Signature Service Online Conference Event Made Easy

Signature service online conference event

welcome to csis online the way we bring you events is changing but we'll still present live analysis and award-winning digital media from our drakopolis ideas lab all on your time live or on demand this is csis online welcome and good morning or afternoon i'm steve morrison senior vice president here at the center for strategic and international studies in washington d.c we're delighted again for the 10th time to be co-hosting with jennifer k senior vice president of the kaiser family foundation these biannual events that try to take account shortly after each international aids conference of what exactly transpired what were the most important developments scientifically politically programmatically and how does this conference set a course for what will unfold in the future including the next international aids conference the international aids conferences remain signature defining moments in the history of the world's hiv aids efforts my cat my colleague catherine bliss authored in 2012 a history of these conferences which remains very relevant i encourage you to look at it if it interests you catherine bliss titled the international aids conference returns to the united states march 28 2012 on the csis.org site this year is truly exceptional as we know coming in the midst of a raging coronavirus pandemic the first instance in which a large and complex enterprise like this international aids conference has been conducted virtually we at csis over the past year and longer have been very busy in supporting the leadership of the conference we have a highly active american friends of aids 2020 group which i co-chaired with ernest hopkins and in which everyone who's speaking with us here today has contributed and participated among many others when we launched a very active podcast series aids 2020 sf slash oak which many of the speakers here today also contributed and which i hope many of you have been able to enjoy and will continue to enjoy before we get started i want to offer special thanks to my colleague maggie mccarten gibbs who worked very hard to pull all the pieces together today and i want to thank my other colleagues clifton jones and john montz who are producing this event for for us i also want to commend the leadership for its courage and perseverance through this difficult period and for making the tough and very abrupt decision this spring not to postpone but to pivot to a virtual conference and to do what it needed what needed to be done on an urgent crash basis amidst all the uncertainty and complexities to pull together the conference kevin osborne and burgeet paniatowski leadership at the ias deserve special praise for mobilizing their team in record time under exceedingly demanding circumstances they kept their cool their good humor and their optimism throughout we should direct the same praise to the co-chairs anton posniak cynthia cary grant and monica gandhi cynthia and monica working with rob newells and larkin callahan and helga ing from the is worked flat out over many months to mobilize the communities in oakland and san francisco and lay lay the local preparations it was no doubt a great disappointment to not be able in the end to hold the conference in these two cities but all of these efforts were not lost in the transition and the translation to a virtual mode we will hear more about what was possible from our speakers in a moment here's how we're going to proceed this morning we don't have a lot of time and we're going to cover a lot of ground we're going to spend the next 35 to 40 minutes in conversation with our four speakers we'll hear first from monica gandhi professor of medicine at ucsf and san francisco general hospital she directs their hiv work and she is the co-chair of the san francisco we'll hear next from shannon hader executive deputy executive director for program at unaids in geneva followed by jennifer kate senior vice president for global health at the kaiser family foundation along with greg millett vice president and director of public policy at amfar we're going to roll through three questions i've asked our speakers to keep their answer short and we want to have a very interactive uh conversation and we'll leave time to come back to the audience and pull in some of the audience's questions um as we move through so let's let's start out with the first question and that first question is really to to try to identify from our four speakers what are the two to three most significant things that happened during the conference monica you want to head that off please yes i think one of the biggest things that happened is when we made the decision to go virtual which was um completely a no-brainer because there was no option to come together as a person uh with the pandemic we realized that we couldn't actually just address hiv in fact it was uh we were trying to plan the sessions for hiv and it seemed almost irrelevant to not talk about covet and the impact of covet on hiv and the and covalent so i think the biggest thing that happened was um uh organizing the first abstract driven covid related meeting um simultaneously with the 8th 2020 meeting so the 8th 2020 meeting was uh for the first four days july 6th through 9th and july 10th was exclusively a covet meeting beyond that the second most significant thing was putting in the impact of coven 19 on hiv into every abstract session for um the uh the uh the typical categories for the late breakers on age 2020 so that every one was invited in all categories to put something in on the impact of kova 19 or the interplay of cover 19 and hiv if it was the basic science category for example or the impact and unh actually talked a lot about the impact of cover 19 on hiv so that was the second most significant thing and then there were i think we'll get into it later in the program the the very significant abstracts um that occurred but but i think i'll stick with this for now to just say that uh it really was a tale of two pandemics completely woven through and i think