C (2:39)

That seems to be exactly what's happened. So these bilateral agreements were supposed to be finished reached by the end of last year. You know, as we've covered a lot of that bled over into the start of 2026, we're seeing some that are still being struck up until, you know, a couple weeks ago and negotiations are ongoing in a lot of places. And then that's just an initial step. What comes next is that then there has to be an implementation plan for how these are actually going to be operationalized. And that just hasn't happened, it seems in almost any country. And so, you know, the programs that were funded by the bilateral agreements were supposed to start in April, but without implementation plans it's clear that they're not going to. And I think that's where you saw that in the State Department instructing cdc. Okay, let your programs run for an additional three months while we get these bilateral health agreements up and running.

B (3:27)

And also just to clarify, when we say programs are running, it's not, it's with reduced funding, meaning reduced services, am I correct?

C (3:35)

That's exactly right. You know, and it's, it's also not all of the programs. And so while the US Agency for International Development was the main implementing partner of PEPFAR programs, they saw a number, you know, USAID was obviously dismantled. A number of the programs that were funded under USAID were cut. They no longer exist. CDC programs did escape relatively unscathed. Most of them were still allowed to operate. They saw some funding cuts over the past six months that saw them have to having to reduce their services during this kind of bridge funding period up until March. And now we're seeing even more cuts over the next three month bridge funding period. I was speaking to one organization that does a lot of outreach to provide both HIV treatment and HIV prevention services to communities in central Uganda. And they've, they've essentially had to cut the program in half since these funding cuts started. And so they're reaching far, far, far fewer people than they used to.

B (4:34)

Yeah, and Jenny, I know you've also been speaking to people on the ground. I think you're speaking to organizations in Kenya and they are also filling this pinch, right?

A (4:43)

Yes, it's interesting that Andrew, you know, reported on what's happening and these programs are Expected to continue for another three months. Because what I'm hearing from organizations on the ground in Nairobi, for instance, is that, you know, some of the like drop in centers that are catering to key populations, for example, have already closed. These are ones that are, that have been supported by PEP par for so long now. There are some that continue but they've already seen reduced funding and support so there's no support for peer educator, peer educators, for example. And so it's interesting how they're going to be continue how they're going to continue for another three months. And I agree with Andrew. The big question is where the, where the funding is going to come from.

B (5:34)

Definitely. And this also brings us to this question of what happens next. I think that's the big question. What happens next? These deals have been signed, but what happens next, like on the implementation side. And this brings us to the Global Fund because the Global Fund seems to have turned out to be a Trump administration darling and it seems like it's being talked about a lot when it comes to the implementation of these bilateral health deals and what role is going to play. And Jenny, you were looking into this this past week and there are a lot of questions about the role that the Global Fund is going to play. What are people saying about that?

A (6:08)

First of all, I do want to bring us a bit back to the replenishment of the Global Fund last year. We're in. Jeremy Lowen, the senior State Department official, when he was announcing the pledge to the Global Fund, he said the Global Fund is a critical partner in advancing the America first global health strategy. So that kind of signals to us that the US looks keen on really partnering with a Global Fund. But also they mentioned something around, I think it was the Global Fund is bringing world class procurement platform. And that links to the kind of things that I'm hearing from sources because one of the things, well, first of all what I'm hearing is that the Global and Global Fund confirmed this to us, that they're in the rooms, they're in the negotiating rooms where, you know, these bilateral deals were being discussed. They said they're mostly an observer providing technical support for their supported programs. But, but, but people are also saying, although this was not confirmed by the Global Fund, they declined to respond to this. But people are also saying that the US seems really keen on working with a Global Fund and using its procurement platform. So you see there's really a lot of interest there in terms of, there's really a lot of, I guess, links when we talk about America first and bilateral health deals. The Global Fund really keeps coming up in these conversations.

B (7:42)

And this is mainly because USAID was dismantled. USAID was working on this big project around procurement and trying to figure out how to fix procurement of health commodities, etc, and that's kind of now gone down the drain. So now we're looking towards the Global Fund. And the Global Fund has a procurement platform called Wombo. Fun name, I always forget it, but Wambo. Fun name. And they're looking towards this procurement platform, but they've actually been challenges with this platform. Am I correct? Jenny, can you take us through some of the challenges that countries have highlighted with this procurement platform?

