As overall sexually transmitted infections (STI) rates continue to rise globally, STI diagnostic and vaccine research and development (R&D) investments remain underfunded and neglected compared to other infectious diseases, a new AVAC report finds.  

This report, Sexually Transmitted Infections: A Review of the 2022 Vaccine and Diagnostic Research and Development Pipeline and Investments, examines disbursements by the U.S. National Institutes of Health (NIH) and the Bill & Melinda Gates Foundation—the largest investors across a vast range of global health R&D areas—and is one of few reports to track funding trends in vaccine and diagnostics R&D, and pipeline investments for some of the most common STIs, including chlamydia, genital herpes, gonorrhea, hepatitis B, human papillomavirus (HPV), syphilis, and trichomoniasis.  

It found that leading philanthropic and public funding for STI vaccine and diagnostic R&D totaled just US $103 million in 2022 with most of the funding coming from the NIH, at US $78 million, approximately 76 percent of total reported funding disbursements. 

“We’re seeing the gap widen—as the global burden of STIs continues to increase, funding for R&D tools to reduce this burden lags behind,” said Alison Footman, PhD, senior program manager for STIs at AVAC and lead author of the report. “If we’ve learned anything from the HIV and COVID-19 epidemics, it’s that we need to get ahead of transmission by prioritizing the health of people and communities and committing the resources needed to develop user-centered diagnostics, treatments and prevention methods. Point-of-care tests that are effective, affordable, and user-friendly, and vaccines to prevent and treat STIs are on the horizon but will only be developed and delivered if money is made available with urgency and scale.” 

Of the total US $103 million in STI vaccine and diagnostic R&D funding reported, only seven percent (US $6.8M) was dedicated to diagnostic research—a much lower amount than vaccine research, which was funded at US $93 million or 90 percent of the total funding. The remaining 3 percent was directed towards projects that examined both vaccine and diagnostic R&D. As with vaccine R&D, the NIH accounted for most of the diagnostic R&D investments (73 percent). 

“Many STI testing programs rely on patients to present with symptoms. But considering that most STIs are asymptomatic, this approach is missing the mark,” Footman added. “We need to be investing in tests for STIs that will improve detection, and therefore limit the time between test and treatment, and hopefully prevent transmission. The overall STI R&D investments are already too little overall, and just seven percent of total funding dedicated to diagnostics is not commensurate with the public health need.”  

Other Key Findings

• Six institutes and centers within the US NIH contributed the bulk of funding (US $78 million) toward STI diagnostic and vaccine R&D.
• 59 organizations were funded worldwide to conduct STI R&D; of those, 78 percent (n=46) were located in the US.
• Institutions in South Africa and Zambia were the only African countries where local organizations were funded to conduct STI vaccine and diagnostic research. In total, US $814,279 was provided directly to these two countries, representing less than 1 percent of total funding spent.
• By pathogen, most funding (51 percent) was dedicated to HPV R&D, with gonorrhea and syphilis rounding out the top three pathogens funded.
• US $50 million was spent on HPV vaccine R&D, $18 million on gonorrhea vaccine R&D, $9 million on syphilis vaccine R&D, $8 million on chlamydia vaccine R&D, $3.5 million on genital herpes vaccine R&D, and $2.8 million on Hepatitis B vaccine R&D.
• NIH spending accounted for most STI diagnostic R&D investments (73 percent).
• Of diagnostic funding available, 66 percent was dedicated to multi-pathogen research, 33 percent towards HPV, and 1 percent towards hepatitis B. (Multi-pathogen diagnostic projects included research on syphilis, gonorrhea, genital herpes, and chlamydia).

The report also includes spotlights on DoxyPEP; on WHO’s new reports and manuals that provide information on diagnostics currently available to guide development; and on seven AVAC partners in East and Southern Africa who received funding to conduct projects on community needs to prevent, detect, and treat STIs. These advocacy projects helped build a stronger advocacy movement to improve funding and commitments in and around STI vaccines and diagnostics.  

