Carlos del Rio is professor of medicine at Emory University School of Medicine and professor of global health and epidemiology at Emory’s Rollins School of Public Health. He is also chair at the PEPFAR scientific advisory board. Mitchell Warren is AVAC’s Executive Director and a member of the PEPFAR scientific advisory board. This piece first appeared on Devex.

US President Joe Biden has repeatedly praised the United States’ leadership in the global effort to end HIV/AIDS. Early this month, in marking the 40th anniversary of the start of the AIDS pandemic, the White House noted the “heartbreaking human toll” of nearly 35 million global AIDS deaths, the ongoing, high rate of new HIV infections worldwide, and the enormous progress being made against the epidemic by the US President’s Emergency Plan for AIDS Relief, or PEPFAR.

But surprisingly, more than five months into the new administration, PEPFAR remains with an acting global AIDS coordinator and, thus, effectively leaderless, for far longer than at any point in its history.

The silence on who will run US efforts to control and reverse the AIDS pandemic is a source of increasing anxiety and frustration for advocates, public health officials, PEPFAR partners around the world, and members of the PEPFAR scientific advisory board, on which we both sit.

PEPFAR is the largest single-nation effort to address a disease in history and is one of the few examples of a highly effective and truly bi-partisan government program, garnering both Presidential and Congressional support for almost 20 years.

Since its creation, PEPFAR has enabled more than 18 million people to receive life saving antiretroviral treatment, and provided HIV testing for 50 million people.

As members of PEPFAR’s scientific advisory board … we know that the best-intended efforts by committed staff and capable advisers still require clear and consistent leadership.

PEPFAR’s DREAMS initiative has reduced new infections among adolescent girls and young women who are particularly vulnerable to HIV in several sub-Saharan African countries.

Moreover, the HIV policy, programmatic, and laboratory infrastructure that PEPFAR has helped to build over the past 18 years is the strongest foundation for an equitable global response to COVID-19 and future pandemics. To put it simply, PEPFAR is US global leadership at its best.

PEPFAR’s impact is so enormous, and its leadership is seen as so important to US efforts to advance global health and security, that its program director holds the title of ambassador — unique among US global health employees, and its activities are coordinated by the US Department of State. Of all of the vacant ambassadorships in Washington, PEPFAR’s vacant leadership is one that causes global health advocates the most alarm.

Of course, this multibillion-dollar global initiative continues to function, even without clear leadership. But the lack of a Presidentially-appointed and Senate-approved PEPFAR director is beginning to take its toll on efforts, such as those approved at the 2016 United Nations High-level Meeting on HIV/AIDS, to end the global AIDS epidemic by 2030, where US leadership was necessary to secure global commitments.

PEPFAR-supported infrastructure is also critical to ending COVID-19 globally, an effort that must be coordinated between a permanent PEPFAR director and the recently appointed Gayle Smith, the State Department’s coordinator for global COVID-19 response and health security.

As US Representatives and HIV/AIDS Caucus co-chairs, Barbara Lee and Jenniffer González-Colón noted in a recent letter to the White House, PEPFAR’s strategic plan, which lays out its global AIDS-control vision for the next five years, is currently being developed with no leader in place.

Daily decisions on efforts to ensure the delivery of critical PEPFAR services, now severely tested by COVID-19, are being made without the benefit of a director with a clear line to the highest levels of the US government.

That situation could have been understandable in the early weeks of a new presidency, but more than five months into the Biden-Harris administration, it’s past time to give PEPFAR leadership the priority it deserves. The administration’s failure to have named PEPFAR leader to work with member states at the recent UN High-Level Meeting, and to represent the program at the upcoming International AIDS Conference next month sends a message that HIV is no longer a priority for the administration.

Few doubt this administration’s commitments to a robust response to HIV/AIDS. The recent appointment of Harold Phillips as the director of the White House Office of HIV/AIDS Policy — a position left vacant since 2017 — will strengthen efforts to control and reduce the US’s own entrenched national HIV epidemic, which disproportionately impacts people from racial and ethnic minorities, men who have sex with men, heterosexual women, people who inject drugs, transgender people, and people from other marginalized communities.

As members of PEPFAR’s scientific advisory board, however, we know that the best-intended efforts by committed staff and capable advisers still require clear and consistent leadership from a director who brings the demonstrated confidence of the President, Secretary of State, and Congress to the table.

The world has just commemorated the solemn anniversary of 40 years of AIDS. Now it’s time for the President to nominate a strong PEPFAR leader with the vision and commitment to help lead global efforts to control and eliminate AIDS in the years ahead.

Check out the new resources and events available on avac.org, plus a new site for global AIDS policy resources!

