This week we are reminded of the importance of sexual and reproductive health and rights as we marked World Contraception Day (Sept. 26) and International Safe Abortion Day (Sept. 28). 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.

At AVAC, we are thinking about how to be a champion for choice. Wherever our work takes us. Here are a couple of things we are working on and we invite you to be a part of.

The idea of reclaiming choice played a major role in the International AIDS Conference this year, especially around the dapivirine vaginal ring (DVR) and the dual prevention pill (DPP)—both of which could improve the landscape of prevention for adolescent girls and young women (AGYW) and pregnant and lactating populations (PLP). Get updates on both the ring and DPP in these webinars:

Private Sector Delivery Opportunities for the Dual Prevention Pill (DPP): Lessons from family planning (FP) for the introduction of multi-purpose prevention technologies (MPTs)

Wednesday, October 12 at 7:30am ET

AVAC and FP2030 will explore new findings on private sector opportunities for the DPP in Kenya, South Africa and Zimbabwe. With anticipated rollout of the DPP just two years away, planning for where to introduce the DPP in the private sector will be critical for ensuring access, but will hinge on where PrEP delivery is already permitted. Learn more about the webinar and register here.

The Choice Agenda hosted a conversation around the latest in DVR advocacy last week: RINGing the Bell for Choice: Actions and Solutions on Dapivirine Ring Access.Watch the webinar, explore up-to-date resources on DVR hereexplore up-to-date resources on DVR here, and sign-up for The Choice Agenda listserv (a growing community of over 700 prevention advocates and counting).

And save the date for:

Doxycycline for STI prevention: Evidence and Current Research

Webinar: Friday, October 7, 2022 at 10:00AM ET

Join The Choice Agenda for the latest scientific data and discussion around a new STI prevention strategy, doxycycline as post-exposure prophylaxis (dPEP) to reduce chlamydia, syphilis, and possibly gonorrhea. Join us to hear the implications for policy and program. Register here.

The Global Fund’s Seventh Replenishment conference begins this weekend in New York City. Held every three years, these conferences bring governments, philanthropies and the private sector together to pledge their investments to the largest global grant-making source for health systems in low- and moderate-income countries.

The UNAIDS Report released in July showed us that we are off-track in reaching global targets for HIV, and the field of global health knows the world is similarly off-track with TB and malaria targets. At least US$18 billion for the Global Fund’s Seventh Replenishment would save 20 million lives, cut the death rate from HIV, TB and malaria by 64 percent and build resilient and sustainable systems for health, and to strengthen pandemic preparedness.

The US government already committed $6 billion over the next three years. Now, the rest of the world needs to step-up with their support for the Global Fund. Plus the US needs to ensure that PEPFAR is robustly funded. Next year, PEPFAR will be up for Congressional reauthorization, allowing advocates opportunities to influence and sustain PEPFAR’s priorities. These priorities must advance pandemic preparedness and be defined by what impacted communities need and want.

The Global Fund and PEPFAR together constitute a core foundation for pandemic preparedness and global health security. Investing in both is fundamental to making full use of existing platforms and expanding them to achieve global health security and equity. Read our latest P-Values blog, What does multilateralism mean and why it’s right for the future, from AVAC’s Senior Policy Manager, John Meade for more.

And check out other resources and background to inform your Replenishment advocacy.

• Webinar Recording: AVAC hosted a webinar earlier this month summarizing the Global Fund Investment case, and Results Report for 2022
• Global Fund Advocacy Network (GFAN) social media toolkit
• The Global Fund Seventh Replenishment: Fight for what counts
• The Global Fund’s Key Numbers and Messages
• Friends of the Global Fights’s social media toolkit celebrating the role of US leadership in the Global Fund’s 7th replenishment
• KFF Article: The US Government and Multilateral Global Health Engagement: 5 Key Facts
• Story: Tanzania gives vending machines a new use, an example from myService and African Community Advancement Initiative (AFRIcai) of innovative programming in Tanzania using Global Fund investment, a feature story on ProtectingGlobalGains.org

What does multilateralism mean and why it’s right for the future

COVID-19 was declared a Public Health Emergency of International Concern by the WHO in January 2020. There was unprecedented speed and urgency at the start of the pandemic that resulted in rapid development of diagnostics and vaccines to combat the spread of disease. It was a terrific example of multilateralism at work—when nations recognize a shared threat or interest, and come together toward a common purpose.