dr millett's uh uh talk actually exemplified that but so did many that this concept that there was no way to untangle them anymore because the effect on disproportionately how hiv affects communities the same things happening with covid how uh uh shannon hater talked about it when she gave the unaids update it was completely you're unable to speak about progress in hiv without talking about the setback and progress that's occurring with covert 19 so i think that is the biggest way i want to start with what how this was so different from any other media thank you monica shannon your two to three top top thoughts a really great on-ramp right um i think i think for me for unaids certainly this conference is a milestone in the year where we get to take stock of where the world has gotten to in the hiv response the year before and so this conference was the launch of the world's 2019 data of progress against the global hiv targets and the update data on progress for the three free start free stay free stay free for pediatrics and you know as we're one year away from that 2020 data before we launch into the next sort of strategy i think marking the fact that there's been such tremendous progress but we're also we're going to miss the 2020 goals even before covet came into play you know we're still seeing nearly 700 000 deaths from aids per year we're still seeing 1.7 million new infections you know we've we've got now 63 percent of all new infections monkey population members and frankly we have plateaued with our pediatric new infections and our pediatric treatment coverage i mean treatment coverage for kids of only 53 percent that's criminal and so already having that stock having this unpredictability but this real worry of how how backwards we might go in some places during covid it just really emphasized the frame that we've got massively unequal progress the fact that we see so many tremendous i think successes just says whether it's across regions across countries within countries and particularly among populations and peoples these remaining inequalities we've just got to like jump into um second thing that came out i think from some really interesting data in the conference but it's also enhanced by our coveted context is the importance of human rights there was a really i think um striking abstract from lions that showed um that men who sex with men living in african countries where hiv is criminalized have way higher hiv rates you know they compared countries with no criminalization that had rates of 8 percent countries with criminalization had hiv prevalence rates of 20 percent and countries with really severe criminalization because we still have countries that have death penalties and really severe sequelae with hiv prevalence rates of 52 so we can't deny we never have but we've got to sort of say everybody who touches hiv programs and policies at all i don't care what your discipline is we can't ignore human rights and when we see in some countries how covet has actually provided this excuse a wrong-headed excuse to use and put in even more severe infectious disease policies um to persecute vulnerable populations including key population members we've just got to say no and then i think third it was um really exciting to see and reconsider even the next focus on differentiated services you know policies practices and packages and what they're going to mean to ironically see rapid scale up of some things that have been stuck like multi-month dispensing or telemedicine they're now being put in place because of covid but should service for a long time um to really re-emphasizing that um packages that include let's say sti uh diagnosis and treatment or hepatitis c treatment if we're to reach some people who haven't been reached yet we've got to rationalize those packages to really respond to their comprehensive needs and not just hiv so those are a few of the things that really caught my attention that's great shannon thanks so much jen cates good thank you thanks yeah thanks um and thanks steve and maggie and csis everyone at css for for this but also for our partnership on on doing this every other year we actually talked about whether we should do it this year and um you know part of the reason we do it is to because it's hard for any individual to to fully grasp what happens at the conference and i will say it's not easier when it's a virtual conference so um we'll do our best to capture the main things uh so picking up on on some of the things that people said and and trying to add to them there's three things i wanted to highlight um one is is the pivot of the hiv field um around covet i want to say something about that two is just there there was a lot of science at this conference i'm just going to mention to two studies or three uh three things that i just want to make sure people are aware of and then a third um is in these readouts we often talk about the role of the us government so i just want to say a couple things about that so on the first we heard about from from monica and and shannon and steve said in the beginning there was no way to separate out covid and the impact that that's having on everyone's lives from the hiv response that's you know um we'll be living with that for a very long time what's i think really amazing and and important is that the hiv feel given the experience of researchers advocates policy makers and others in dealing with an infectious disease for so long and all of the challenges that it brings in terms of research whether it's in the lab delivery of care um how to how to quickly be how to be innovative how to adjust that's what it the hiv response has been about and because so much of that expertise is in that in our community there was an incredible pivot of the community to take this on and in some cases that's been really hard because some of the key researchers and many of us working have had to put a lot of time in that and that has an impact on hiv the hiv response but it's also i think a testament to to the expertise and and long long experience that people have had in dealing with with another