For years, AVAC has been tracking investments and funding trends in HIV prevention and cure R&D. 

HIV Prevention Research & Development Investments 2021: Shifting investment priorities fund innovation in a challenging global health landscape

Global Investment in HIV Cure Research & Development in 2021

This new report on STI vaccine and diagnostic R&D is intended to help decision-makers and advocates identify current funding investments, opportunities, and gaps. Tracking investments over time can also demonstrate the effects of public policies and guidelines, such as WHO’s STI Vaccine Roadmap, on funding decisions and inform research priorities. 

For more information on the state of STI vaccines and diagnostics R&D, visit STIWatch.org, or get in touch at [email protected].

Last October when an unprecedented proposal to cut $767 million in federal funding for domestic US HIV programs was put forward in the Congress, AVAC joined PrEP4All, HIVMA, PrEP In Black America, NASTAD, the HIV+Hepatitis Policy Institute, The AIDS Institute, AIDS United, NMAC, and several members of the Federal AIDS Policy Partnership to launch the #SaveHIVFunding campaign. Since then, thousands of advocates and community members, along with over 100 organizations, joined the fight to demand Congress continue the bipartisan commitment to fund Ending the HIV Epidemic (EHE) efforts.

With key deadlines in the FY24 budget process quickly approaching, it is more important now than ever that you join us in telling Congress to reject cuts and #SaveHIVFunding by sending letters to your Congressional representatives.

The House bill also proposes to cut 53 percent of spending for the Minority HIV/AIDS Initiative, which seeks to eliminate racial and ethnic health disparities in HIV. The bill would also completely eliminate funding for the Minority AIDS Initiative within the Substance Abuse and Mental Health Administration.

Together, these funding cuts would eliminate all activities of the EHE, reverse recent progress in bringing down annual HIV rates, and leave state and local health departments and community-based organizations without critical funding to provide services to their communities. With 70 percent of the 1.2 million Americans living with HIV projected to be age 50 and older by 2030, the impact on the aging HIV community would be severe.

In contrast, the Senate bipartisan spending bill proposes to maintain HIV funding for Fiscal Year 2024 (FY24) and includes a proposed increase of $3 million dollars to continue the fight to end the epidemic and begin work toward a National PrEP Program. 

Please help us push Congress to pass a final FY24 spending bill that rejects cuts to HIV programs and instead would #SaveHIVFunding by sending letters to your Senators and Representative now! Please also review the #SaveHIVFunding social media toolkit that you and your organization can use to urge our leaders in Congress to #SaveHIVFunding.

In the year ahead, staking out a course that will advance the HIV response and global health equity faces serious headwinds.

Several African countries are seeing historic attacks on civil rights aimed at persecuting the LGBTQIA+ community, and most notably, Uganda is embroiled in crises with the enactment of Anti-Homosexuality Act. PEPFAR Re-authorization has been stalled by utter dysfunction in the US House of Representatives, the same body that has proposed massive cuts in domestic HIV funding. Negotiations on the WHO’s Pandemic Accord have so far failed to prioritize meaningful commitments to equity—jeopardizing global preparedness against future health threats. And at least 43 countries are holding elections in 2024, with several countries, including the US, facing serious threats from authoritarian candidates.  

But in HIV prevention, there’s also momentum. The scale-up of PrEP began accelerating in 2021 and has kept apace, with more than 6.2 million people initiated oral PrEP, and another approximately 4000 people have initiated either injectable cabotegravir or the dapivirine vaginal ring. If planning, policies and programs get it right and offer choices in programs that are co-designed by communities that need prevention most, modeling indicates the world could reach UN targets of 10 million PrEP users by 2025. But what does it take to ensure choice, what priorities will ensure policies, programs will serve the communities burdened by HIV? 