An “HIV Prevention Buffet” and a DJ

The AIDS Foundation of Chicago, in partnership with AVAC, the Black AIDS Institute, Desmond Tutu Health Foundation and SisterLove, is hosting a June 29 webinar, What’s Your Pleasure? Expanding Your Choices on the HIV Prevention Buffet. The event will feature global HIV prevention research experts, spoken word artistry and a smokin’ DJ (yes, a DJ!). The focus of the webinar will be on the HIV prevention research pipeline, including a wide array of molecules and modalities. Speakers include Desmond Tutu Health Foundation’s Dr. Linda-Gail Bekker, Dazon Dixon Diallo of SisterLove and the Black AIDS Institute’s Rob Newells-Newton. Register here.

Monitoring Progress Towards PrEP-FP Integration

Authors from the OPTIONS, PROMISE and CHOICE consortia, including AVAC’s Jessica Rodrigues, recently published an article, “Integrating oral PrEP into family planning services for women in sub-Saharan Africa: findings from a multi-country landscape analysis” in Frontiers in Reproductive Health. In the piece they share their desk review to develop a PrEP-FP integration framework—as integration of HIV and family planning services sees a renewed focus for national policy makers, donors, and implementers in sub-Saharan Africa. In the authors’ analysis, none of the countries included had made substantial progress toward integrated PrEP-FP service delivery. Check out the article for a road map for policy makers, program implementers, and health care providers to assess and monitor progress toward PrEP-FP integration. This work complements AVAC’s ongoing SRH/HIV integration work. Read more.

PrEP “Cycling”: The dance of oral PrEP

The landscape for PrEP is in the midst of transformation, with opportunities to understand and improve HIV prevention. With increasing numbers taking oral PrEP and new products on the horizon, such as the Dapivirine Vaginal Ring and long-acting cabotegravir, the world must get rollout right. There are vital lessons to learn from how people use oral PrEP and critical questions to answer. AVACer Jeanne Baron’s blog, PrEP “Cycling”: The dance of oral PrEP explores one key lesson from today’s PrEP users that could mean a new definition of success with PrEP. Read more.

A New Look for the GAPP

The Global AIDS Policy Partnership (GAPP) is a coalition of over 70 organizations committed to expanding and improving US global HIV/AIDS programming, and they’ve got a new website! Visit globalaidspolicy.org for information on member organizations, global AIDS policy resources and a calendar of events. AVAC is a long-time member of the GAPP and hosts the staff secretariat for the partnership. Read more.

UN HLM: Civil society says “Yes — AND” to the 2021 political declaration

A special HLM page on avac.org recaps some of the events at the HLM earlier in June and includes an editorial from AVAC’s Maureen Luba, published in Science Speaks, which puts the Political Declaration in context and sharpens the focus on the need to eliminate punitive laws and structures that result in discrimination and stigma. Read more.

Last week, UN member states approved the 2021 Political Declaration on HIV and AIDS at the fifth High-Level Meeting on AIDS. On the face of it, this year’s Political Declaration, passed with overwhelming support, includes much to applaud: new ambitious targets for prevention, investment targets for treatment, and a financial and moral commitment to end gender inequality, stigma and discrimination. But the vote was not unanimous, various member states undercut the basic commitments to human rights and political divisions could well threaten the targets and the ultimate achievement of ending AIDS as a public health threat by 2030.

The COVID-19 response and last week’s Declaration make it clear that the biggest obstacle to overcoming HIV and other health threats is not money but laws and policies that affect access to prevention, treatment and care for all populations. Advocates can find resources and information to support their work on these issues at this dedicated page on AVAC.org, featuring:

• A statement from more than 80 organizations, including many partners from AVAC’s COMPASS and Advocacy Fellows programs, raises the alarm that the Political Declaration does not address the harmful and hateful effect of criminalizing key populations, such as gay men and sex workers.
• An editorial from AVAC’s Maureen Luba, published in Science Speaks, puts the Political Declaration in context and sharpens the focus on the need to eliminate punitive laws and structures that result in discrimination and stigma.
• No Prevention, No End: The importance of Leadership for HIV prevention – How decisions can turn an epidemic
  AVAC’s Mitchell Warren and partners, Joyce Ouma and Lilian Benjamin Mwakyosi, discuss the role of leadership to achieve the HIV prevention targets by 2030. Check out the recording from the special session on HIV prevention convened by the Global Prevention Coalition.
• Facts of Life: Youth, Sexuality & HIV
  A lively debate between young people, government representatives and other experts on what’s working, what isn’t and why in securing young people’s sexual and reproductive health and rights. Check out the recording.

UN Political Declarations come and go. But the first-ever UN High-Level Meeting on AIDS in 2001 was transformative—catalyzing the creation of the Global Fund to Fight AIDS, TB and Malaria, and eventually PEPFAR, and establishing a truly global response to the epidemic. This year’s meeting and Declaration remind us that turning progress into lasting change depends on our collective action.

Maureen Luba Milambe is the African Regional Advocacy Advisor: COMPASS and AVAC, based in Malawi. This piece first appeared on Science Speaks.

