President of Friends of the Global Fight Against AIDS, Tuberculosis and Malaria
David: Good morning, Chris. Thanks for your time. Many people, certainly many Americans, think that the AIDS epidemic is over. When you hear comments about that, how do you react?
Chris: Sometimes I worry we've done too good a job of letting people know that we have the potential to end the AIDS epidemic. We do have that potential, but we're very far from reaching that point. In the United States, we still have a serious epidemic, although incidence is now gradually falling, which is a great recent sign. But globally for all the progress that we've made in terms of saving millions of lives, getting treatment to people, we're not seeing HIV incidence fall as fast as we'd like among adults. We're really not headed towards ending the epidemic globally at this point. And there's every reason to be concerned that we could actually backtrack in terms of the HIV infection rate, globally, in part, because we have a whole generation of young people in Africa coming of age. And we haven't scaled up the prevention and treatment interventions for those young people to the degree we need to. We really need to be reaching them in an intensive, comprehensive way to help them a grapple with this epidemic.
Dave: So it sounds like you fear that there really will be an increase in infections rather than either steady or declining.
Chris: I think it's very possible that in the next few years we’ll be seeing an increase in the HIV infection rate rather than a decrease and that’s because of several factors, like demographics in Africa, but also because we've simply failed to go to scale with the things that we know work, the HIV prevention and treatment interventions that we've had. We've done a great job in many areas of getting treatment to people and that's an amazing accomplishment. But we need to continue to reach people who are living with HIV and need treatment, and then do a much better job of getting prevention interventions to people.
David: Two years ago, at the United Nations High Level Meeting on AIDS, there was a political statement and some commitments made by the member countries. How well have we followed through on those commitments?
Chris: Well, I think the High Level Meeting on AIDS several years ago was positive, in that it set ambitious targets in terms of delivering treatment and prevention to people, but we really have failed to follow through on those commitments. At this point, we're actually seeing donor aid on HIV flat line or even fall from many countries. And it's worrisome because this is a time where we need more money in implementing the programs that we know work. So right now, I think we'd have to say we haven't seen the world rise to the occasion of all the fine words that they issued in New York at the High Level Meeting. And what's needed is a rekindled commitment among world leaders, including donor countries and countries most affected by HIV, to implement what we know works and follow through on their commitments.
David: You talked about needing an increase in funding. What's the global funding level now? And how much of an increase do we need?
Chris: Right now, we're spending about $21 billion annually on the response to HIV in low- and middle-income countries. UNAIDS thinks that in the next couple of years we really need to get that number to $26 billion. And that's both donor spending and spending by implementing countries themselves. So there's a real gap of about $5 billion. That is a lot of money. But in the context of the global economy, it really isn't that much.
And the fact is, for a $5 billion additional investment, we really could get on track to begin to end one of the worst epidemics in human history, HIV. So it's a prudent investment. We have the tools now to bring HIV incidence and mortality down. It's a matter of delivering those tools to the people most in need and that's really the challenge in front of us. The good news is we have the technology and we know how to do it. We just don't have the resources to get the job done at this point.
David: You have spoken about the balance between donor countries and implementing countries. What's the current balance and do you feel like it's an appropriate balance?
Chris: Well, right now, 56 percent of financing for HIV and low- and middle-income countries comes from those implementing countries themselves. And that's good. We need to increase domestic investment, for sure, if we're going to end any of these epidemics, AIDS, TB and malaria. We just absolutely need to be supporting countries and moving towards investing more in the health of their own people. But that said, in many of the countries that are most heavily affected by HIV, they simply don't have the fiscal capacity to finance the entire response. Many countries are really going to need substantial ongoing financial support if they're going to tackle the HIV epidemic. So even as we're urging countries to invest more in the health of their own people, we've got to be making the case to donors that they also need to increase their investment in the HIV response. And again, what we're asking for is investment in things that we know work: prevention, treatment that can save lives and bring infection rates down. The central thing standing in the way is achieving the right level of investment that will scale up these proven solutions.
So we need to be making that case to both implementing countries and to donors right now. But certainly, you know, in the long run it's imperative we move to increase domestic finance along with donor finance. One thing I will say about the Global Fund is that it really sets up an incentive structure where implementing countries themselves need to invest more of their money in the health of their own people. The Global Fund actually withholds part of its grant until the country shows evidence that is investing more in health. So that's really worked. We've actually seen domestic investment grow by about 40 percent over the last three year cycle, which is very impressive. We need to keep growing in that direction, need more domestic finance in the future. But we need to be really honest with ourselves, that even as we see that increased domestic finance, we're simply not going to have enough money in the HIV response without growing donor investment too.
David: This will be a big issue coming up this year, I know, when the Global Fund is up for replenishment. What's that process like and how are the decisions made and when will they be made?
Chris: 2019 is a particularly critical year in all of this because the Global Fund is going to be up for replenishment. That replenishment session will be held in October of 2019. It's imperative that we get increased investment in the Global Fund. The Global Fund is the biggest funder of the HIV response, after PEPFAR, and it's the biggest funder globally of the response to tuberculosis and malaria. So this is a time where we need to be rallying faith-based and private sector and all aspects of civil society to work with donor governments and implementing countries themselves to increase that investment in the Global Fund. None of this gets done without a growing Global Fund that's able to partner with countries, partner with PEPFAR, with other bilateral programs, to increase delivery of things that we know work. So for advocates on global AIDS, 2019 is a critical year to organize. And a big part of that organizing needs to be around the donor commitment to the Global Fund. In terms of the timing, the way this'll work is that in February 2019, the Global Fund will issue its investment case, which outlines how much total funding they're seeking for the 2019 replenishment. And then it's our job as advocates to get donors to the Global Fund up to that level of commitment.