Decolonizing global health can and must be a guide star for these efforts. In 2024, it’s time to double down. Decolonizing global health is not a dream. It’s not an “extra” to reach for only when it’s easy. It’s not wishful thinking. Decolonizing global health is a cornerstone in reaching global targets, making prevention a reality, ending the epidemic, and preparing for the next one. 

It demands changes across the field, from research to rollout. AVAC is tracking this progress, developing strategic resources, and supporting the advocates who know that global health will advance or decline depending on progress in key areas:

Empowering Community Leaders & Following Community Priorities

Models of leadership that center communities necessarily involve money but must go beyond the size of the check and whose name is on it. New structures are needed, based on collaboration, transparency, and trust. The COMPASS coalition is pioneering a model to do just that. Read more about this exciting work here.

Pursuing a People’s Research Agenda

A community driven agenda is needed to define research questions and recommendations for HIV prevention research, rollout and investments. With an active HIV pipeline in research and development that is increasingly weighted toward early-phase science, a need for unstinting support for vaccine research, and momentum in cure research, it’s critical for informed and intensive community advocacy to shape the research enterprise. See the pipeline here. 

Program for Choice 

The promise of new options in HIV prevention must not be squandered in siloed programs, or by poorly planned supply chains, or because of disconnected policy decisions. People have diverse needs and face complex challenges; ending HIV depends on finding the option that works best for each individual. Read more about the choice initiatives and the Choice Manifesto and the Global HIV Prevention Roadmap for Key Populations.

Create a New Global Architecture Founded in Equity for Pandemic Readiness

When the next pandemic hits, allocating tools to the most vulnerable is the most effective and efficient way to fight it. County commitments, engagement with civil society, funding levels, and how well planning incorporates equity as a principle has yet to be secured in the Pandemic Accord or other agreements related pandemic planning. Advocates have a role to play in demanding engagement and ensuring equity. Find resources to keep you up to date on the issue here. 

Embrace the Role of Prevention in Global Targets

To end AIDS as a public health threat by 2030, prevention efforts must make dramatic strides to reach fewer than 370,000 new infections by 2025. As the UNAIDS HIV Prevention Roadmap documents, the most successful HIV responses have come from countries who “have directed resources towards high-impact combination HIV prevention programs and supported and worked with community-led responses that reach the populations and places most in need”. UNAIDS targets will continue to falter at the global level if the field fails to learn the lessons of countries such as El Salvador, Kenya or Thailand where incidence saw steep reductions by centering prevention programs around the needs of key populations.   

In the months to come, AVAC will be following progress toward these goals and reaching out to you to discuss, debate, collaborate and unite.

AVAC is thrilled to see the launch last week of injectable cabotegravir for PrEP (injectable CAB) in Zambia—the first program outside of the US to do so. And earlier this week the Desmond Tutu Health Foundation in South Africa also announced “the first jab” of injectable CAB administered in its FASTPrEP study. This news comes on the heels of another important gain—the announcement of a new licensing agreement that will double the supplies of the dapivirine vaginal ring (DVR) across Africa. 

All represent significant milestones that we hope will be the first of many in 2024. Leveraging these achievements so that people who need and want HIV prevention can access choice is the prevailing question on our minds at AVAC. Choice is the key: it requires robust investment in the policies, planning and programs that ensure every proven product—oral PrEP, injectable CAB and the DVR—are included in the package of HIV prevention options, along with sustained research and development of new interventions.

So what is the status of access among PrEP options as 2024 begins?

As it stands, oral PrEP is offered in 122 countries with cumulative initiations reaching more than 6 million (2012 – December 2023). (Check out the Global PrEP Tracker for details.) Trends in initiations saw great progress over the last two years, but to reach UNAIDS targets of 10 million PrEP users by 2025, initiations of oral PrEP alone will not be enough. People will need to find an option they can use for as long as they need it. PrEP coverage, seeing the most people possible using an option that works as long as they need it, regardless of product type, is the goal—with programs and products to support them.  