However, as the pandemic progressed, decisions around COVID-19 vaccine distribution revealed deep and enduring inequalities that prioritized nationalism over multilateralism. Citizens of high-income countries have access to third and fourth rounds of shots while citizens of low-to-middle income countries are still fighting for their first doses. This nationalist approach in the midst of an emergency is the basis for catastrophic failure in any pandemic response, as shown over the last two years.

Multilateral organizations—those jointly supported by multiple governments and other partners—with a shared aim of health as a common good, are instrumental to global health security, overcoming health inequities, and building resilient health systems around the globe.

One of the world’s most important multilateral efforts is The Global Fund, which has made possible a groundswell of innovative and community-centered initiatives. These programs set up a bulwark against HIV, TB and malaria, while addressing COVID-19. Models of innovation at the ground-level such as these represent essential preparation for future epidemics and pandemics. Human-created borders cannot be allowed to constrain this work.

To succeed, the Global Fund works interdependently with The President’s Emergency Plan for AIDS Relief (PEPFAR), a country-to-country (bilateral) program that represents the world’s largest investment in delivering HIV treatment and prevention. Each makes the other stronger.

HIV is a constant threat to global health, leaving millions all the more vulnerable to other diseases, and demanding vigilance and steadfast, fully-funded strategies to end it as a global epidemic. Global Fund operates in 78 countries where there’s no PEPFAR presence, drawing lessons from PEPFAR experience, expertise and technical assistance. In the countries where PEPFAR works, Global Fund is shoring up health systems and buttressing the supply chain.

(Source: Kaiser Family Foundation)

(Source: Kaiser Family Foundation)

Political Will and the Future of Global Health

The Global Fund’s Seventh Replenishment, taking place the week of September 18th, is an opportunity to rise to the challenge and raise essential funding. The minimal need required to get back on track to reach global targets for HIV, TB, and Malaria (that were derailed by COVID-19 and nationalistic policies) is pegged at $18 billion. But this figure will leave a $28 billion gap, spurring demands from civil society to go further.

The US government has committed to investing $2 billion in fiscal year 2023, and $6 billion over three years. Although this is a major win for the U.S investment in multilateralism, the Biden Administration requested a $20 million cut for PEPFAR that will impair HIV programming around the globe. This blow comes as new leadership at PEPFAR holds great promise to extend the reach of one of the single most effective programs in the history of global health.

This year PEPFAR welcomed its first African-born leader, Ambassador John Nkengasong. As he charts the course for the agency’s global HIV/AIDS programming, his extensive experience in pandemic preparedness and response as the head of Africa CDC provides the opportunity for a fresh vision that looks toward the future of global health security and global health equity, while scaling-up successful prevention interventions and shifting control to local organizations and institutions, strengthening PEPFAR’s impact.

Now is not the time to pull back. Next year, PEPFAR will be up for Congressional reauthorization, giving advocates an opportunity to push PEPFAR’s priorities to better align with pandemic preparedness and what impacted communities need and want, transforming the US’s response to HIV/AIDS and global health at large.

Call to Action: Fully Fund PEPFAR and GF

This interdependent relationship between the Global Fund and PEPFAR must continue, and be strengthened and leveraged. Investing in one over the other is detrimental, irresponsible, and will have adverse consequences for reaching global targets against HIV, TB and malaria and will undermine global health security.

Advocates and civil society organizations have an important role to play in ensuring that Global Fund and PEPFAR are both fully funded, working together and recognized as essential platforms for pandemic preparedness and response. Here are some specific calls to action that advocates can take to get involved:

1. Work with policymakers to maximize donor country contributions to Global Fund replenishment.
2. Raise awareness that Global Fund and PEPFAR together constitute a core foundation to pandemic preparedness and global health security.
3. Highlight to policymakers how PEPFAR and Global Fund work in coordination with each other, how that coordination saves money, and how fully investing in PEPFAR is not redundant.

