US say that they want to support Lena Capiver. I think at least one of the questions I've heard from people, which it sounds like you're hearing as well, is how, how do you deliver it?
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B
Right.
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A
Because if a lot of the avenues of delivery or a lot of these programs that would have reached these communities are not getting the funding they need or are being shut down, that can might make the sort of delivery and execution piece of it more difficult. One of the things that I found notable in the article that you wrote about sort of the hit to prevent services was that that UNAIDS report said that the, the result could be something like 3.9 million new infections in the next five years. And so that gives you sort of a real tangible as, you know, I mean, you know, I think globally the effort really is to try to prevent and end new infections so you can bring an end to the disease. Right. And so I think that certainly would seem like a pretty significant setback on the global stage. I wanted to turn to talk a little bit about what we have learned that the US Government is, is doing. Right. So we know that some of this prevention stuff outside of Lena Capavir is deprioritized and defunded and things like that. But you know, with the America First Global health policy, we have seen sort of the direction that they want to go in. And a big part of what they've talked about is working with two sets of partners, faith based organizations and the private sector. And in the past week we've sort of learned a little bit more about their engagement on both. And so I was hoping to sort of turn to both of you to talk, to talk about that a little bit. And one of the things we saw was an announcement that the US would fund Zipline, which is a company that uses drones to deliver various supplies. And Catherine, I wonder if you could tell us a little bit about sort of how you view that announcement, what we learned in that announcement.
- [05:14]
C
Yeah, absolutely. It's definitely one I'm following with great interest. So as you may have seen in Michael's piece on Zipline, Jeremy Lewin really talked about this as an example. They want people to see this as kind of case in point of what they're talking about when they're discussing innovative results driven development. The way that this is structured and this comes up a lot in the way tech companies engage in development is pay for performance. So the way that works is that initial payments to Zipline will unlock when governments sign contracts committing to pay for ongoing logistics services. So this is kind of a departure from like a grant that's decided upon on a multi year basis and then, you know, hopefully it works. This is an oversimplified way of breaking this down. But whereas with pay for pay for performance, funding is unlocked when certain milestones are achieved, essentially. So Zipline has been working both domestically and on the African continent for years and it's a company I've reported on in the past. One of the shifts, I think this partnership is indicative of a couple of things. One, yes, it's indicative of the way that this administration wants to work in the global health context. And they said as much. Basically this kind of indicates the way we want to work and it's a huge departure from the way global health supply chains have worked in the past two. I think it's a very interesting example of how private sector companies might engage with the US government in these markets moving forward. Frankly, for a long time the way people saw ziplines work in Africa was sort of a place where they could test ultimately a more profitable model in markets like the U.S. so you know, Zipline has worked in Rwanda for years. Rwanda has sort of welcomed. Zipline has a very welcoming environment for tech innovation and partnership. Zipline is one of many companies who have done kind of pilot type work, testing work in Rwanda and it was sort of perceived as a way that they could test what's ultimately their main focus is, you know, delivering things to people who can pay in high income markets. And they're doing that, you know, in, in domestic markets as well. Here in the U.S. although what you kind of Michael's piece, he talked with Caitlin Burton, the CEO of Zipline Africa, is that they actually see a perhaps profitable future in Africa. So that I think it's again, this partnership is indicative both of global health partnerships in this America first era and also how companies might engage in these markets, not just as a way to sort of have a testing ground for more profitable markets, but there actually could be a profitable pathway forward for them, which of course makes their engagement much more sustainable. It's not a charity effort. It's not like a short term test. It's something they're thinking about long term as a focus for the company.
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A
I think one of the other pieces obviously is around more engaging with faith based organizations. And this, this is not necessarily a new focus for the US Government. The US Government has engaged with faith based organizations. But it was interesting in reading our colleague Sarah Jerving's article that faith based organizations themselves do see this engagement as different in part because it's happening earlier. You know, the State Department is currently sort of on a tour of African countries as they're negotiating these new bilateral health agreements. And in quite a few countries they've actually brought in faith based organizations as part of that consultation process. And they're saying that that feels very different than just being sort of turned to at the end of the process, saying, here's, you know, a grant or a contract. Do you want to, you know, bid on this and going up against big organizations? Jenny, I'm curious what else sort of you're hearing on that sort of faith based front. What else is sort of striking you on this piece of the focus for the US Government?