Injectable CAB supplies are an important factor. Late in October 2023, Injectable CAB’s developer, ViiV, forecasted a 40% increase in available doses to low- and middle-income countries, reaching 1.2 million doses through 2025. These doses are headed to implementation science (IS) studies that are evaluating how to scale up delivery and to national programs supported by PEPFAR and Global Fund, including Zambia’s. 

Zambia is now the second country in the world, after the USA, to roll out injectable CAB outside the planned and ongoing IS studies. And more countries are expected to follow in Zambia’s path, including Malawi and Zimbabwe. Check out our Country Planning Matrix that tracks this progress of injectable CAB as well DVR. 

In addition, 11 countries have approved the DVR, and 38 implementation science studies are delivering or planning to deliver injectable CAB and/or the DVR. Check out our Integrated Study Tracker that catalogues these projects. 

As these products start arriving in country, key issues must be addressed:

• increasing supplies and obtaining lower prices for both products;
• ensuring the delivery mechanisms for rolling out injectable CAB and DVR are integrated into prevention programs that are well-designed to reach those who could benefit from PrEP products;
• establishing how to deliver acceptable HIV prevention services to a wide range of populations, including adolescents, pregnant and lactating people, sex workers, LGBTQ+ communities and people who inject drugs; and
• advancing a learning agenda across programs that are delivering HIV prevention—inclusive of injectable CAB and DVR—to ensure information, lessons and insights are shared.

But above all, effective delivery must be defined by delivering choice through programs where end-users are supported to select the option that best fits their lives. AVAC’s Wawira Nyagah and Mitchell Warren outlined these issues—and the lessons from oral PrEP that need to be leveraged—in a recent commentary in Bhekisisa: Bending the curve: What a decade-long roll-out of the anti-HIV pill can teach the world. 

As 2024 begins, at AVAC we see possibility. PrEP initiation trends, country approvals for new products, program launches, and efforts at transparency and coordination could pay enormous dividends. But fulfilling this promise is not certain. It depends on overcoming systemic challenges around access and choice.

Let’s not waste 2024.

AVAC and Pangaea Zimbabwe are thrilled to announce Pangaea Zimbabwe’s new leadership of the Coalition to build Momentum, Power, Activism, Strategy & Solidarity (COMPASS) Africa, a historic milestone in the development of innovative models for power-sharing in coalition and an important step toward decolonizing global health.

Launched in 2017, COMPASS Africa is a civil society coalition with 29 organizations working in three countries as well as regionally and globally, using data-driven advocacy to improve the HIV response with high-impact campaigns. Its achievements to date have set new standards for mobilization and advocacy, improving laws and policies, increasing investment in programs, elevating the leadership of affected communities in the HIV response, and holding all stakeholders to account for targets, commitments and impact.

In December 2023, Pangaea Zimbabwe signed a new two-year, $4.9 million grant agreement with the Bill & Melinda Gates Foundation as the new secretariat of COMPASS Africa. For the first 6 years, AVAC served in this role, and worked with a coalition-wide governance committee to develop a clear transition plan for COMPASS to be led by African civil society organizations.

“Since 2017, we’ve been breaking new ground under COMPASS Africa. We’ve expanded our networks and brought together the superpowers of new and seasoned advocates who have diverse strengths and have joined together to develop and share technical expertise and winning strategies,” said Imelda Mahaka, executive director of Pangaea Zimbabwe. “This is a foundation of collaboration, knowledge-exchange and trust that can and will accelerate innovative advocacy under African leadership. We are so proud to take this step with AVAC and with support and collaboration of the entire consortium.”

COMPASS Africa supports coalitions and organizations based in Malawi, Tanzania, the United States and Zimbabwe, and COMPASS Africa members are currently leading more than two dozen active campaigns to advance HIV prevention and treatment. 