No organization or country can address these complex epidemics alone. Now, the world is facing a turning point where overcoming nationalism with political commitments to fully fund the Global Fund and PEPFAR could decide the fate of global health for years to come. Will the global community be prepared for emerging pandemics while responding effectively to a current one (COVID-19) and protecting global gains against long-standing epidemics (such as HIV, TB and Malaria)?

The actions of world leaders in the weeks to come will tell the story. AVAC and our partners will be watching. Stay tuned for updates and further opportunities to join the fight.

September is a big month for global health, for the HIV response, for pandemic preparedness and equitable access to care around the world. The Global Fund will be hosting its seventh replenishment conference the week of September 18th in New York City. Held every three years, these conferences bring nations and the private sector together to pledge their investment to the largest global grant-making source for health systems in low and moderate income countries.

The Global Fund is seeking $18 billion, from 2024-2026, to address HIV, TB, & malaria with investment in frontline health workers, disease surveillance, robust supply chains and program innovation for resilient health systems. Advocates have been scrutinizing the numbers, raising questions, and framing demands. Budget targets and donor commitments must meet the need, and reflect the crucial role of the Global Fund within a larger picture.

Global health resilience includes full funding to Global Fund and PEPFAR, and a bottom-to-top, beginning-to-end commitment to people-centered approaches. AVAC will be at the conference September 19th, when pledge commitments will be made public, to watch and report.

In the meantime, check out the Global Fund Advocates Network (GFAN) Communications Toolkit, which outlines key advocacy ahead of the conference.

Follow our coverage on Twitter at @HIVpxresearch and watch this space in the days to come for more resources.

Yesterday we heard that Dr. Anthony Fauci will step down from his role leading the US National Institute of Allergy and Infectious Diseases (NIAID) after a half a century of public service. His vision, passion and commitment to ending the AIDS epidemic and advancing global health equity has been an inspiration to AVAC and to so many. As we contemplate the huge leadership gap Dr. Fauci leaves, we look forward to working with him and all stakeholders to ensure that hard fought gains in public health under his leadership are not lost and are further built upon.

This August reading (and listening) list is a great place to start building on the legacy of Dr. Fauci and taking charge of the work ahead. As Dr. Fauci reminds us: “much accomplished; much still to do”.

• Where are we with an HIV vaccine and cure — this podcast episode from Conversations with CEI (Clinical Education Initiative) features conversations on HIV vaccine and cure research with Marina Caskey from the Rockefeller University, the REACH Cure Collaboratory and the AVAC Board, and Mitchell Warren, AVAC’s executive director.
• An Advocate’s Guide to Research in Pregnant and Lactating Populations — background on the need for research in PLP and how advocates can advance inclusion. Also check out this four point action plan on the issue.
• PxWire, April-June 2022 issue — A quarterly update covering the latest in biomedical advances in HIV prevention R&D and delivery.
• A Look Back at AIDS 2022 in Montreal — AVAC’s highlights from the AIDS 2022 conference.
• HIV Prevention 2025 Road Map — A global coalition of stakeholders and community groups breakdown an ambitious set of HIV prevention targets.
• AVAC’s Plan for Accelerating Access and Introduction of Injectable CAB for PrEP — a comprehensive overview of the parts involved in delivering this new PrEP option and priorities for swift and ethical delivery. Summary document also available, and check out Stop squandering opportunities to end AIDS: be responsive to the needs of HIV prevention users, a commentary from Linda-Gail Bekker, from the Desmond Tutu Heath Foundation and AVAC’s board and Mitchell Warren.
• The Choice Agenda — This global forum for advocacy on the latest in HIV prevention research has convened a series of webinars on key topics, including lessons from the field of contraception and improving rollout of proven products, with more to come. Check out the archive and sign up for upcoming webinars.

In Montreal the pressure was on.