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B
I agree with you, Adva, about, you know, how this seems to be refreshing for some of these African faith based groups because they're not just being called to participate in funding opportunities, but they are being engaged. And in some places, even when their own governments have not essentially consulted them to be part of the consultations, the State Department itself has actually asked them to be part of the consultations. As we unpack this America first global health strategy, we're seeing, you know, we're seeing some positive comments, really narratives coming from African groups, African leaders on the direction of it. And this is one thing, but I also want to emphasize there, there still are questions. Yes, they are being consulted by the State Department itself, but the African, the faith based groups still have questions around, you know, what happens to funding. Because right now we know the negotiations are bilateral. It's with governments right and their question is, so once those agreements are concluded, will we get some money from it? And that's a big question still that we don't know and perhaps we will see in the coming weeks.
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A
Yeah. Because my understanding is that quite a lot of these negotiations, they're hoping to wrap up by the end of the year. So they probably won't be implemented until around April, I think, is what I'm hearing. And I guess one of the things on that issue of sort of the questions they're asking, I think one of the things that they're asking is also governments change. So. So, you know, one government might decide to fund something through a faith based organization, but will the US Sort of agree with the government but still fund sort of local organizations to carry some of this out? So I think that's where some of those questions arose in that piece.
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B
I remember in Cyrus piece there was one proposal to also have a separate funding for faith based groups. I think that's one of the proposals that they're putting forward. But again, whether that's taken up or that happens, we don't know at this point.
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A
Yeah, I think at this point, what we know is that there does seem to be, at least in some countries, increased engagement where they're sort of sitting in the room with, you know, U.S. state Department leadership and sharing their ideas and being asked to sort of contribute documents and reports and comment on things. So I think it'll be interesting to see how that develops because one of the things we do know is that some of these faith based organizations have really broad reach, particularly into really rural areas that can sometimes be harder to reach with services. So I think we'll see how that all plays out. I think it's really interesting to see how this is evolving and I think it's a part of the sort of US Foreign assistance infrastructure that we're actually learning a lot more about sort of every week.
- [11:46]
C
This portion of this Week in Global Development is brought to you by pivotal, which works to accelerate the pace of social progress for women and young people in the US and around the world. We are proud to spotlight pivotal's Action for Women's Health initiative that awards innovators who are shaping the future of women's health from North America to Southern Asia. I'm Catherine Chaney, senior editor for special coverage at devex, and I'm thrilled to be joined by Liselle Lifschitz Gudino, executive Director of Mujeres Aleadas. I wonder if you can start by just telling us what inspired your Work. And also, what is the specific challenge that you're working to address?
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D
Mujeres aliadas is an NGO. We work in central Mexico, rural, indigenous Mexico, for 17 years. And mujeres Aliadas means allied women, so women coming to work together. So we were born from women being tired of the experience of obstetric and gynecological violence. And we were also tired of feeling shame around our bodies and its processes, because our work is defined by the midwifery model that brings women to the center. And it's an intercultural model of health care built around women's rights, women's voices, dignity, and respectful care. So we aim to have the recognition of midwifery as a safe, dignified, culturally sensitive practice. Interests for women vary from these from one place to another. So it's important to have women at the center of their health, their decisions, and our own knowledge about our bodies.
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C
How has that approach changed the way that women in your region can access reproductive and maternal health? And what lessons do you think it offers for broader health systems?
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D
We've noticed along our 17 years of work here in the region that there's a lot of shame around body processes.
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And a lot of not. Not holding my health in my own hands. So we tried, us women, to. To think and believe that I'm the main actor of my body, of my health, of my decisions. So this is an important driver. We don't want to be like the medical authority telling you what to do with your body and your health and your decision, because you are the expert in your own body, not. Not someone external. So this can shift. This is very powerful. This is very empowering for women and shifts the way you perceive your health and hence other decisions. Right. So we say that the revolution starts within our body because it's our first territory.
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C
Congratulations again on this award. And I wonder if you can talk about what it will enable you to do. Thank you.