“From its founding, COMPASS Africa pursued a vision of collective power and shared decision-making that planned for a future in which an African-based organization would assume leadership as a vital step to sustaining this essential work,” said Mitchell Warren, executive director of AVAC. “The communities who are most affected by HIV uniquely understand their context, challenges and opportunities—their leadership is essential to developing solutions that work. With inclusive governance structures formalized, including Pangaea Zimbabwe as the new secretariat, that leadership is in place, and we are excited that AVAC will continue to be part of the coalition in its new form.”

“As planned from the inception of COMPASS Africa, coalition members are taking their highly successful model to the next level. We are jointly investing in the long-term success of African leadership because it is absolutely essential to breaking cycles that perpetuate inequity and that stall progress in the HIV response,” said Justine MacWilliam, senior program manager and COMPASS Africa partner at AVAC. 

Along with the handover of the secretariat from AVAC to Pangaea Zimbabwe, COMPASS Africa has developed a new governance manual strengthening operating structures for the growing coalition. AVAC will continue as a COMPASS Africa sub-grantee and technical partner focused on advocacy strategy and tactics, including ensuring community priorities are influencing global-level HIV policies, funders and programs.

“This effort put a premium on creating structures to deepen and sustain transparency, accountability, effectiveness and continuing growth within the coalition. COMPASS has a track record of remarkable achievements, this new leadership structure ensures we leverage lessons learned, scale up our advocacy, strengthen each other, and set ambitious goals for impacting the HIV response,” said Dr. Lilian Benjamin Mwakyosi, executive director of DARE Organization in United Republic of Tanzania and co-chair of the COMPASS Governance Working Group.

COMPASS Africa has been unparalleled in testing and succeeding with new models for transnational collaboration. The results have brought campaign after campaign that have marshalled the power of data-driven advocacy to advance community priorities and have convinced policymakers to do the right thing. With these latest innovations, COMPASS Africa is now pioneering a leadership structure that offers the field a sustainable model for decolonizing global health.

We are delighted to share our new Translation Index, a resource for journalists and advocates, to help bridge the gap between scientific research and community understanding. The Translation Index offers health journalists and advocates accurate translations of commonly used and essential scientific and medical terms in 10 African languages.

Journalists and community health workers are often at the forefront of helping people understand complicated science and health terms in their own languages. Providing information in the language it will be reported minimizes errors and helps journalists reach a wider audience. AVAC is grateful for the Sabin Vaccine Institute‘s support in the development of the Translation Index.

“Since many journalists in community radios may not be highly specialized, the translation of technical science terms into vernacular languages is essential for audience comprehension. This becomes particularly relevant during crises, as witnessed during the pandemic when different radio stations provided varying names for COVID-19 in the same language.”

—Esther Nakkazi, founder of the Health Journalists Network in Uganda

Since 2012, AVAC has collaborated with health journalist associations in East and Southern Africa through its Media Science Café Program to strengthen the capacity of journalists to report on HIV prevention research. In 2020, AVAC and partners  expanded this work to include COVID-19 science. Today, AVAC partners with health media associations in Kenya, Malawi, Tanzania, Uganda, Zambia and Zimbabwe to bring journalists together with researchers, implementers, civil society, policy makers, regulators and policy makers to build relationships that will foster accurate reporting of HIV, COVID-19 and other science or health stories in those countries.
 
Join us, Tuesday, January 23 for a webinar, Reporting the African Science Story: Decoding scientific research to support public health in Africa where we will share highlights from our Media Science Café Program. Click here to register.

“Having a platform in Malawi for communicating science in local languages is a great innovation that will also enable more of the population to be able to follow science, research and other innovation in global and public health from a scientific perspective and participate in the discourse.”

– Dingaan Mithi, journalist and JournAIDS program manager

We hope you will visit the Translation Index and join us on the 23^rd.