AIDS 2022 showed the global response to HIV at a crossroads. The field has achieved groundbreaking advances in biomedical solutions. But intensifying disparities in HIV prevention and global health at large threaten to eclipse these achievements. Scrutiny of the inequities was center stage in Montreal. While the UNAIDS report In Danger, released at the conference, documents what HIV advocates have known—that during the earliest phases of the COVID-19 pandemic, progress against HIV did not just stall, it actively lost ground—the HIV Prevention 2025 Road Map by the Global HIV Prevention Coalition released just days later navigates a path to get back on track.

Advocates see how much is at stake at this moment and were making the connections to crises across the field of global health. Their call to action was constant. Protests, formal and informal, were diverse and targeted. They demanded political support and full funding to rollout the dapivirine vaginal ring (PrEP Ring), confronted the developer of injectable cabotegravir for PrEP to go further in affordable and transparent pricing, took on an anemic response to monkeypox (POZ coverage here, TheBodyPro coverage here), challenged ongoing criminalization of sex workers and other key populations, and criticized Canada for blocking the visas of hundreds of delegates to the conference.

Veteran voices such as Fatima Hassan of the Health Justice Initiative were calling out the implications of “vaccine apartheid” in the COVID response and the “pandemic profiteering” that drives it. Global health activist and epidemiologist Gregg Gonsalves called on health advocates to go beyond “the technocratic solutions… and fight our way back to equity.” Advocates challenged the legacy of colonial imperialism in global health, and some voices demanded total reform of the intellectual property and trade system, to name a few of the issues and actions raising the heat.

Are They Listening?

Important steps in decolonizing global health are beginning to take shape. Advocates from the Global South hosted and co-hosted meetings with key decision-makers to make the urgent case for faster and more equitable access to new PrEP options—including meetings with Winnie Byanyima of UNAIDS, Amb. John Nkengasong of PEPFAR and Atul Gawande and Han Kang of USAID. These discussions, as they go beyond community engagement and towards community leadership, represent a model for how the global response must change—voices from communities where HIV is hitting the hardest must be in leadership at every stage, for every crucial decision. The UNAIDS, PEPFAR and USAID leaders say they are listening. Advocates are watching this space closely. Accountability, at every level, is essential—for HIV prevention, treatment, human rights, health systems and health equity.

Getting Rollout Right

Fulfilling the current promise of new HIV prevention options requires advancing a people-centered, integrated approach for introducing proven products. This priority was also center stage in Montreal. The Coalition to Accelerate Access to Long-Acting PrEP (with AVAC serving as the secretariat), The HIV Prevention Road Map announced by the Global HIV Prevention Coalition, and the just-launched WHO guidelines for injectable PrEP that simplify PrEP delivery, are helping to lay the groundwork. The agreement between the Medicines Patent Pool (MPP) and ViiV is also a welcome step toward a sustainable market of generic manufacturers for injectable CAB and future products.

But more must be done. Delivering the fruits of science must become as urgent as their development. Putting in place the right programs, policies and investment to deliver choices at scale and bend the curve of the epidemic utterly depends on a commitment to integrated, equitable, people-centered, and community-led approaches. Be sure to read AVAC’s Plan for Accelerating Access and Introduction of Injectable CAB for PrEP, (or a summary of it), which outlines why funding commitments, creating demand, WHO guidelines, implementation studies, technology transfer, generic manufacturing and more must be coordinated and expedited now.

Several sessions and events at AIDS 2022 took a deep dive into why and how this people-centered, integrated approach must frame product introduction. Here are quick highlights on key sessions:

• Accessing long-acting HIV prevention and treatment innovations: Landscape, service delivery, and pathways to affordability. This session included CAB drug-maker, ViiV, on the panel, and advocates disrupted the session turning up the fire on demands for a speedy rollout of affordable CAB for PrEP. Uganda’s Lillian Mworeko said, “we cannot talk about five years, we need to talk about now” and called for strong accountability.
• Equitable roll out of health products: What will it take? Panelists discussed the need for much greater integration between product development and getting those products to the people who need them. The most efficacious product will fail without investment in innovative, tailored programs. This session also discussed how advances in HIV self-testing and adaptable community-based access do support effective product delivery.
• PrEP-ing for 2030: Why optimization and scale-up of the PrEP service and product mix is critical to addressing unmet PrEP need and supporting effective use towards 2030 HIV prevention goals. 3 million people have started oral PrEP by June 2022; however, this represents a small fraction of the tens of millions who could benefit from it. This session provided a look at PrEP scale-up and examples of community-led delivery that propelled increases in the number of people starting PrEP. AVAC’s Jessica Rodrigues detailed the factors contributing to this unprecedented increase, most notably the role of PEPFAR funding in major gains in PrEP uptake.
• Our next shot: Effectively delivering injectable cabotegravir for PrEP. Imelda Mahaka of MOSAIC and Pangaea Zimbabwe AIDS Trust (PZAT) discussed barriers to rolling out CAB including cost, testing, service provider capacity, and access.

Scientific Advances

The meeting saw incremental progress in research on several of the pandemics destroying life around the world today. Sessions on TB, HIV, COVID-19, monkeypox, and STIs drew lessons from the COVID-19 response. But with all that the world is learning, research and discussion have yet to tackle how to create the integrated systems needed for a truly effective global health response. This kind of pandemic preparedness means advancing health equity.

Our friends at aidsmap provided in-depth reporting on a number of sessions; you can check out their highlights here. In the meantime, here is a brief summary of some of the scientific advances we found interesting at AIDS 2022:

• A study looking at the use of the antibiotic doxycycline as a post-exposure prevention (PEP) for sexually transmitted diseases (STIs) was stopped early due to its high efficacy.
• New analysis from Imbokodo data showed that trial participants with high antibody response to a target on HIV known as the V1/V2 loop showed an association with protection. But it was NOT statistically significant enough to serve as a correlate for measuring protection. For more on the implications of these findings check out the aidsmap coverage of this analysis.
• Several sessions discussed the future of vaccine and bNab research, including the role of mRNA technology, and experimental medicine trials. It’s still not known if mRNA will speed up HIV vaccine development, nor if a neutralizing antibodies will finally be the ticket to vaccine efficacy. The HIV vaccine field must bring clarity about the state of the science to community and stakeholder engagement processes, and prepare now so that equitable access goes hand in hand with vaccine development and licensure. As Ntando Yola from the Desmond Tutu Health Foundation and Advocacy for Prevention of HIV and AIDS in South Africa said during a discussion on mRNA, “there is excitement but we need to understand that excitement doesn’t prevent infections; important science needs clear communication, sustained engagement and commitment to equitable access”.
• A case of an additional patient to achieve a possible cure was announced (check out AVAC’s new guide for HIV cure terminology). The City of Hope patient has remained free of HIV since ending HIV treatment 17 months ago. He is now the fifth known case of an HIV cure after receiving a stem cell transplant. And the case of a Barcelona woman, a long-term, post-treatment controller, was also announced at AIDS2022. The Barcelona case involves sustained undetectable levels of HIV without treatment (no stem cell transplant involved), though sensitive tests detect some viral reservoir of HIV. As the science accelerates for HIV cure, advocates are stepping up, and the focus is on moving cure research to Africa. The session Africa HIV cure research: Strengthening industry-community engagement in clinical research brought home the need for community engagement in cure research. As AVACer Nandi Sikwana said, “It is never about one trial, one community or one issue… it is about relationships that transcend a trial.”
• A years-long study led by the NIH’s Vaccine Research Center has identified 44 genes associated with latent HIV. While this is early laboratory science, the resulting sensitive gene assay could unlock a path to discovering strategies that target the HIV reservoir and a potential cure.