pandemic and that came through in the conference um and i just think it's quite notable and many of the people as we know who are working to um advance the research on covid are coming out of the hiv field second there were advances in the science um and a couple that i want to highlight one what are the results of hbtn083 which is comparing the efficacy of long acting injectable prep kabbategravir with daily oral truvada for prep and importantly finding that it was as effective there's still a lot of questions uh but it's it's definitely the where we're moving in the future is to long-acting um ejectables for prep or for for treatment so having that data uh be presented was really important uh i'll just want to highlight that that's that um trial was with cisgender men and transgender women who have sex with men there's a companion study going on hptn084 for cisgender women so we still need to to have those data to get the full picture um and it's important that those try both those trials are being done but it was you know uh a step forward in understanding that we can be moving this direction it's very promising there was more data presented um confirming the um importance of uh w tegravir as a recommended regimen for pregnant women who are hiv positive that it's not likely to cause more um neural tube defects for infants there had been not without going to the whole history this was just another you know the follow-up at this point i think was really important to have there and then the third thing that i put in the category advancements in science is that there was such a rich discussion and i just know greg will probably get into this on the importance of social determinants of health and how to and race and equity and how to you how to you can't disentangle any of that from understanding the hiv response um and i felt like there was a new emphasis on that um you know in a very prominent way um so those are the science pieces and then lastly on the u.s government the us has always played a key role in these conferences um in many different ways the the us government has funded these conferences and was a funder one of the funders of this conference uh through presentations of u.s leadership through not much of the research some of the research i cited was supported by nih but it is again and many of the key officials involved in the u.s global and domestic hiv response were did present at the conference but it was a different feeling um because many of them are now being pulled to address covet um and uh and this was um one of the things that they were participating in on and while their attentions are elsewhere and i think that was it was commendable that they were participating i mean tony fauci was in i don't know how many things he did but he um he was ever present um and i believe steve will be talking to him later today actually um but you know that there it was it was mixed in in their presence but it was still there was still a presence there so i'll leave it at that thanks so much jen greg sure thank you and and again thank you for pulling together this this uh form for all of us to really reflect on what took place during the conference yeah i think for me the three takeaways that i had um was um you know past this prologue and covet 19 and hiv and social determinants of health as well as disparities that was the first uh the second um is covet 19 susceptibility and some of the uh science out there in terms of hiv and susceptibility to covet 19 and then the third um which i think shannon started to really get into a little bit was um you know policies matter and they continue to matter in terms of how health outcomes for people living with hiv so really to take a look at some of the science that was presented in the first bucket of disparities um there was a study that was presented looking at opportunistic infections in latin america for people who are taking hiv treatment they had a total of 9 000 participants across several countries and they still saw this high proportion of opportunistic infections despite the fact that we have art available for pulmonary tuberculosis candidiasis pcp etc and then the disparities issue as well we're seeing that younger individuals who are hiv-positive as well as women were far more likely to have these ois um i think the second thing in disparities you know really came out in terms of um prep um so there was a study in the uk that was taking a look at how successful they've been in reducing hiv diagnoses by the increase in proportion of individuals taking prep in msm in clinics in the uk but they still found that blacks as well as other ethnic minorities particularly those who were born overseas were far less likely to have access to prep and those those successes were not being born equally within those communities there's also a prep study in the united states that showed that at least 28 000 women in the us have started prep and it's good to see that we're seeing more prep uptake among women in the u.s a problem though and this is where the disparities issue comes back in again um is that most of the women who are taking prep work from the northeast states um and those states where we know prep need is the most which is the south where we have higher rates of hiv um the prep uptake was really lagging so that was the first bucket in terms of disparities i think the second thing that came out was coca-19 susceptibility um for people living with hiv there was a study a small study in south africa that found that the strongest risk factors for coca-19 death in western cape population were older age and diabetes and tb but they found that approximately eight percent of covid19 deaths could be attributed to hiv um but at the same time the presence of tdf tenofovir in art regimens was associated with a reduced risk of hiv of death which was really interesting to see there's also a study from the u.s a va study was a cohort study of about 6 000 veterans and they found essentially no differences between those veterans who are hiv positive or hiv negative on a range of outcomes related to covet they didn't