A (8:15)

Sure. So this has been established for a while now. It's been going on. But the thing is Global Fund. So Global Fund provides funding to countries. Right. And they procure commodities. And some of that fund, some of that procurement happens through Humble. But at the same time, the Global Fund wants countries to also use their own, you know, not Global Fund grants, but their own domestic resources and still use Wombo for their own procurement. Now there was a, an evaluation back in 2022 wherein they looked at how much countries are using their own resources when it comes to Wombo. But there are a few challenges there that they've seen. And that includes countries are not a lot of countries are really using it. And for a few reasons there are longer lead times. And in some instances, countries, through their own local procurement are able to even get cheaper commodities than they would through wambu. So there have been a lot of challenges around that. There's also in the evaluation, there's also a mention when you're using Wambo, countries need to already make payments to be able to make their orders and all of that. And some countries, well, we know countries don't always have the cash at hand to be able to do that. And so that's also been seen as a barrier to using this platform.

B (9:50)

Yeah, and also speaking about procurement, some of the health deals actually mention countries using their own local or government procurement entities in order to procure health commodities for the America First Health Strategy and the bilateral deals. But there are also challenges with those. I'm definitely aware of that because I'm in a country where we had a state of emergency around health commodities. We had stockouts. And I think in almost probably every African country you can go to a lot of the times there are stockouts of like common drugs and in some cases life saving drugs. And this is one of like the big criticisms around cancer, for example, in Kenya. And you highlight this in your story that cancer recently had stockouts of life saving medical supplies, but it's expected to take on this procurement process within the America first global health deals in just a few months. What are people saying around that?

A (10:49)

There's definitely concerns. I think one, one health expert succinctly explained this to me. People will die. This person was telling me, like if there are stuck outs, if there are disruptions, interruptions in terms of access to critical life saving treatments, you know, that really goes down to, you know, affecting the health outcomes of people. And I think that really explains how crucial having a good, you know, supply chain really is for these types of things. Eastern Europe and Central Asia face one of the world's fastest growing HIV epidemics. Conflict in Ukraine and displacement across the region are compounding the crisis. RADIAN is a transformative partnership between Gilead Sciences and the Elton John AIDS foundation working to change that. Through local organizations on the ground, Radian has already reached over 367,000 people with HIV prevention, testing and care. Ending this epidemic here brings us closer

B (12:04)

to ending it everywhere.

A (12:05)

Find out more@radianhiv.org

B (12:10)

and another area the Global Fund is supposed to kind of step in. Well, people are hoping it'll step in in this thing is inclusion of civil society organizations. So it seems within America first, civil society is out, Global Fund potentially in, faith groups, potentially in. But civil society has generally been left out of these discussions. And the question is, can the Global Fund bring in those voices and make sure that they're included? And a big question around this is key populations. When you look at HIV and HIV prevention, if you don't have civil society being a part of this service delivery, what happens to key populations? What are some of the arguments you've heard for including civil society?

C (12:59)

Andrew, in the immediate aftermath of the Trump administration's decision to pause funding for HIV services and then just subsequently cut a lot of the programs like we were talking about earlier, key population groups really felt targeted. And so for the past year, I've been talking to a number of them across various countries, primarily in Sub Saharan Africa. And what they were telling me is that, you know, they're very upset, they're very concerned about the ongoing delivery of these services and what's going to happen to people who benefited from their programs. But they felt like they had this backup or this safety net that was the Global Fund. Because the Global Fund has always been very responsive to the needs of key populations, it's made an effort to put key population representatives on the advisory committees within countries Also in international level advisory committees. And then what I started to hear was a growing sense of disappointment with the Global Fund, that the Global Fund officials weren't being particularly responsive to the needs of key populations. And then there were some cuts that were made to previously assigned Global Fund grants because the funds that they were supposed to have didn't come in. Now we're seeing a situation where the Global Fund replenishment didn't meet the total that it was supposed to. And so I do think there's a real fear among key populations that they're at risk of being left behind, not just by PEPFAR and America first, but also now by the Global Fund. And there's a real sense of devastation about what that could mean for the future health and livelihoods of the groups, the people that have benefited from their services.

B (14:34)

Speaking of the replenishment, it was basically seen as a success because the US chipped in, but the target was 18 billion. The Global Fund got just over 11 billion. And country allocations are going to be affected by that. Jenny, I know you've been hearing that the specific allocations are supposed to come out this week, but they've been reduced, right?

A (14:56)

Yeah. So as of this moment, I do know that the allocation letters are arriving in countries, but when Global Fund will actually publish all of those, we don't know yet. Their target is to be able to publish that this March. But. But we'll definitely have to follow up with them when that's coming out. They want to publish it once all countries have received the allegation letters. And so it's interesting in the sense that organizations are looking, especially organizations led by key populations are looking to the Global Fund to really make sure that the services continue. But at the same time you're seeing an organization that is now going to be operating with the much reduced resources.

B (15:49)

So proof that I'm a big fan of Jenny Le Ravello's reporting. The country allocations for this year in total will be 10.78 billion and it's the lowest since 2020. Or maybe I was just really fast at Google.