On Tuesday (June 8), the UN General Assembly voted overwhelmingly to approve the 2021 Political Declaration on HIV and AIDS introduced as part of the now fifth High Level Meeting on HIV/AIDS. Previous Declarations were accepted by unanimous consent, following months of negotiations. This year’s Political Declaration includes much to applaud, including new ambitious targets for prevention, investment goals to ensure everyone who needs treatment has access to it, and a financial and moral commitment to end gender inequality, stigma and discrimination. While all true, the overwhelming vote in favor, 165-5 (it was unexpectedly forced to a vote by the Russian Federation) obscures divisions that still exist around human rights and support for key populations and will undermine the targets and goals set forth in the declaration for the next five years, unless we pay heed.

The Russian Federation and a handful of other countries worked in the weeks ahead of the HLM to eliminate mention of harm reduction and rights-based programming, and weaken provisions related to key populations and youth. As Permanent Representative of Australia and meeting co-facilitator Mitchell Fifield noted, the Russian Federation made 73 changes to the document and then voted against the declaration it had weakened. Then after the vote, many countries that voted in favor of the declaration quickly disassociated themselves from the areas in it that addressed the rights of key populations or young people. Courtney Nemroff, the US representative, highlighted the problem in her remarks: the declaration, although an important step forward, still “lacks the ambition needed to meet the stated goals of this high-level meeting — ending inequalities and ending AIDS.”

Early in the epidemic, which quietly spread for years, and 40 years ago this month began to receive attention from healthcare workers, scientists and activists, financing appeared to be the main obstacle to protecting the health and welfare of all those affected by HIV. There were some who thought the global “mortgage” of a commitment to treat all could never be fully funded. This was never true, and COVID-19 has shown that money flows when the political will exists. The additional US$10 billion in investment that UNAIDS calls for to end the HIV epidemic by 2030 seems modest in comparison to COVID-19 investments.

What the COVID-19 response and last week’s declaration demonstrate is that the biggest obstacle to overcoming HIV and other health threats is not money but laws and policies that affect access to prevention, treatment and care for all populations. The declaration commits to reducing annual HIV infections to under 370,000 people and to ensure by 2025 that 95 percent of people at risk of HIV infection are able to obtain appropriate, person-centered and effective combination prevention. But how can this be achieved when countries continue to criminalize or restrict the autonomy and rights of those people they need to reach?

A number of organizations and activists have spoken out after the adoption of the declaration. Together these responses represent a community amendment to the declaration. Together they say ‘yes’ to the declaration and…

• Protect human rights and eliminate structural barriers that result in discrimination, gender inequality, underfunding and excluding people living with HIV and people most at risk of HIV, such as key populations, priority populations and children who may be at elevated risk of HIV.
• Protect the sexual and reproductive health and rights of women and girls, eliminate gender-based inequalities, gender-based violence, stigma and discrimination, as well as punitive legal and policy environments.
• Commit to global accessibility, availability and affordability of safe, effective and quality-assured medicines, including generics, vaccines, diagnostics and other health technologies to prevent, diagnose and treat HIV infection.

Even though the vote on June 8 was overwhelmingly in favor of the Political Declaration on HIV and AIDS, the problem with a split vote is that it no longer sets the standards for policy in the way that a consensus adoption does. A new study from Georgetown University found little evidence in support of the argument that criminalizing behavior of marginalized people in a pandemic results in positive outcomes for them or their national response. The Political Declaration could have defined the minimum standards for developing policies that support those most at risk of HIV. Instead, it becomes the ceiling that may never be reached by many countries, unless civil society again makes the case and governments actually adopt policies that acknowledge that there is no end to the HIV epidemic without involving, supporting and accepting everyone.

The latest Protecting Global Gains, Connecting Ecuador’s indigenous communities to health care through training in native languages, describes how health workers are reaching marginalized and geographically isolated communities during the ongoing pandemic.

Thanks to an innovative virtual training program launched by Universidad Católica de Cuenca and Project HOPE—a global health and humanitarian assistance organization—community health workers in Ecuador are delivering critical messaging on COVID-19 prevention in the native languages of Kichwa and Shuar. Health workers who successfully complete the training form a health brigade responsible for educating at least 2,000 local leaders who continue the knowledge-sharing within their own communities. By using local languages to communicate the importance of mask wearing, social distancing and handwashing, healthcare workers are providing life-saving health information to some of the most rural and far-flung communities.

Ecuador’s community health workers and this inclusive outreach holds promise beyond the context of COVID-19; the health brigades can help administer standard childhood vaccines, conduct prenatal consultations, and provide treatment for common ailments, much of which has been placed on hold during the pandemic lockdowns. The program’s success highlights the importance of adaptive and client-centered services that are responsive to the unique needs of marginalized populations.

Follow Protecting Global Gains on social media at @HIVpxresearch, @theglobalfight, @Amref_Worldwide, and #ProtectingGlobalGains, and consider amplifying these stories on your own social media. Advocates who are health care professionals can also join Project HOPE’s volunteer roster to help strengthen health systems in vulnerable communities around the world. Visit www.protectingglobalgains.org to learn more about how to take action.