find any differences in hospitalizations they didn't find any differences in icu units intubation mechanical ventilation or even death rates unfortunately though they did find that black veterans made up over 70 percent of the cohort and they were more likely to have covid compared to white veterans and latino veterans were also 40 more likely to have covet compared to white veterans so that disparity issue was still there as well um there was also a london study that found that people with hiv did not suffer worse outcomes after admission to a hospital um with covet 19 compared to people who didn't have hiv so it was really interesting to see this whole issue of covet 19 susceptibility and some of the data that are coming out for people living with hiv really starting to grow that that research base starting to grow as part of this conference i think the third bucket though is is policies and i i think that shannon did a great job in mentioning um a study that i was also going to highlight in terms of msm living in african countries that criminalize homosexuality where essentially they found a five-fold increase in hiv infection in those countries with the worst criminalization policies um but i think that there's another study that came out from kaiser family foundation looking at insurance coverage and viral suppression here in the u.s that was also incredibly important where kaiser really updated the data looking at medicaid and the degree to which people living with hiv rely on medicaid in the us and it's about 40 percent for people living with hiv compared to 15 percent of the general population and kaiser family foundation also found that states that expanded medicaid under the affordable care act um that people with hiv were significantly more likely to be covered by medicaid than states that had not expanded um and that uninsurance rates um were actually far higher in states that had not expanded medicaid compared to those that had um and then more importantly you know kaiser also highlighted the disparities issue as well finding that african-americans and latinos with hiv were more than three times as likely as whites to be uninsured so policies continue to matter policies continue to matter in terms of helping to bridge some of the disparities that we see in terms of trying to make sure that we have proper access for key populations in others um and it was very clear that kogan 19 really helped shine a bright light on many of these issues of social determinants of health as well as continuing disparities that we continue to see even in the hiv epidemic globally thanks greg and also i just want to say your your plenary session was spectacular and we all you know we all benefited from that and congratulations and thank you for that um the second question we're getting to is has to do with is there a consensus forming around what type of threat covid poses to hiv programs interests populations providers infrastructure and the like and i just want to say a few words before coming back to our speakers the pandemic we're talking about an overlay of two pandemics one that's been around for almost 40 years and the other that's very new they're very different pandemics obviously but as we've seen the conference pivoted into looking at the degree to which they be have become intertwined with one another and independent now the pandemic has been late the covid the coronavirus pandemic has been late to arrive um in africa uh as opposed to other continental experiences it's taking off now as we've seen i mean the dramatic surge that's underway south africa but you know it arrived late the vast majority of african countries in mid-march imposed pretty stiff lockdowns that flattened the curve that bought some time many of those lockdowns may not have been sustainable and some of them were ultimately lifted other methods now we're seeing sort of a an acceleration but we don't have as much experience in terms of when you look at it in in the course of early july trying to reflect on how much of a threat does this truly pose given that where we are in the arrival of the pandemic i think there's an appreciation interestingly in the discussion around what is possible in terms of getting a a vaccine developed quickly uh for covet 19 it's been very interesting that the global infrastructure created over the last 25 years in terms of hiv field trial clinical field trial infrastructure is turning out to be vitally important to that effort and um and and and certainly that means that that that infrastructure is is is is going to be i i believe highly protected uh in this period um you we've already talked about how what we've seen here in the covid in terms of the inequities and the disparities in the disproportionate disproportionate burden and disproportionate vulnerabilities borne by certain populations people of color people who are poor people with underlying conditions the elderly and the like that with that is being replicated and and that the hiv population is very much um within that we know that this pandemic has struck in a universal way across the world and that has had that has pushed many countries into a very inward perspective in a period of of strong nationalism a lag there's been an absence of summitry around this a very a void in terms of high-level thinking this this gathering at the international aids conference is about the closest thing to a systematic and high level deliberation around what is that what is this threat pose to these to these programs um the but but we're in we're in an early point in this in this in in the in the response here so the question that i'm putting to our speakers here which is has a consensus formed about the nature of the threat that covet poses to the to the hiv aids efforts um and how how do we how do we characterize that is it a monumental and strategic threat that could very well overwhelm us in the coming year year and years or as it's something that is perhaps less extreme and less severe and required and we've already begun to see ways to to manage and avert the worst outcomes so i wanted to sort of put that