Who’s Driving This Ship?

Over the last year, governments and health leaders have been working to restructure the global health system to ensure pandemic prevention, preparedness, and response. The COVID-19 pandemic forced a reckoning, exposing a deeply inequitable global health system, and advocates, civil society, health workers and leaders representing southern populations, have called on governments to rewrite the world’s contract – in particular, asking Global North governments to finally give up some power and, in the service of preventing and preparing for pandemic threats, agree to join a system that is equitable and aims to prevent health threats everywhere and prepare everyone.

At AVAC, we have put a lot of hope in the processes of the Pandemic Accord, the UN High-Level Meeting (HLM) on Prevention, Preparedness, and Response (PPPR), and the development of a medical countermeasures (MCM) platform. (To understand how these three efforts fit together, see AVAC’s Advocate’s Guide to PPPR.) However, sadly, and in honesty, predictably, many high-income countries seem unwilling to alter the status quo. We see four main sticking points that come down to whether these countries will relinquish control:

Data sharing

Global agreements to share pathogen data and genomic sequencing in the event of a novel pandemic threat represent one of the most important areas of negotiation in these processes. Understandably, many countries are keen to ensure they can have access to data on newly discovered pathogens so they can create a vaccine or treatment as soon as possible and protect their citizens. But since research, manufacturing capacity, and resources are concentrated in the Global North, such an agreement presents a bad deal for countries in the Global South. Such an agreement would require them to share the data they have access to, but continue to be last in line for the vaccines or other interventions that get developed from that data.  To add insult to injury, they may well be punished for sharing it, as was the case when the Republic of South Africa shared data on the Omicron mutation of COVID-19 and then saw Global North countries subsequently block entry to their citizens.

But so far, the countries pushing to secure agreements on data sharing refuse to grapple with these concerns. They have not budged and remain unwilling to support language that would ensure access to the beneficial medical countermeasures and that are developed from shared data. While the potential for open science and a platform for data sharing holds promise, these efforts will predictably result in simply exacerbating inequalities unless these agreements beef up commitments around equity. Negotiations on this issue have been tense, with no resolution in sight.


The concentration of research capacity in the Global North represents another major hurdle. Because the majority of resources for R&D are held by either Northern governments or corporations headquartered in the North, their priorities dictate the answers to questions such as which pathogens, what intervention to pursue, and what populations to help first. For example, $35.8B was spent on medical research worldwide in 2022, but only $3.95B was invested in R&D on diseases with an outsized impact on people living in the global south (including HIV, tuberculosis, and malaria) in 2020. Some governments, like the countries in the ‘Group on Equity’, are calling for more distributed investments, more collective resources dedicated to pathogens of pandemic potential (such as those in the Africa CDC’s priority list), and agreed-upon standards for the diversity of populations that must be included in clinical trials. Negotiations are ongoing, with a lot of opposition coming from pharmaceutical corporations.

MCM platform

We are quite concerned with the current process of developing an MCM platform that has been proposed by the G7 and G20, along with WHO’s support. The stated aim of the platform is to coordinate equitable development, distribution, and delivery of medical countermeasures for pandemics, including vaccines, therapeutics, diagnostics, and other tools, and to implement the platform in ‘peacetime’ before the next pandemic hits so we’re ready. So far, however, the development process has been largely driven by G7 and G20 countries, both because it will take investment from these countries and because less-resourced countries simply do not have capacity to engage in another PPPR-related process in addition to the Pandemic Accord and UN HLM. Discussions between civil society and country representatives are not happening – while WHO and different agencies have held official meetings with countries, civil society have been relegated to separate discussions. Some global health leaders, from both countries and agencies, have expressed a desire to leave ‘thorny’ issues out of it. But public health advocates and civil society insist that these issues such as intellectual property, clinical trials and R&D prioritization, allocation, the inclusion of marginalized groups, and governance must be considered now before the platform is stood up. It’s unclear who is making the decisions here, but it is certainly not those most burdened by disease.