David: You mentioned PEPFAR. That's the President's Emergency Plan For AIDS Relief. It was launched by President George W. Bush back in 2003 and it comes up for renewal every five years. So 2018 is one of those years. I know it's always had strong bipartisan support. What are its prospects now?
Chris: Well, as you say, PEPFAR has enjoyed strong bipartisan support in Congress since George W. Bush called for its founding. That's because it consistently shows results. PEPFAR has always been oriented around being able to quantify and show to policymakers and to the public what they're getting for their investment. And it's just been amazing to see the trajectory of success for PEPFAR in terms of getting millions, millions of people on treatment, being part of the effort to bring down HIV incidence. So I see continued support on the Hill for PEPFAR right now. As of November 2018, Congress is moving, it looks like finalizing, a reauthorization bill for PEPFAR. We hope that happens in the current Congress. There is, again, bipartisan support for it.
One thing that's great to see in this time – when there are so many splits in our country politically and Congress itself is so split and unable to move forward on many of the priorities – that it's in global health, and in HIV, TB and malaria, in particular, where we see both sides of the aisle really coming together for sustained funding for global health and for global AIDS. And we’ve seen, in both the Senate and the House, PEPFAR reauthorization bills with lead authors that were Democrats and Republicans. So the bipartisan nature of support for HIV and America's leadership on HIV, that continues. And I think as people who care about this issue, we need to constantly stay in touch with our policy makers, our representatives in Congress and let them know we want them to keep on track to support PEPFAR and to grow the US investment in that highly successful program.
David: As you say, in this troubled political time, that was nice to see, to find places where we can work together. So is money really all we need? Or are there other issues that we have to address if we really do want to end AIDS.
Chris: Money is certainly a big part of it but we also need to go where the virus is. And one thing we've really failed to do well is reach some of the populations that are most at risk, that includes young women and girls in southern Africa, for example, who have infection rates much higher than young men their age. And there are a whole host of reasons for that. But a big part of it is social and economic inequality of those young women in their societies. So we need to do things like the DREAMS program in PEPFAR and HER: HIV Epidemic Response program in the Global Fund that are really concentrating resources in a comprehensive way to address the risk factors affecting young women and girls. That's essential.
Chris: And governments all over the world, donors but also implementing countries – have neglected the needs of key population groups, groups that are marginalized in their own country, like gay men and other men who have sex with men, people who inject drugs, sex workers, trans people, prisoners. These are people who are marginalized in countries all over the world. They are at heightened risk for HIV. They often need tailored services because they don't feel safe coming into the health system. Governments have turned their backs on them, in many cases, because they were socially marginalized. In too many countries, their behavior is illegal, so they don't feel safe seeking care. So a crucial part of being successful in the response to HIV is having adequate financing to reach key populations, having policies in place that make it possible for them to access services, but also really working to change the social and legal context, so that people feel comfortable coming forward for care, and know that they will be treated with respect. That, along with financing that focuses on reaching the people who are most in need and then getting the resources to do it. Those are two of the most crucial things in front of us.
David: What role do you see for people of faith, faith-based groups, religious groups, especially in addressing these issues, the social issues that you just talked about?
Chris: Well, faith-based groups, from the beginning of the response to HIV, have been absolutely at the center of the response. They've been essential in getting services to people. I know the faith community is responsible for saving literally millions of lives in terms of getting treatment to people. So there's a lot to be proud of there. There's a legacy of the faith community that we all need to be aware of and continue as we go forward. The faith community can also play a huge role in combating the stigma and discrimination that affects people living with HIV, including those key population groups. I think having faith leaders speak out on the fact that we need to not discriminate against people because of their membership in a group, that everyone deserves health care that's delivered with respect.
Having prominent faith leaders send those kinds of messages about equity and nondiscrimination. We need that more than ever. We are going to absolutely need the faith leadership and the message, about equitable, decent care for everybody, if we're going to reach people most affected by HIV. So I think the faith role is as important as it's ever been in the HIV response. We need faith leadership to continue to deliver HIV treatment and prevention. And we need to make sure that the prevention that everyone's delivering is evidence-based, in other words, that it's based on things that we know work in terms of bringing HIV incidence down. And we really need faith leadership, even more broadly, to send the message about inclusion and nondiscrimination and reaching everybody with the services they need.
David: Thank you. One last question, Chris. If an American were to ask you what he or she could do to help end AIDS, what would you ask them to do?
Chris: There's so many things that people in our country can do to combat AIDS, globally and at home. One is – and I know this is something that people get tired of hearing, but it remains so true – is to let each of your elected officials know that you care about the issue. That is more important than anything. And I will say also, as someone who's working in Washington every day, having members of Congress hear from faith constituencies can be enormously powerful. In fact, there's a very influential senator, who I heard say recently that, when you're talking about investment in global health, most senators are just “two faith leader calls” away from changing their attitude on the issue. In other words, faith leaders reaching out to elected officials and saying, this matters to me and here's why it matters to me and this matters to my congregation, that can be extremely powerful in bringing senators and members of Congress around to supporting increased financing for global health.
So speaking out to your elected officials, bringing people in your community to speak with elected officials, that's absolutely crucial. And then, I think, people of faith all over the country are already involved in their congregations. I mean the groups that are supporting care, particularly in Africa. I think that continues to be an important role. Just making direct financial contributions to organizations that are advocates on HIV or delivering that care. That's absolutely important. But I think all of us can be outspoken, with our friends, with the groups we are part of, with our elected officials, standing for continued US leadership in the fight against AIDS, increased investment, and support for reaching everybody who is affected by this disease, including marginalized people.
David: Chris, thank you very much for your time.