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D
We're super excited about the grant. This is really great news for us. It's been the news of the decade for us. This comes in a very important time in Mexico because now we have a female president for the first time in history, and she's talking big time about women's rights. So this is important. And part of these public policy things that are changing in Mexico is talking openly about midwifery. So now there are some norms and general policies, federal regulations regarding midwifery. So this means recognition. It's been a struggle. It's been hard for years. And now this grant allows us to be. To have some leadership within the midwifery community, which is very large in Mexico. The so it's a time to come together and push midwifery, push our agenda towards having women centered services, respectful, dignified. Right. So at the same time as we do local work at the community level, we can also work at the policy level nationwide.
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C
Well, Liselle, congratulations again on this exciting award and I look forward to forward to following your work.
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A
I wanted to turn to another subject and that is weight loss drugs. It's something that I feel like is in the news headlines a lot. I think most people sort of, at least in the US increasingly know at least someone who's taking these weight loss drugs and sort of, we've been looking at the issue recently of sort of, you know, as generics come online, what is the impact for low and middle income countries, particularly in battling, you know, diabetes and non communicable diseases and, and things like that. And, and I know that the WHO came out with some new rules on these weight loss drugs and you wrote about that, Jenny. So I'm hoping you can tell us a little bit about what those rules say and sort of your impression of the implications for sort of the low and middle income countries of the world and whether they'll, they'll be gaining better access to some of these medications.
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B
Well, just before WHO came out with its recommendations really for using these weight loss drugs, we did a story.
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Last week around it and there's some excitement because Semaglutide, which is the main ingredient in some of these popular weight loss drugs like Wegovy, right. Ozempic, its patent is expiring in several markets such as China, Brazil, India. And we know that's going to be, you know, there's a race now for producing generics which has the potential to really bring down the price of this, of this weight loss drugs and make it more accessible. But at the same time that accessibility.
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A
80% drop in prices. Right.
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B
Like that's one of the things they're looking at right now. But at the same time there are questions really whether that's going to bring access to a lot of people because first of all, you know, there's really a high demand for this in, you know, wealthy markets. And so, you know, one of the things that experts are saying is like even the generic companies might be actually going to these wealthy markets because that's where the money is. At the same time, we shouldn't forget that these are also drugs to help manage diabetes. And there are questions about, there are concerns that people living with diabetes maybe, maybe get left behind because you know, everybody wants to have this weight loss drug. I know anecdotally, you know, and in some countries, even here in the Philippines, there are, are these drugs are available in the pharmacies, private pharmacies and they're always out of stock. So, so you know, some people living with diabetes couldn't even, you know, get their own stocks for themselves. So those are some of the concerns. But also it's just that, you know, there's more than 1 billion people living with obesity right now and it's a real serious public health issue. A lot of people are struggling with their weight. But at the same time, you know, experts are saying these drugs may be, may become accessible but at the same time, you know, it shouldn't be seen as a silver bullet. We should, you know, governments should also still be promoting healthier environments, diets for their own population. Who I think it was, it was on Monday issued the recommendations that this may be used for adults excluding pregnant women. And they also added a second recommendation that about including behavioral therapies to help aid in, in weight loss. But this, what's interesting is these are conditional because there are some uncertainties, right. And I think each of the experts involved in developing this guidelines still want more evidence in terms of long term safety of, you know, of this medicines and they don't even have a recommendation in terms of proper, when's the proper discontinuation? Because they don't have that evidence yet. But what's good about those recommendations is they're looking at it continuously, the evidence and they're planning to update it as more information comes in.
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C
One thing I found really interesting from Katherine Davidson's story on this was even though the prices are coming down, which you know, seems to mean good things in terms of access, it's important that the brand name drugs like Wegovy and Ozempic still play a role because revenue from the big pharma companies is what funds donations which is often the only source of treatment for lower income patients. She talked to Jay Iyer from the Access to Medicines foundation who said even if procurement does happen at the national level, it's important that governments don't just opt for the cheapest generic available. So I think that'll be an interesting balance to watch, like people wanting access to cheap medicines, but the importance of these brand names for longer term financing for the lowest income groups. It'll be interesting to watch how that shakes out.