Populations and Products in Focus

The following sessions put an important spotlight on particular populations or products:

• A session on how prevention programs can prepare for multipurpose prevention technology (MPTs) such as the Dual Prevention Pill (view slides), which combines protection against pregnancy and HIV, offered marketing insights. Among the key takeaways: breaking down silos with the family planning community will be essential. The session presented recommendations for provider counseling on a combined product. See the DPP Consortium’s e-poster.
• The CASPR and AVAC Research-to-Rollout Literacy and Networking Zone hosted several discussions on a more inclusive HIV research agenda. One discussion focused on growing consensus, and an action plan, for the inclusion of pregnant and lactating people in research (see AVAC’s guide to the Inclusion of Pregnant and Breastfeeding Populations in Research).
• Another Networking Zone discussion updated on the work prioritized in No Data, No more: Manifesto to Align HIV Prevention Research with Trans and Gender Diverse (TGD) Realities. Brian Minalga from HIV/AIDS Network Coordination at Fred Hutch shared new literature raising the profile of these priorities and discussed progress, in particular two trials underway centering TGD people. The Get It Right Study, looking at interactions between treatment and gender confirming therapy (GCT). And HPTN 091 looking at the co-location of HIV services and GCT.

AVAC at AIDS 2022

For a look at AVAC’s work at AIDS 2022 go to our dedicated page. And in case you missed it, the latest webinar from The Choice Agenda provided a status update on the rollout of injectable PrEP, with presentations from providers, researchers, the WHO and others.

The picture of HIV prevention today is full of promise and peril. Navigating the challenges is both possible and imperative. Here’s how AVAC Executive Director Mitchell Warren put it at the launch of the new Global HIV Prevention Roadmap:

“In 41 years we’ve never had such opportunity in prevention. We have a package of proven methods for the first time, and global health leaders are offering renewed commitments to spearhead and sustain programs that are designed to reach those who need prevention most. These programs should be focused on integrating HIV services with sexual reproductive health and rights. But we won’t get this done without going beyond simple community engagement and the old siloed models of delivery. Now is the time to integrate, coordinate, and invest. Now is the time for a global response that is community led.”

AIDS 2022 in Montreal just wrapped up, and stay tuned for our full summary soon. For now, though, a quick update on injectable cabotegravir for PrEP (CAB), which was a hot topic at the conference and the subject of next week’s Choice Agenda webinar.

• New data from the HPTN 083 and 084 trials re-confirmed the safety and efficacy of CAB for PrEP;
• WHO guidelines added injectable PrEP as an additional prevention option;
• ViiV, the drug-maker of CAB for PrEP, and the Medicines Patent Pool announced an agreement to provide a voluntary license and begin the process of identifying generic manufacturers;
• A new coalition convened by Unitaid, WHO, UNAIDS and the Global Fund, with AVAC serving as the secretariat, will collaborate with civil society, normative agencies, governments, and funders, in accelerating access to longer-acting PrEP; and
• Advocacy and activism around global access to CAB included on-stage protests, meetings with key decision makers and many, many other discussions led by advocates and partners.

Join us Monday, 8 August at 9:00 ET / 15:00 SAST for our next The Choice Agenda webinar, Faster, Smarter and More Equitable – Accelerating Roll Out and Uptake of CAB for PrEP.



As injectable cabotegravir (CAB) as PrEP begins to be introduced, what lessons have we learned from the first 10 years of oral PrEP implementation? How can the field do better with a new PrEP intervention that offers new opportunities and distinct challenges? These are the questions our panel will be discussing and more.

• Rachel Baggaley, World Health Organization
• Caroline Carnevale, New York Presbyterian Hospital
• Monica Gandhi, University of California San Francisco
• Mitchell Warren, AVAC
• US cabotegravir (Apretude) user – RJ Mitchell

Resources

• Getting Rollout Right: This collection of resources distills some of the most important insights from studies using human centered design and findings from real world experience delivering oral PrEP. Read the full report and issue briefs.
• AVAC’s Plan for Accelerating Access and Introduction of Injectable CAB for PrEP provides a view of all the moving parts. Learn how and why funding commitments, creating demand, WHO guidelines, implementation studies, technology transfer and more must be coordinated and expedited now.
• Tune into this Px Pulse podcast, which discusses and builds on principles from the rollout of oral PrEP in the past to inform how we equitably and effectively deliver the PrEP ring and injectable CAB for PrEP.
• Just six injections a year can prevent HIV: Here’s what it will take for the world to afford them.