The Pandemic Accord draft and the draft UN Declaration on PPPR include few concrete references to PPPR financing targets or finance reform. One of those few is the mention of new-to-the-field Pandemic Fund as a primary resourcing vehicle. This apparent reliance on the Pandemic Fund raises serious questions, as the Fund has offered just $300M in the first round of funding. PPPR agreements that defer finance commitments to the Fund are misguided at best and reveal a lack of ambition to effectively confront pandemic threats. The world currently needs to turn this ship around. Pandemic preparedness must not be an afterthought, a half-hearted boondoggle that only serves the interest of rich countries. All of the issues raised here, in addition to the need to upgrade and expand surveillance systems, increase and strengthen the health workforce, and build up regional manufacturing capacity, need resources to be implemented. On top of those pressing needs, many of the countries that are in most need of investment in pandemic preparedness are straining to manage enormous debt burdens imposed by wealthy countries.  Advocates are asking that governments include, in the UN Declaration on PPPR and Pandemic Accord, reference to existing mechanisms such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria (currently the largest funder of PPPR worldwide), the WHO Contingency Fund for Emergencies, and the IMF Resilience and Sustainability Trust as existing vehicles for pandemic preparedness resourcing. PPPR will advance equitably and effectively, and less resources will be needed, if countries commit to leveraging what has already been built in the ongoing responses to HIV, tuberculosis, and malaria. PPPR must learn from twenty years of demonstrated success fighting pandemic and epidemic threats.

So who is driving this ship?

It appears that those who have historically held control have not learned their lesson after yet another global pandemic that abandoned poorer countries and left all of us more vulnerable to the next pandemic. Instead of facing the reality that disease knows no borders and resetting the global health system, those who hold the purse strings seem content to continue with the status quo – hoarding the fruits of science, reinforcing exclusive and hegemonic systems, consolidating power among the few, and keeping health systems fragmented and underfunded. It’s an upside-down system – with those most secure and least in touch with the impact of their decisions in charge. The PPPR ship must be driven by those most burdened by pandemic threats and ongoing epidemics, or we will most certainly face another devastating pandemic and decision-makers will wish they turned it around now.

Our Take: Are the UN Declaration on PPPR and the Pandemic Accord going in the right direction?

The last few weeks have been filled with high-level negotiations among UN Member States on the way forward for global pandemic prevention, preparedness, and response (PPPR) efforts. Below, please find an analysis of the negotiated language to date in the Pandemic Accord, and the UN Declaration on PPPR, and their implications for equity in PPPR. These analyses were conducted by AVAC and partners working in collaboration to track progress toward equity in these agreements and develop an advocacy agenda for provisions in both that ensure equity in global health advances. The Declaration is an agreement that involves heads of state and potentially a role for all ministries of government. The Pandemic Accord is being negotiated by members of the WHO to strengthen PPPR.

The Pandemic Accord: A look at negotiations to date

The first draft of the WHO-led Pandemic Accord was released in May, containing edits to the zero draft from the Member States. As expected, edits from high-income countries introduced challenges to equity provisions in the text— particularly provisions aimed at ensuring that agreements to share access to data on pathogens is paired with commitments to also share the benefits developed from research using those data (termed pathogen access and benefits sharing). Other equity provisions that were challenged include intellectual property, and language on how the world should allocate vaccines, therapeutics, and diagnostics in the event of a global pandemic threat. Throughout the document, certain high-income Member States inserted caveats or wording, such as “encourage” or “as appropriate”, which would make implementation voluntary or compliance more subjective. Other phrases to weaken the agreements, such as replacing “commit to” with “recognize the importance of”, were also inserted.

Negotiations so far have resulted in weaker, alternative language to several key articles than in the so-called zero draft of the accord. These include articles on technology transfer, the Pathogen Access and Benefit Sharing (PABS) System, health workforce strengthening, and the proposed Supply Chain & Logistics Network. There are, however, some clauses that have been strengthened. Global R&D networks, laboratory networks for genomic surveillance, knowledge translation, and the harmonization of regulation to accelerate WHO pre-approval and authorization all have stronger commitments and more details than before. You can find the first draft here and a closer analysis of the changes made between the zero and first draft here.