C (16:05)

And just to chime in, one of the, one of the concerns that key populations have had is exactly what Jenny was reporting about the, the fact that Global Fund was in the room as these negotiations were taking place for bilateral health deals, that there seems to be this kind of close tie between the Global Fund and the Trump administration in order to secure perhaps the, the funding commitment from the US for this replenishment round. And that has let key populations and other groups that have been targeted by the Trump administration to question, you know, does the Global Fund still have their back? What is the commitment? What kind of promises are being made or negotiations struck between the Global Fund and the Trump administration behind closed doors?

B (16:45)

Speaking of closed door negotiations, one thing you also mentioned, Jenny, is how the expanded global gag rule could have, like, an effect on service delivery. And there are apparently supposed to be discussions happening between the Global Fund and the Trump administration around this as well.

A (17:05)

That's so far as we know, there's discussions happening between the US Government and the Global Fund. We don't have any details as to what the status of that is, but certainly there's a lot of concern. And when you think about what this expanded global gag rule says, it has expanded prohibitions, it extends to international organizations. And when you look at international organizations, that's going to flow down to their primary and sub recipients of funding. So if those prohibitions apply to the Global Fund and the US Pushes for it to go for it to comply strictly to the expanded global gag rule policy, then there's definitely a lot of concern on the impact of that on the ground, especially for populations already stigmatized, discriminalized, and even some countries stigmatized, discriminated, and in some countries, criminalized. Yeah, yeah.

B (18:21)

And I guess this brings us to the broader question that a lot of organizations, NGOs and international organizations are sort of grappling with. How do you work with the Trump administration? Because obviously, like, every organization has got its values and things that it believes in, but then you also sort of need to work with the organ, with the administration, especially maybe in this interim period. Like, if you look at it right now, the Global fund reached around 11 billion for its replenishment. Six billion of that is coming from the U.S. what does it mean for funding for programs if we take away that 6 billion? So I see a lot of organizations sort of struggling to figure out how to work with the Trump administration. Andrew, are you seeing that as well?

C (19:05)

Yeah, I mean, I think what we're looking at is just this severely constrained funding environment for global health programs, HIV services, and even worse for, you know, things like neglected tropical diseases, malaria, tuberculosis. And so, you know, even though the Trump administration has restricted some of that funding or pulled back some of the financing, like, the United States is still the biggest player in the room. I mean, they, they still hold the purse, purse strings. And so organizations, you know, if they want to continue to respond to these diseases and continue to make advances or not lose the gains that we've had over the past decades, then there is going to have to be some attempt to try to figure out how to operate within whatever restrictions the United States is putting in place.

B (19:48)

Yeah. And I do want to.

A (19:51)

Sorry, Remy, just want to add, because that relates to. I was invited to an event near Capitol Hill this week. Obviously, I couldn't go, but the. It. I think that that's, that's related to a bill that they're pushing for US Support for global health workforce. And the thing with that is they saw the America First Global Health strategy, they saw there's a mention about health workers, and they saw an opportunity to be able to push their priorities. So I think groups are still trying to work with the US Government. They still is a big player in global health. Yeah.

B (20:36)

That also reminds you of a conversation that I had last week with Donald Kaburuka, who's the AU special envoy for Financing the Union. And he basically said whoever is paying is going to set the agenda. And the only way that the agenda can change is if someone else foots the bill. And unfortunately, within this transition, it's very hard to find anyone else who is able and willing to foot the bill. So working with the Trump administration seems like it's somewhat of a must for a lot of people. But another thing that's happening within the global health space this week is the last week of negotiations, negotiations before the May deadline for the PUBS agreement. So PUBS is basically the Pathogen Access and Benefit Sharing annex to the pandemic agreement. Countries had been trying to agree to the terms of this part of the agreement for two years, I think, and they failed to do so. And so negotiations on that continued. And that basically means that if countries are sharing information on pathogens that are circulating within their borders, they should then be able to access the benefits that come from that, which could be vaccines and other health commodities. And figuring out the technical details and what actually goes into the agreement has proved to be challenging. Jenny, what's the latest that you're hearing on pabss?

A (22:05)

Yeah, so this. I just came off a press briefing with civil society organizations have been really closely following this from day one. And as often I hear from these conversations, there's still a lot to be negotiated at this stage, in particular in terms of benefit sharing, really. Countries, particularly developing countries, who have been really pushing for this, to guarantee benefits from sharing this pathogen data. An interesting one was the start of this week's negotiations. They mentioned there's a tension already because the text that they're about to negotiate, the latest texts that were put forward to them didn't include or didn't include the state, the proposals made by developing countries. So there was a tension around that. And so they decided to use the. Or return to the, to the text that was being discussed from the previous meeting. But then, you know, one of the things, but there's still a lot of things that they still need to agree on. Two months before May, one of these things is around what are the guarantees, what are the benefit sharing guarantees during a public health emergency of international concern? So in the pandemic agreement, there was already a provision there that in the event of a pandemic emergency that manufacturers, there's a guarantee for manufacturers to allot at least 10% medical products that to who through a donation process and then the other, perhaps 10% or so can be negotiated at an, at a more affordable price. Now the question, now they're. One of the things that they're supposed to be discussing in the PABSS annex is, you know, what happens during public health emergency. Public health emergency of international concerns.

