The AIDS world managed to hold the first, partly, in person, COVID-19 era conference in Montreal from Friday 29 July to Tuesday 2 August. In addition to the main event, with plenary presentations, abstract driven papers and posters, there were pre-conferences, satellite sessions, meetings in the Global Village and the exhibition area, and of course a number of protests.

The meeting was smaller than it had been prior to COVID-19. Nonetheless the programs were full and there were thousands of delegates, all wearing masks, which made recognizing friends and colleagues challenging. Most of the sessions were available online, indeed some were only available virtually. At previous meetings bulky program books were produced, listing sessions and speakers. In Montreal there was a tiny booklet which only listed the sessions, although the details were available online. For those delegates who did not have portable devices, or who were not always online, choosing sessions required careful planning.

This overview article for the special issue of the GFO on the conference is somewhat personal, and I can only cover the events I attended. Nonetheless the Aidspan team of two (we should have been three, see below), our staff member Samuel Muniu and I as a Board member, will bring you some of the highlights relevant to our readers.

There is no getting away from COVID

COVID-19 dominated at both personal and programmatic levels. I had the misfortune to be infected, on an intercontinental flight, a few weeks before the meeting which meant my attendance was, at times, in doubt. Fortunately, I both tested negative and recovered in time to travel and attend the meetings. It was striking how many of the people I spoke to had had COVID-19 in the last few months. The pandemic is far from over. The conference may well be a super-spreading event, despite the mandatory facemasks. Fortunately, hospitalization and case fatality rates have plummeted. A fear has to be that bringing delegates, and variants of the virus, from all over the world to one central place, could lead to new variants. Let us hope this is not the case.

The disgraceful situation regarding visas meant many important stakeholders could not attend

The rich countries and industry were well represented. Missing were many delegates from the lower-middle-income country (LMIC) nations and the reasons for this are covered in our last two Global Fund Observer (GFO) articles: in GFO #414, Key populations, communities and civil society face obstacles in attending international meetings and GFO #415, The voices of those who lost out on visas and the response from the conference organizers IAS.

And it is not only LMICs’ civil society, communities and the most vulnerable populations who were denied scholarships and visas, but also others who could more easily prove economic solvency, such as Aidspan’s own Executive Director, Ida Hakizinka, who didn’t receive her visa in time. See also https://www.cbc.ca/news/canada/montreal/montreal-aids-conference-2022-visa-problems-1.6536449.

In addition, the Canadian International Development Minister Harjit Sajan cancelled his appearance at the meeting. This was politically wise, as he would have faced protests and hecklers had he attended. It did reinforce messages about the lack of Canadian commitment to the AIDS pandemic. This is a sorry comment given previous conferences: one of the first international AIDS meetings was in Montreal in 1989; this was followed by the one in Vancouver in 1996 where the development of effective treatment was announced; and the 2006 meeting in Toronto marked the scale up of treatment. I note, in passing that the then Prime Minister Stephen Harper decided not to attend the 2006 conference. He was a member of the Conservative Party of Canada so this is not surprising, and the enthusiasm of the hosts and presence of Stephen Lewis made up for it.

The economic message

I came to Montreal a few days before the main conference to attend the International AIDS Economics Network (IAEN) pre-conference meeting. This meeting of economists has taken place ahead of the IAS gatherings since 2000. The IAEN website is www.iaen.org and the presentations referred to will be posted soon. The key message from the IAEN is that economic analysis continues and is increasingly sophisticated. The meeting discussed government decision-making; the impact of COVID on long term HIV financing and programming; innovative approaches; activity-based costing; and allocation of resources among men who have sex with men and intravenous drug users. There was a session of the spill over effects of the US President’s Emergency Fund for AIDS Relief (PEPFAR) investments on indicators such as mortality, health and the macro-economic situation. It is clear that COVID-19 has had a devastating impact on resource allocations, flows and programming.

The release of the special issue of the African Journal of AIDS Research, AIDS in the time of COVID, was particularly timely and includes my editorial as well as an article by Aidspan GFO Senior Editor Arlette Campbell White. It is open access and is available at https://www.tandfonline.com/toc/raar20/current with a  PDF at https://www.nisc.co.za/media/docs/165901845028.pdf

The frightening situation of AIDS thanks to the events of the past two years

A number of agencies released new reports, chief among them was the Joint United Nations Programme on AIDS (UNAIDS) Global AIDS Update 2022, starkly titled In Danger. Some of our other articles in this special issue bring you a summary of this in Article 4, for those who did not attend and would prefer to read a summary rather than the entire report, and several other articles covering the main releases and messages.

Money, and the lack of it

This brings me to my major take home point: funding. It is clear the trend of international funding of the AIDS pandemic is downwards.  UNAIDS noted that at the end of 2021, $21.4 billion was available for AIDS in LMICs, and 60% was from domestic sources. The estimate is that $29 billion will be required by 2025 for the AIDS response in LMICs. Almost as an aside the report notes this includes ‘countries formerly considered to be upper-income countries’. In other words, those nations that have seen their GDP contract enough to change how they are categorized. It should also be noted that the international goal of 0.7% of GDP being given as Overseas Development Assistance (ODA) probably won’t be met and the fall in the size of GDPs will reduce ODA commensurately.

A constant theme of the meeting was the lack of resources: from donors; governments and the out-of-pocket payments of ordinary citizens. COVID-19 means that all budgets are constrained. An important point of economic literacy is to understand the GDP growth forecasts. To use the UK growth as an example, it was an anaemic 1.7% in 2019; in 2020 this plunged to -9.4%. The data for 2021 show a rebound of 7.5%, it must be remembered this was growth from a smaller baseline and it may be years before it returns to 2019 levels. This trend is repeated around the world.

The Global Fund’s Executive Director Peter Sands was upbeat about the forthcoming Global Fund replenishment at various meetings at the conference, but then he has to be. The Global Fund wants at least $18 billion to be pledged in the Seventh Replenishment which will be hosted by President Biden in the United States in September.

Sadly, while the theme was a shortage of money there were few economics papers presented. Indeed, these tended to look at cost effectiveness: how best to use an existing pot of cash. Given the contraction in funding this is a zero-sum game. What needs to be brought into the conversation is cost benefit analysis: why it makes sense to allocate more to health in general and HIV in particular.

In the absence of COVID-19 we would have been celebrating steady progress in the fight against AIDS and the hope that numbers would continue to fall. The gains of the past years are now in doubt and AIDS will have to jostle for attention with many new issues, from COVID-19 and other diseases to poverty and inflation. The future will be challenging.

*Professor Alan Whiteside, OBE, is Emeritus Professor University of KwaZulu-Natal and an Aidspan board member