The UN Declaration on PPPR: What’s in the Zero Draft?

The zero draft of the UN Declaration on PPPR, set to be adopted at the High-Level Meeting on September 20, was released in June.

Many provisions in the draft Declaration are positive, recognizing and affirming key points related to human rights and inclusive provisions that prioritize vulnerable and marginalized populations. The draft recognizes vaccine inequity as a vital concern, affirms key principles of equity and non-discrimination and the need to ensure adequate support for both health workers and the WHO. However, there are very few, if any, concrete targets set, leaving little to hold countries accountable. Missing from the Declaration, in particular the section on Overarching Health Related Issues, is the need for countries to prioritize and commit to building on the global responses to ongoing epidemics, including HIV/AIDS, TB, malaria, polio, other neglected disease outbreaks such as Ebola, Marburg, and cholera, and antimicrobial resistance (AMR).

This is a missed opportunity with enormous implications. It signals a troubling and serious global inability to build on existing health and community infrastructures, integrate responses, and avoid erecting isolated pillars in global health architecture. Many of the capacities needed for PPPR already exist in the response to these other health threats. They can and must be expanded and strengthened for broader pandemic preparedness. In addition, the history of the responses to HIV/AIDS, TB, and malaria have made clear that community leadership in the response and civil society engagement are essential to achieve success in PPPR. The current response to existing health threats, which through trial and error have built resilient and effective systems, should serve as the foundation for any future pandemic preparedness and response efforts. The Declaration’s silence on this issue is gravely concerning.

The Declaration’s clauses relating to agreements on pandemic-related tools and products are strong, and notably stronger than those in the first draft of the Pandemic Accord. But equity provisions, and access to those tools, could be strengthened further, by including compulsory licensing and transfer of know-how when necessary.

It’s vital for advocates to engage with these processes, and leverage their power to influence the emerging architecture in global health. Decisions being made now will have implications for years to come. And the voices of advocates are having an influence. For example, the US government’s contribution to the current draft of the UN declaration recently added specific recommendations from AVAC and partners on the inclusion of Good Participatory Practice. It’s up to all of us to make sure GPP and other provisions that ensure equity in global health are in place when the drafts become final.

You can find the Declaration zero draft here and see our analysis and the changes we call for here.

What’s Next

These negotiations are setting the direction for pandemic readiness for years to come. As discussions continue in the weeks and months ahead, it’s imperative for advocates and countries to be raising their voices and calling for language and commitments that will ensure equity in PPPR. Building on the lessons the world has learned from ongoing epidemics, and integrating the response must be a priority to ensure the tragic results of inequity in global health are not repeated, again and again.

AVAC will be sharing these analyses with our partners and governments with whom we work with. For more background, read AVAC’s Advocates Guide for PPPR. And you can take action now by sending these resources to your country’s UN representatives and other influential voices in your networks!

New Px Pulse Episode on LGBTQIA+ Advocacy in Uganda

Our latest podcast, LGBTQIA+ Advocacy in Uganda: Facing down fear and fighting for justice, is available now!

This episode looks at Uganda’s just-passed anti-homosexuality bill, that now awaits final action from President Museveni. The broad-reaching legislation further criminalizes LGBTQIA+ people and is part of a wave of anti-gay hate laws and actions by authorities that are sweeping across the region with recent crackdowns in GhanaKenyaRwandaTanzania and Zambia.

The Ugandan bill would make it a crime to even identify as lesbian, gay, bisexual, transgender or queer, with sentences up to life imprisonment. It gives authorities wide powers to crackdown on anyone who does not report on same-sex couples or who promote gay rights, including prohibitions on news coverage and media. And the law could impose death sentences in some cases, including for the transmission of HIV. Uganda’s President Museveni has the power to stop the bill. But so far he is issuing statements for other African countries to follow Uganda down this path.

