The interlinkages between the response to HIV and the COVID-19 pandemic was an emerging theme at the AIDS 2022 conference. Of importance was how to harness lessons learned in fighting both HIV and COVID-19 to inform efforts to restructure the global public health framework in preparing for the next pandemic. There were numerous panel discussions and presentations on these topics throughout the five-day conference. The Global Fund Observer (GFO) was present at the conference, and we highlight some of these key discussions.

HIV, COVID-19 and health systems are inextricably linked

The health systems supporting the provision of HIV services are the same as those that help countries respond to COVID-19, as well as to other health threats. And those same systems will also be the ones to address emerging new threats such as monkeypox as well as future problems. These were the sentiments of Angeli Achrekar, Principal Deputy U.S. Global AIDS Coordinator, the United States President’s Emergency Plan for AIDS Relief (PEPFAR). According to Angeli, one of the critical components for responding to COVID-19 was the status of systems that were already in place for HIV. These include human resources such as health and community health workers, surveillance, laboratories, supply chains, and community systems. She reiterated that established HIV health systems were essential for protecting people living with HIV amid COVID-19 and contributed significantly to countries’ response to the pandemic.

Failure to utilize gains made in advocating for and accessing HIV medications

Globally, we failed to translate the successes of the HIV response into solutions to address the pandemic. This is particularly true for lessons learned from community organizations and civil society activists working on issues around access to treatment. Denise Byrnes, Executive Director of Oxfam-Quebec told attendees at the AIDS Healthcare Foundation-organized panel discussions at the conference that there has been a repeat of the same pattern of inequality seen at the beginning of the AIDS pandemic. She painted a worrying picture of scientists developing treatments, often with public money, that never reached the public. Unfortunately, lifesaving treatments are often the monopoly of pharmaceutical corporations, with profit being the bottom line. They then become inaccessible to most people. An exception to this is the Oxford-AstraZeneca vaccine which was made available at cost to developing countries.

This is a recurrence of what happened in the 1990s when HIV treatment first became available but was too expensive for Africa and indeed most of the developing world. As a result, AIDS-related deaths continued to rise. This was partly because pharmaceutical cartels meant the price of HIV treatments was completely out of reach not only for Africans but for their governments as well. Byrnes applauded the grassroots movements, that later developed into international movements supported by doctors, activists and politicians including Nelson Mandela and others, for stepping up to advocate for increased access to HIV medication. The result of this advocacy was countries’ growing capacity to produce generic cheaper versions of the medication. This significantly brought down prices and people today have much better access to HIV treatment and drugs.

Byrnes noted, “we had an opportunity to build on the successes of the HIV and AIDS movements, but thus far, we haven’t done better.” Regrettably, the world is faced with a unequal system where drug companies hold all the power even when people’s lives are at stake. She pointed out that drug companies have grown richer during the COVID-19 pandemic as they prioritize profit-making over peoples’ health. Rich countries hoarding COVID-19 vaccines exacerbated the situation. She further elaborated that “we [Canada] had way more vaccines than we needed. We have enough vaccines to vaccinate every Canadian five times and that’s similar in other countries. So, what we see are inequalities rearing their heads.” Byrnes was optimistic that change is possible when people speak out and come together, and when health system components work in conjunction with each other and the people who use them. The AIDS 2022 conference was one such moment where the whole system came together to talk about lessons learned from the pandemic and how to move forwards.

The new Financial Intermediary Fund seems to replicate already existing mechanisms

Pandemic preparedness and response (PPR) is a currently a major topic of global concern. Indeed, it is of such international importance that the new Global Fund Strategy 2023-2028 has a special PPR “evolving” objective. Hardly surprising, therefore, that a new global approach to PPR was a hot topic for AIDS 2022.

Many of the conversations were around the newly created Financial Intermediary Fund (FIF) on PPR established by the World Bank on 30 June 2022. We explained more about the FIF in our GFO #414 article on the New Financial intermediary: a new model that duplicates the Global Fund. Conference panelists shared the same view that creating the FIF was a duplication of already established and effective mechanisms. For example, there are distinct areas of overlap with the Global Fund’s work. The Global Fund was created in a similar manner to the new intermediary fund. Since its creation the Global Fund has had over twenty years to develop the experience needed to efficiently and effectively allocate resources to developing countries, using a transparent and successful partnership model. This has taken time, trial and error over a fairly long period of time.

Panelists further described the uniqueness of the Global Fund as a partnership that not only listens to donors but does its best to pay equal attention to the interests of its grants’ implementers, including civil society and communities. Furthermore, the organization receives bipartisan support from the US Government which is almost unheard of, as few other organizations receive this kind of direct support from the US.  Some panelists also described the Global Fund as unique in being an organization that receives significant civil society and community advocacy in support of its replenishment campaigns, a type and level of advocacy which is not seen when it comes to fundraising for other international organizations.

Several conference participants regard the newly created FIF as an old-fashioned model for helping developing countries using a top-down approach. Most panelists viewed the FIF model as donor-centric with little input from civil society and communities. What worried many was the notion that the FIF is likely to use UN systems and national governments as implementers, thereby ignoring the work already being done by civil society and communities. Thus, the FIF lacks a lot of the Global Fund’s strengths and demonstrates a paternalistic and colonialist approach (for more on this, see our article on Racism in the aid sector in GFO #415). Consequently, panelists felt that the FIF should be adapted to a new 21^st century way of working or be dissolved and its financial resources passed to the Global Fund. Because, unfortunately, raising funds to support the work of the FIF means potentially less resources available for the Global Fund’s replenishment this year, even more so given the global economic downturn and the increasing pressure on northern countries’ development aid budgets.

However, panelists also pointed out that although the Global Fund might be the vehicle of choice for PPR, its Board has still not approved the expansion of its mandate beyond fighting AIDS, TB, and malaria (and expanded to include health systems, to a certain degree). Thus, the Global Fund’s mandate is no longer clear but has become muddled. While the Global Fund has successfully mobilized billions of dollars for fighting COVID-19 and sustaining key health systems and programs, it was nonetheless unprepared for PPR and has become so ‘on the hoof’, learning by doing. That it was able to do so and has clearly learned from experience, as the differences between the 2020 and 2021 COVID-19 Response Mechanism (C19RM) programs show, is to its credit.

Some panelists felt that the World Bank was trying to do something that nobody else is doing. Others applauded PEPFAR for allowing its funding platform to be used for responding to the latest epidemic, monkeypox, although they also felt that much more still needs to be done. Some panelists expressed the opinion that other organizations such as the Global Fund should emulate PEPFAR and allow their funding mechanisms to be used to respond to monkeypox.

Conclusion

There is a lot to learn from the HIV response that could be translated into preparedness for future pandemics. However, the failure to transmute the lessons learned in fighting HIV into a meaningful response to the COVID-19 pandemic indicates that we are not leveraging these lessons in the most efficient manner. We must build on experiences and strengthen existing institutions that are fit for purpose if the world is to be better prepared for future pandemics.