By Jeanne Baron

At the ongoing International Conference on AIDS and STIs in Africa (ICASA), the struggle to sustain an evidence- and rights-based HIV response is heating up. HIV prevention and global health equity depend on continuing to build on the gains to date, to learn from mistakes, and to invest in scaling up now-proven solutions while developing additional ones. But all these principles are increasingly threatened by political reaction and short-sighted investment. AVAC and partners released four major calls to action at ICASA to confront these urgent challenges, which are imperiling the communities most burdened by HIV and other health inequities. Each of these resources set an agenda to address critical gaps. 

Upholding Civil Society Voices in Health International Conferences: A response to the suppression and cancellation of community voices at ICASA 2023

A permitted People’s March scheduled for December 5 in Harare was cancelled due to acute safety concerns following the arrest of conference attendees at a demonstration, and other intimidating police actions against civil society and key populations at the conference. AVAC is part of coalition that issued an open letter to the conference secretariat condemning the suppression of community voices and calling for the People’s March to go forward and future guarantees that ICASA host countries commit to allowing community voices to be heard and ensuring their activities are unhindered. 

The Global HIV Prevention Roadmap for Key Populations

This roadmap outlines a strategy for the equitable expansion and delivery of HIV prevention services to key populations (KPs) globally and regionally. It introduces a critical, coordinated approach led by KPs to accelerate the implementation of existing and new HIV prevention interventions. Developed by the Global KP HIV Prevention Advisory Group (KPAG) and allied stakeholders, this roadmap represents near-term priorities for funding, U=U, PrEP targets, the advancement of rights— particularly decriminalization of key populations and more for key stakeholders and regions to achieve by mid 2025. This roadmap is a terrific complement to the recently-released Choice Manifesto, led by women advocates throughout Eastern and Southern Africa.

“This is nothing new, we’ve been saying this for years, but now it is more urgent than ever: Funding to key populations must go beyond services to support our advocacy and our activism.  Decriminalization is imperative. We are not criminals, and with a stroke of the pen decriminalizing key populations could lead to lower incidence of HIV,” said KPAG member and former AVAC Fellow, Josephine Aseme at a press conference promoting the importance of this roadmap.

Mobilizing People of Faith to Build Networks to Protect Human Rights and Overcome Homophobia

Faith leaders from across the region convened by African Services Committee, AVAC, GALZ & Inerela joined in solidarity in defense of human rights and evidence-based HIV prevention, including for vulnerable populations. Among the pledges, participating faith leaders are committing to engage in cultural and legislative initiatives related to LGBTQIA+ issues that promote love, grace, compassion, equity and justice for all. 

Call to Action for Voluntary Medical Male Circumcision: The job is not done yet

Despite impressive achievements in bringing voluntary medical male circumcision (VMMC) to scale, the pace of funding and the expansion of programs delivering VMMC must intensify to reach 2030 global targets for HIV prevention. Modeling studies suggest the approximately 30 million VMMC’s conducted between 2008-2020 averted 615,000 new HIV infections. By 2030 that number could be 1.6 million infections averted, if the HIV response sustains and expands VMMC. This joint report was prepared by AVAC, Azali Healthcare, Bill & Melinda Gates Foundation, Jhpiego, the Coalition for Health Promotion and Social Development (HEPS-Uganda), Treatment Advocacy and Literacy Campaign (TALC), the Joint United Nations Program on HIV/AIDS(UNAIDS) and the World Health Organization (WHO). Find a two-page summary here and the full report here. 

“VMMC offers us an exceptional opportunity to get men into the healthcare system but we have gone off track. We can’t afford to lose momentum. The job is not yet done. New funding is needed now. Integration is needed now. Sustained commitment is needed now.” – Chilufya Kasanda Hampongo, TALC Zambi

All four initiatives launched at ICASA take aim at critical gaps in the HIV response. Each provide resources that outline next steps and roles for stakeholders across the field to advance equity, and in turn help the world reach global targets to end the epidemic.