This podcast episode features several leading Ugandan advocates, whose fierce and imperiled voices are readying to fight for LGBTQIA + people in Uganda, but at AVAC, we know they are fighting for all of us. Listen as they dig into the specifics of how these attacks have gained momentum and their ties to US-based religious extremists. For the full podcast episode, resources to learn more on the issue, and the archive of previous episodes, visit avac.org/px-pulse. And subscribe on Apple PodcastsSpotify or wherever you get your podcasts!

Uganda-based advocates are urgently organizing and raising money to challenge this law. You can donate to SMUG and Chapter Four Uganda.

Catch Up on the Advocacy for IP Waivers, Tech Transfers and PPPR

In case you missed it, highlights from our April 6 webinar, Global PPPR Equity: Why do we need agreements on IP and tech transfers?, are a must read. Panelists, bringing a range of expertise, explored lessons learned from the HIV/AIDS epidemic on IP and tech transfer advocacy and what’s next in the fight for global equity in pandemic prevention, preparedness and response (PPPR).

Featured speakers included:

-Fifa Rahman, ACT-A CSO and Health Poverty Action
-Brook Baker, Northeastern University and Health GAP
-Fitsum Lakew, WACI Health
-Esteban Burrone, Medicines Patent Pool

Listen to the webinar to learn:

-Why patents matter for diagnostics, despite assertions from industry that they do not
-The impact of intellectual property monopolies during COVD-19
-About the need for rapid scale up of manufacturing in African countries and more

“There are five key reasons we need licensing and tech transfer: they reduce prices, accelerate access to new and innovative treatments and other technologies, enable production of greater volumes, contribute to supply security, and support geographical diversification of manufacturing.” – Esteban Burrone, Medicines Patent Pool

Check out our summary of the webinarwatch the recordingdownload the slides and find links to a host of resources on PPPR, including an Advocate’s Guide to PPPR and two recent podcasts on the global architecture being put in place to make investments and coordinate resource sharing.

With pandemic prevention, preparedness and response an area of increasing investment and planning, these voices are sharing insights and messages that are instrumental for collaboration and advocacy. Tell us what you think and contact Samantha@avac.org to get involved!

AVAC at the 2023 Biomedical HIV Prevention Summit

The Biomedical HIV Prevention Summit, now in its seventh year, will be held in Las Vegas, Nevada, on April 11-12. This annual meeting focuses on biomedical interventions for treatment and prevention of HIV and approaches to implementation of these tools to end the epidemic.

This year’s theme highlights the role of sex and pleasure and includes a plenary featuring advocacy to right the wrongs of a failed US federal PrEP response with a US National PrEP Program.

AVAC and partners are involved in a number of sessions and activities; scroll down for information on these and click here to check out the full conference agenda.

And finally, be sure to follow our Twitter feed, @HIVpxresearch, Tuesday, April 11, when our Senior Program Manager for Policy, John Meade Jr., takes it over to report on the meeting live from Las Vegas.

AVAC and Partners at the Biomedical Prevention Summit

Tuesday, April 11:

10:30 to 12:00 PM PDTNo Data No More: A research scorecard for transgender inclusion
Session 1 Workshop
If we are to end the epidemic, we need biomedical research data that are representative of transgender communities. AVAC has designed a Scorecard tool with which to hold researchers accountable for the meaningful inclusion of transgender people in all HIV clinical trials. Join this session to learn how milestone HIV studies from 1991-the present have scored on transgender inclusion—and how you can ensure “No Data No More.”

4:30 to 6:00 PM EDTLong-Acting Injectables: Revolutionary prevention drugs require revolutionary adaptations in delivery
Session 3 Workshop
Current delivery models for longer-acting injectable (LAI) PrEP require consumers to travel to outpatient settings and be seen by providers qualified to deliver injections. Yet, many providers serving HIV-impacted populations do not have sufficient capacity to offer LAI PrEP at the volume necessary to end the epidemic. Additionally, structural barriers and serious inequities within the United States healthcare system prevent many from engaging in HIV prevention. This workshop will explore how the HIV prevention community can draw lessons from other fields to successfully develop, advocate for, and implement alternative delivery models for LAI to increase access, and realize the promise of these revolutionary interventions.