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A
Yeah, no, that's a really, a really interesting point. The Last topic I wanted to sort of jump into today is something that I know you've been tracking for a while, Katherine, and that's this idea of digital public infrastructure. And I think, or DPI as a lot of people refer to it. And I think when people sort of hear that, they can be like, what does that mean? But I think most people, if you sort of break it down, will understand what it means. So maybe we'll start by sort of asking you to tell us a little bit about, you know, when we talk about digital public infrastructure, what are we referring to? And then, you know, I know you've done some recent reporting sort of on how the field is evolving, so it'd be really interesting to sort of hear how things.
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C
How things, yeah. So it's funny you mention kind of mixed understanding of the definition of dpi. We can start there. I've written about DPI many times over the years, and I keep wondering when is going to be the time when I don't need to define it at the top of the story. I think we're still in the realm of needing to define it, but essentially how it's often described. And I think a helpful way to think about it is similar to roads and power lines, kind of the digital equivalent to that. You know, roads are a public infrastructure and then all kinds of private innovation and services and daily life, you know, depends on those public roads, power lines, similarly. So these are digital rails, public rails on top of which private innovations can occur. And I will kind of go back, back in time and talk through a few moments that I think have led us to this point. So first, Covid. I think during COVID it became very clear that governments that had invested in digital public infrastructure could better serve their communities, their citizenry. One example is Togo, which had this novisi platform where they could kind of target the highest need segments of their population and get them aid quickly. Governments who did not have digital public infrastructure in place didn't have a way to reach their citizens so efficiently and equitably. I think Covid was a big moment. Flash forward to 2022. At the UN General Assembly. In 2022, there was a big gathering of organizations including the Gates foundation, which, when we talk about the influencers in any given space, who holds the influence? The Gates foundation has been a very influential player in DPI. I recall that in 2022, and I was revisiting this story when all these donors came together, Bill Gates called this the most important area in all of development. He said probably the most helpful thing in all of development. So it underpins a lot of his approaches and ways that the Gates foundation spends their resources. But specifically working with countries to build digital public infrastructure has been a big priority for Gates. At that time they actually committed, I think it was something like 200 million. Yeah. So 295 million was committed by various bilateral donors. 200 million of that was from the Gates Foundation. Now we're starting to see some of those investments play out. So India is often looked at as kind of the pioneer of digital public infrastructure. Gates and other actors certainly supported India in that journey. But a lot of India's work on DPI was self funded and state dominated. They're known for their Aadhaar identity system and a universal payment interface that built on that. So when we talk about what is dpi, I think India is a good model because this has been in place for a while when it comes to verifying identity, identity, making payments, exchanging data securely. India has built those rails and this is how really the, the country is operating. There are some real concerns here too. Like you can imagine how that unlocks a lot of possibilities from cash transfers to digital health to small businesses. But imagine it's all that more devastating really for someone who is not online. Suddenly the entire economy is moving digital and they might be left behind. So that's a real concern. So India's really been a pioneer. The model has spread. India actually used its G20 presidency to really champion digital public infrastructure. Brazil and South Africa, also doing interesting work in dpi, went on to champion digital public infrastructure most recently. And this is a story I had up last week. The Global DPI Summit happened in Cape Town, South Africa. And to me, the big takeaway from that conference, having tuned in from afar, was essentially what I see as the big conversation in DPI right now. For so long, this has really been a top down effort. It was rolled out in a top down way in India. Donors have really defined the agenda here, Gates and others. And for a number of reasons, African countries are looking to have more control now. There's a tension here because they still rely on, many of these countries, still rely on outside aid, but they want to shift from aid to agency. Right? They want greater control over digital tools. I think a few things have driven this one. It just makes sense. One of the huge complaints in dpi, and this is kind of true of many aid projects, is that the whole process has felt very siloed. You know, this project here, this project there, they're not interoperable. When the donor leaves the project ends, etc. We've seen the story play out across many spaces, but in digital it's particularly problematic when things are not interoperable and are built in a siloed way. The dismantling of USAID this year made that very clear. One of the examples that came up at the DPI summit was that health systems that had gone digital completely fell apart when USAID was no more. Because the project relied on that funding, and not just the funding, all the infrastructure that had been set up around that, the digital infrastructure, the people infrastructure. I think the other thing driving this demand for sort of digital sovereignty is