question forward how do you characterize the opinion climate coming out of this international aids conference which paid so much attention at trying to disaggregate and and and illuminate what these impacts are does it amount to a strategic threat or does it amount to something less than that monica you want to kick things off yes um i did talk about cobit and hiv before and i just want to spend one second before i answer this question to say if we i did need to go back to the research just a little bit for the science of the media because i didn't know if we weren't going to come back to that um i i do want to mention that there was more than hptn083 because that got so much attention and i think it was amazing that uh intro uh intramuscular capital every eight weeks was actually superior to daily tdf ftc for um msm and transgender women but um but i think we need to see the resistance data and the concentration data out of that study as the authors kept on warning because there were these strange uh breakthroughs on cabo tegravir when it was given perfectly so i'm waiting for the resistance date on that because we definitely don't want to kill instead which is our most important drug and then i i really need to mention weight gain as something that came out a lot at this meeting because uh it is important to say that this was a bad meeting for metabolic effects and weight gain i think taff and dolotev were together in the advanced study had already at 48 weeks the advanced study is comparing photographer and favorites essentially but with different formulations of taf or tdf with the dolo tegravir and the weight gain kept on going up with women in the advanced study um with dollar tiger and taf and then tafalone in a very big u.s based cohort looked like there was a quite significant weight gain with 4.5 kilograms over nine months with taf if instead of tdf and the reason that's important is that this time for the first time we were seeing metabolic effects of that weight gain so cardiovascular effects lipid effects hyperglycemia effects and diabetes so we can't ignore anymore that our therapies may be contributing to hearkening back to the early days of lipidustrophy maybe contributing to metabolic effects that we have to now as people live longer we have to decide what we're willing to to tolerate and um figure out sparing regimens of maybe these nucleosides that are most associated with weight gain um so to to to the the um the covid and hiv story i think there are four pillars of hiv control that are being affected by covenant those four pillars are hiv susceptibility hiv testing hiv prevention and hiv treatment and those are absolutely at this meeting all shown to already in this relatively short period of time to be in a very negative way affected by combat 19. so hiv susceptibility to start with i think there's this idea that people don't have um hiv risk during a pandemic and there was a there was a survey of over 18 000 lgbtq individuals um around 138 countries uh presented at the covid meeting on the last day and what uh what the socio-economic deprivation that occurs from kovid is doing in terms of people's livelihoods in terms of people's hiv risk selling sex for money um the miserable the misery of uh what covett is doing in terms of taking away people's fundamental um rights and employment and and there's no doubt that uh there's a concern that hiv susceptibility will increase uh during cover 19. so i think we need to get away from that question there's higher rates of substance users higher rates of overdose deaths and major cities around the country that's hiv susceptibility is not going to go down hiv testing this was not um at the meeting there was a there was a abstract from the fenway uh clinic in boston about prep reduction which i'll talk about in a minute but an important finding of that paper is that hiv testing is down 85 in boston during the last three months we had a report in the chronicle in san francisco at the same time that the dph here in san francisco reported 90 reduction in hiv testing over the last uh three months which means that when people go to the er they're all ruled out for covid um even if they have fever and pharyngitis and rash um and have hiv risk but uh they are never ruled out for hiv people are just like there's a massive turning away from hiv testing and that's that's true in papers from kenya as well and then the third is prevention uh that fenway abstract that i told you about um prep picking up your prep refills even though it's all over the phone and telehealth that had reduced um massively in the setting of of covid there was a 200 increase in refill relapses uh and uh so the impact on prevention especially when prep was being considered like a secondary thing to do in in low and middle income countries um is expected to be very high and then hiv treatment i think it's i will i will let shannon please tell us about the model from unaids from may because that model has been haunting me so i won't take away that thunder but um there was uh quite a bit of um concern that this will affect hiv treatment outcomes and in our clinic at ward 86 which is an hiv clinic in in san francisco we already have seen decrease in neurologic suppression rates over the last three months exacerbated among the homeless there's there's in my mind there's no doubt that those four pillars are going to be massively affected and i really want to hear shannon so you would monica you would characterize this as a historic strategic threat yes definitely okay thank you shannon yeah um thanks for that i mean i think i would say that there is a certain amount of consensus of how bad this could be you know and i'll talk a little bit about that and monica started talking about that i don't think that there's a full consensus of how we should react or act on that threat um what do i mean so you know consensus on multiple fronts on how bad this could be um some of the modeling that we at unaids did with who and a collection of um the hiv modeling consortium did a what if right i said okay well what if in sub-saharan africa alone since