4:30 to 6:00 PM PDTPrEP in Black America: An equity movement in HIV prevention
Session 3 Workshop
Black people in the US bear a disproportionate burden of HIV, representing approximately 13 percent of the population while comprising more than 40 percent of incident HIV diagnoses in 2019. Despite this, biomedical HIV prevention tools remain underutilized by Black people and more than 90 percent of those who can benefit from PrEP have not been prescribed PrEP. The PrEP in Black America Summit (PIBA) was convened by a cadre of Black HIV activists, advocates, leaders, and public health professionals to address these frustrating factors on the 10th anniversary of the Food and Drug Administration’s approval of the first medication for biomedical HIV prevention. Summit leaders gathered more than 150 individuals, in person and virtual, in the spirit of confronting the historical injustices and race-based discrimination that continue to drive HIV and other sexual health inequities experienced by Black communities to develop a Black-focused agenda or “roadmap” for HIV prevention.

Wednesday, April 12:

10:30 to 12:00 PM PDTCAB 4 PrEP: Opportunity for advancing equity and improving access
Session 4 Workshop
Injectable PrEP uptake in the US has the potential to reduce HIV infections, but only if its introduction can address the impediments to its implementation. Participants will engage with panelists that have experience with injectable cabotegravir in this workshop.

Challenging a Season of Hate in 2023

A look back at the last few weeks brings a heavy heart, and, for us at AVAC, a renewed determination to fight back against a sea of reactionary policies that jeopardize healthcare and dismantle civil liberties around the world.

As our Executive Director Mitchell Warren recently told the TheBodyPro, “This is, frankly, a global pandemic. Right-wing politics, moralizing legislatures, and moralizing judicial systems are putting people’s lives at risk.”

Extremist courts and legislatures in the US and in many other countries are pursuing laws that will, at the very least, turn back time in our progress against HIV and at worst destroy the lives of whole segments of society.

In the last two weeks alone, AVAC has had to issue three statements condemning unjust, dangerous and deeply flawed legal maneuvers.

On March 24, we condemned Uganda’s Anti-Homosexuality Bill of 2023, a more poisonous version of a 2014 attempt to further criminalize the LGBTQIA+ community. It’s also just one of condemned Uganda’s Anti-Homosexuality Bill of 2023 several draconian anti-gay bills sweeping across Africa and the US. As Brian Kanyemba of Advocacy for Prevention of HIV and AIDS (APHA) told TheBodyPro, it’s a “Homophobic Spring”. (Watch this space for a podcast in the coming days with stunning reports from Uganda-based advocates on the fight against Uganda’s proposed anti-homosexuality law.)

Two US court rulings have since come down, each attacking access to fundamental healthcare. On March 30th, a US federal judge in Fort Worth, Texas, struck down a section of the Affordable Care Act that requires insurance coverage for many preventive services, including HIV testing and the provision of PrEP. This ruling reinforced an earlier decision that ruled PrEP provision may violate individual religious freedom. AVAC’s statement condemned this ruling that endangers access to PrEP, as well as other life-saving prevention services.

And today, we are again condemning a court ruling from a different US federal judge, this time based in Amarillo Texas, who has issued an unprecedented preliminary injunction suspending the US Food and Drug Administration’s (FDA) approval of mifepristone, a safe and effective abortion medication approved more than 20 years ago. If this decision is allowed to stand, it will restrict access to the most widely used method of abortion and undermine the FDA’s authority on drug regulation generally.

“This decision throws open the door to reversals of other drug approvals based on one individuals’ personal or political beliefs rather than science and evidence. It’s yet another blow in a campaign to roll back bodily autonomy and human rights and cannot be allowed to stand,” said Warren. “In solidarity, we stand with the millions of individuals and families who will be affected by this highly political decision, and we stand with science and medical evidence, which is increasingly under attack in the US.”