the rising AI wave. And I low and middle income countries kind of face this dual risk as I outlined in the story, where they could either completely miss the AI wave and all the potential that could come with that, or that they could actually see harm as a result of the rise of AI because they were not able to take part in its development. So for a number of reasons there are these demands for digital sovereignty. It's something that Sanjay Jain from the Gates foundation actually said at the DPI Summit that the Gates foundation wants to support. They want countries to kind of be in the driver's seat. And what will be interesting to watch is the platforms that they are asking countries to consider. Mosip, which is an open source tool for digital ID and, and Mojo Loop, which is an open source tool for digital payments. These are Gates backed efforts that Sanjay Jain noted countries and donors should kind of get on board with CO Develop, which is an organization that helped to organize a DPI conference and something launching this spring, which is a World bank trust fund focused on DPI Gates backed efforts. So there is sort of a line in the story from someone I spoke with from CO Develop saying keep in mind donors bring their own agendas to this space and that's something to watch closely. But essentially that's, that's how I see DPI evolving. Countries are looking for more control as this is becoming a growing priority in development and for these countries and I think there is a tension there because the outside support remains critical. And of course donors come with their own agendas. So I think things to watch will include building local capacity like essentially if you don't have tech talent domestically, there's only so much control you can have over these tools. And yeah, many more questions to follow. It's a story we'll be following closely. I'll also just flag. We had a recent DEVEX survey on DPI to kind of get a sense of how the global development community is looking at this space. I think as you mentioned Eva, there is growing awareness of its importance, but I think much more, especially given the nuance in this space and how quickly things are moving, much more to be kind of teased out in our coverage and help our audience to navigate this quickly changing space.
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A
Yeah, no, no, I think that's true. In that survey, I think it was 8 out of 10 of the 500 people we surveyed had some familiarity with it, but 39% of them had little exposure to it directly. And it seems like the, the area that most people are familiar with is digital payments. Right. Which is something that I think is, you know, it's one of the pieces of this that is probably the most evolved and in some country and really pioneered by some sort of lower, lower middle income countries in a way that has spread globally. Right. If, if you look at like M. Pesa and Kenya and sort of the, the wave that that's created. But you know, I think one of the things that I think about in this digital public infrastructure space is that, you know, you're talking about the questions and a piece of this is that connectivity piece. Right. And there still are a lot of people, and I think particularly a lot of women when you talk about sort of the digital divide, that, that are at risk of being left behind. So I think that, you know, and it's not only access to devices, it's, you know, reliable Internet which needs often reliable power. And so I think that there's, you know, there's a lot of the sort of backbone that a lot of these things need to be built on. Actually some of that still physical infrastructure, there's still room to grow there in a lot of countries as well.
- [29:37]
C
Totally. And one other thing I'd add. So there's that risk of people being left behind because of connectivity gaps, access to affordable mobile devices, et cetera. There's also a risk when it comes to data protection. And this is something actually I'll mention again, Katherine Davison had a, had a nice piece on DPI and she talked about some very real concerns on that front. So of course in order for DPI to work, you need data, including vast amounts of personal data. And many of these platforms that have been created are created with data protections in mind. But in India, for example, the systems were sort of put in place before the data protections were really fully locked in. And that model is very concerning for African countries and not a pattern they want to repeat. You can imagine how that could go wrong, including weaponization by governments actually targeting people based on data that was collected. So I think that's a real concern. And speaking of all the the nuance and tension and debate in this space, I have talked with sources who have essentially said, well, the benefits outweigh the risks. They're talking about particular countries saying the benefits outweigh the risks. All that, you know, DPI can unlock. And you know, on the one hand, yes, there are many benefits to be gained from digital public infrastructure and all the services that can be built on top of that. But who decides whether the benefits are worth the risks? And I actually, for this most recent story, spoke with a source based on the African continent who kind of took issue with that comment that was made by someone in the US that the benefits outweigh the risks. And again, it's a great example that one small piece of the DPI debate, data protection, data security. It's one key example of why African leaders and African voices and governments have to be helping to drive the conversation, not just external actors.
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A
Absolutely. All right. Well, I think we have run out of time. But Katherine and Jenny, thank you so much for joining me today and sharing your insights with all of our listeners. And, you know, we'll bring you much more next week. As usual, this has been this week in Global development.
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Sam.