B (24:35)

All the cool kids are saying fake and fake would be a step down from a pandemic.

A (24:40)

Yes. So, so it's, it's, it's usually been the highest level of alert by who, but then, you know, with the IHR revisions, they said there's another step now, pandemic emergency. But during, but, but they've not really set like, what's going to be how much percentage will manufacturers be donating to WHO during a fake crisis. So that's something where they've not really gone much further in these negotiations.

B (25:13)

And I know that this percentage has been something that manufacturers themselves have been very reluctant to commit to. And we always hear sort of the civil society argument about it. And I think having lived through Covid kind of think, oh, okay, some of us were last in line to get a vaccine, so we really need this. But one source say something really profound to me that Pubs has sort of become the hill that everyone is willing to die on because they weren't able to put like equity in all the other provisions of the pandemic agreement. Pubs has become this hill that everyone is willing to sort of die on. So I think it's also interesting for us to look at the other side of the question coin, which is like the manufacturer argument against these sort of like tight regulations. They're basically saying tight regulations will not benefit the world. Andrew, can you take us through some of their arguments? Because I know you've spoken to a lot of people about this.

C (26:11)

Yeah, I think if the Pharmaceutical industry had its druthers that they would prefer to keep a system that kind of existed during COVID or has existed in the past where there's voluntary sharing that's taking place as countries are discovering pathogens, there's a voluntary commitment or a voluntary sharing of the information on an international level that then the pharmaceutical industry can access and use to kind of create a response, whether that's a vaccine or test or whatever product form that might take. And if that's not going to happen, what they're arguing for is they want something that approaches balance and to their mind, that is not tying any obligations, particularly in the form of payments in return for access to the pathogens. Because the argument that the industry is making is that, that it's very difficult for that for pharmaceutical companies to get a profit or to generate a profit anyway off of their products, that a lot of the work that they do doesn't actually ever reach the market. And to. They're spending a lot of money on research and development that they never get recompensated for. And so if you then make these financial obligations that are tied to accessing the pathogens, then companies just aren't going to pursue developing a vaccine or a product based on that pathogen if they don't think that there is a potential financial incentive for them that would make it worth spending that money.

B (27:38)

And that business case makes sense. To be fair, that business case does make sense. But I guess my biggest concern around this is it's been two years of negotiations and failure to reach an agreement. Right now we're supposed. The meeting is supposed to happen from the 23rd to the 28th. And it seems like a lot of the text is not greened. There's no agreement around a lot of the text. Is it possible to do in one week what people failed to do in two years? Jenny, what are your thoughts? Because I know you've been following this for a lifetime and seats.

A (28:14)

Well, actually, if you. If you include the pandemic agreement tax negotiations, we're now in here for like four to five years.

B (28:23)

Right.

A (28:25)

And I. And that's something I've been asking people, some say, like, I don't really see. We'll reach an, you know, we'll reach an agreement in May. But there's certainly some pressure. I think we're hearing that from different parties. I believe I saw Tedros making a mention of it that talking about a compromise and reaching an agreement in May. But to me, I think the question is who is going to compromise and what is going to be compromised. I think those are the two big questions there.

B (29:01)

And African civil society organizations actually released a statement this week saying that awards are warning against the watered down version of the agreement. So it really feels like no one is willing to compromise for this. But I think in the past with pandemic treaty negotiations, they were able to schedule additional meetings because there wasn't this agreement. So that option exists. But the May deadline is looking a little bit unlikely at the moment.

A (29:32)

There was somebody a civil society person was mentioning about can member states potentially vote on this? They usually vote on very consensus issues at wha, but how that's gonna work, especially that they're always pushing for these things to be consensus based. That's a question at this stage.

B (30:01)

And it also affects constituents like pharmaceutical companies. And those pharmaceutical companies are based in just a few member states, but everyone will then get an equal vote. That's an interesting way. And I think there would be quite a lot of backlash if it ends up being a vote after that. Right. What do you think, Andrew?

C (30:24)

I think that's probably unlikely, but this

B (30:27)

is definitely one of the things we'll be looking out for in the lead up to wha, as well as what's going to happen next with the bilateral agreements with the US and how will implementation now take place. And if you're interested in all this, I urge you to sign up for DEVEX checkup. The next one should be in your inbox tomorrow. And thank you guys so much for joining me.