In what has become a season of hate, we turn our eyes to the work ahead. We call on the Biden administration to take immediate action to safeguard access to every aspect of sexual, reproductive and preventive healthcare, including PrEP, mifepristone and other abortion services. We call on political leaders and health leaders in every corner of the globe to take action in solidarity with LGBTQIA+ people to protect and expand their civil rights. When fear and reaction gather momentum, we must recommit to an advocacy agenda that champions evidence-based and science-informed policy. We must join together, with clarity and solidarity, to face down the hate and build a world for all of us that is safe, healthy and just.

Webinar Recording on Global PPPR Equity

Global PPPR Equity: Why do we need agreements on IP and tech transfers?

Over the past two decades, HIV advocates have engaged in hard battles for equitable access to HIV/AIDS drugs and prevention options and have had some big wins. The process of these negotiations has led to strong relationships that have enshrined certain equity provisions as standard in clinical trials and manufacturing of HIV drugs. Through these battles, we’ve learned clear lessons on the necessity for such agreements and what’s required to secure them.

Throughout global PPPR agreements in 2023, governments and advocates in the Global South are asking for provisions on equity in the form of temporary IP waivers, mandatory tech transfer, and mandatory licensing for pandemic tools.

This panel discussed lessons from the HIV epidemic and explore why governments of the Global South and advocates think we still need to address ‘the IP question’.

Featured Speakers included Fifa Rahman, Brook Baker, Fitsum Lakew, and Esteban Burrone

Watch the recording here.

It’s All About Choice

Real choices in healthcare are fundamental. They empower individuals, advance equity across healthcare systems and transcend healthcare altogether, fostering community resilience. But choice depends on commitment, requires investment and needs champions.

At AVAC, we are thinking intensely about how to be a champion for choice. Wherever our work takes us. Here’s what’s top of mind today.

Our newly launched initiative, The Choice Agenda (TCA), led by veteran advocate Jim Pickett, is hosting its next webinar in its series on HIV prevention, The Research Says Yes, YES, YES – Just Like That, Wednesday, July 13 at 9:00am ET / 1:00pm GMT / 15:00 SAST. Register now.

This webinar explores insights from HIV prevention and sexual health research that point to the many positive outcomes when we center and prioritize pleasure and sexual satisfaction in our interventions and prevention programming.

We’ll be featuring a discussion with experts:

• Christine M. Curley, University of Connecticut

• Dr. Joao Alves Neto, University of Minho (Portugal) and FACEFI (Brazil)

• Anne Philpott, The Pleasure Project

Get access to our previous webinars, register for what’s upcoming on The Choice Agenda webpage, and sign up with jimberlypickett@gmail.com to join the TCA listserve for dynamic, cross-cutting conversations with hundreds of dedicated advocates.

Fighting for Choice Together

All of our voices must be heard to protect and expand access to real choices for everyone who needs them. Especially when it comes to sexual health, which is so often stigmatized and often profoundly under threat. AVAC condemns last month’s decision by the US Supreme Court, which rolls back decades of protections for those seeking safe abortion services in the US and undermines other landmark rulings that safeguard fundamental human rights, privacy and personal liberty.

Read AVAC’s statementRead AVAC’s statement condemning the opinion and declaring our commitment to stand always for reproductive justice and to work with our partners and allies to ensure that the right to abortion is protected.

Learn More About the Impact of Media Science Cafés in Zimbabwe

For more than a decade, AVAC and partners have been leading Media Science Cafés, a program connecting journalists, researchers and advocates to help expand and deepen accurate reporting of HIV science. The program began in Uganda, when a group of journalists were looking for ways to connect with research and better understand both the science of HIV and its impact on their communities. These Cafés began with a focus on HIV with support from the Gates Foundation and the USAID-funded Coalition to Accelerate & Support Prevention Research (CASPR) and have expanded over the years to cover research on sexual and reproductive health and other health issues and, more recently with support from the Rockefeller Foundation, to COVID-19, and are now running, in partnership with health media associations, in Kenya, Uganda, Zambia, and Zimbabwe.

In a blog, Changing Minds: Journalists see a universe of genders, South African journalist, Mandi Smallhorne-Kraft tells the story of how one Café in Zimbabwe, as part of the 2019 program to connect journalists with transgender people, made a critical connection that participants called transformational. It’s a must read. Follow this link to read more.

A 15-Year Review of the PEPFAR Support to Malawi: How Has It Succeeded?

Maureen is the African Region Advocacy Advisor for AVAC. This post originally appeared in the Petrie-Flom Center at Harvard Law School’s Bill of Health.

Malawi was listed as one of the six locations that have made remarkable progress towards ending the AIDS epidemic in a recent report produced by amfAR, AVAC and Friends of the Global Fight. Being one of the poorest countries on the list, Malawi has proven that ending the epidemic is possible anywhere.

But one would want to know what has contributed to this success!

Well, there are many factors. And funding from donors is one of them. The HIV/AIDS response in Malawi is largely funded by the Global Fund and PEPFAR. But for the sake of this blog I will focus on PEPFAR, a US government program launched in 2003 by then President George W. Bush. In 15 years of support, PEPFAR has led the world in funding the global HIV response.

In Malawi, PEPFAR has invested nearly $700 million since 2003, which has brought significant improvements in the HIV/AIDS response.

But as you know, funding alone does not guarantee success. There are other factors that have played a role, such as increasing efficiency in the use of the resources, linking funding to performance and impact, having the right policies in place and widening stakeholder involvement, just to mention a few.

PEPFAR’s attention to geographical locations that carry a high burden of HIV incidence has resulted in funds going where they are needed most. PEPFAR has fought hard for the adoption of evidence-based policies, which in turn led to the implementation of the highest impact interventions.

PEPFAR’s strong recommendation to shift from paper to electronic medical records (EMR) has been another game changer for the HIV response in Malawi. Shifting to EMR improved real time access to data throughout the health care system.

Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS), a PEPFAR program meant to reduce HIV infections among adolescent girls and young women, has been another remarkable initiative rolled out to three districts in Malawi. The program has helped improved the socio-economic wellbeing of adolescent girls and young women, thereby reducing their HIV risk.

The HIV response took another important leap forward when PEPFAR opened up its doors to civil society organizations (CSOs). For me, this was proof of the principle that the best results come when funding and policy decisions are made in the presence of everyone who matters.

I remember attending the first country operational plan (COP) meeting where CSOs were invited. It was a revolutionary moment. Having CSOs in the room changed the course of the discussion. For the first time, we had everyone who mattered in the room. The following year we did it again and we are still doing it now.

But there have been challenges too! The first two years following PEPFAR’s inclusion of CSOs, civil society received limited access to PEPFAR data — it was shared late or not at all. This made it difficult for CSOs to effectively engage in the process. CSOs advocated for a change, and PEPFAR leadership has responded by making the data available, though not always timely. But we are getting there.

The other challenge has been getting policies fully implemented. A policy on paper alone is as good as no policy at all. This has been a big challenge for Malawi largely due to limited funding. Malawians can point to a full range of policies now in place, but yet some of them are live only on the books such as the Pre-Exposure Prophylaxis (PrEP) and the T=T/U=U campaigns, both of which have proven to be highest impact interventions elsewhere!

Moving forward a few things need more attention.

We all love the DREAMS program, but only focusing on three districts is not enough. It is time to scale it up!

As we get closer to epidemic control it’s important that we start thinking about how are we going to sustain the gains made so far. PEPFAR has committed to direct 70 percent of the funding to host country governments or organizations by the end of 2020 — this is highly commendable. However, this should not only be on paper, it has to be fully implemented. Lack of capacity should not be an excuse. Deliberate effort must be made to fill any gaps in capacity.

We need to embrace the model of differentiated service delivery to meet the diverse needs of the community members! To date we still have community members who travel a distance of more than 20 kilometers on foot just to get their ART refill! This is not acceptable! We need to get the services closer to them!

And, above all, policies must be fully implemented.