that's where so many people living with hiv are what if there was a just a full stop six-month interruption of services because of covid what would that do if there was a six-month interruption in treatment services what would that do in terms of cost for people and people's lives and that showed a six-month inter interruption would likely cause uh an extra 500 000 deaths from aids in sub-saharan africa alone so double the number of deaths in just one year knocking us all the way back to 2008 mortality rates so losing a decade of progress in just one year and it would keep going from there and we see the same kind of threats for mother-to-child transmission programs and monica highlighted many of the additional threats due to economic issues and impoverishment and social determinants so the threats are very real how we react or respond to that i think we don't have a consensus about certainly in the let's try to keep those interruptions from happening doing everything we can to problem solve there's consensus there but in these bigger issues i'm not sure there are you know and a few examples of that um you know we are in a year which we are setting uh the targets for 2025 on the way to 2030 you know these big global targets that countries around the world sign on to through the united nations and as the experts have been working on this before covet um it was clear that even without kovid a lot of countries weren't going to make their 2020 targets and there was a discussion like well if the country doesn't meet its 2020 targets should we lower the standard for its 2025 targets and there was a lot of heavy debate over this and i think the the consensus from civil society to academia to everyone was like you know what no we can't lower those targets we've got to do is enhance the strategies to catch up and accelerate um but i think in the context where with kovid now um and you know there are estimates coming back out similar to hiv that many of the sustainable development goal indicators might go back a decade um i'm feeling a lot more i'm hearing a lot more like well is it unrealistic to keep bold targets shouldn't we just sort of like lay off a little bit um yet when you start to unpack country by country and being very i think sensitive to what that means for programs to catch up you know we see that in many cases when you impact country by country what has gotten in the way of getting to 2020 can be a very focused gap it can be missing men and missing children that just putting a pause or lowering the standards or giving an extra year or five years in general for the targets still will not fix that fundamental issue of who's being missed if there's not a focused and intensive strategy to address those gaps that were already there that are probably enhanced because coved two so my biggest fear i guess is that this lack of consensus will dilute the political will to have bold targets that will dilute the pressure for investments to say you know what even if the whole world's in an economic recession i think we just experienced what happens if you're not investing in the health of people before something big happens i mean this should be an argument for more investment not less and so i am worried that we might feed into um futility factors or lower goals because it sounds so reasonable to be overwhelmed by covid instead of using this as an opportunity to double down on the solutions double down on the investments and double down on the leadership commitments it's going to take to really get us back on track thank you shannon i just want to make one remark here that late last week we did a session with mark locock the under secretary general for humanitarian affairs and the director of ocha along with two members of congress susan brooks and amibara along with julie gerberding from our commission um you you and ocho has put out a very very dramatic statement along with an appeal the largest appeal in its entire history 10.3 billion dollars for on a six-month period but the you look at the analysis there's 190 page analysis backing the five-page appeal and it's sweeping in terms of what lies on the horizon in terms of famine extreme poverty disruption of services and and more and the hiv community fits in that the hiv world fits in that and there's and they're drawing from unaids work and others in in saying this is what we are walking into this is this is what's on the horizon and you know sound in terms of sounding the alarm to the world um as to the urgency and the magnitude of the threats this was this was an astonishing document and argument it seemed to me and coming right after the aids conference is partly why i was motivated just to try and ask this question of how much of a sense of urgency and alarm and what is it we're supposed to do because if these if what is laid out in the scenarios of this is what's going to happen if there's inaction and an inadequate response it's it's profound uh and the countries that we're talking about where the hiv program and footprint is the largest and where the burden is the largest are the most vulnerable and across that spectrum of countries jen cates do you have thoughts on is this a strategic threat or something something more manageable well i mean i agree with what others said it was there's a consensus that this is a strategic threat um for all the reasons that that were sad i i that came through loud and clear and i think everyone realizes it and um there's already the direct impacts that have that monica was talking about that have been documented um the projected impacts from even small disruptions um that we that have been modeled a couple other things i wanted just measures of direct impact i wanted to highlight but then talk about two other factors who did a survey of countries to assess arv stock out situation and they found that 73 countries um warned of that there were risks of stockouts of arvs and 24 already reported critical critically low stocks of arvs that's danger very very such a danger zone in addition the global fund which has mobilized a very quick response of up to a billion dollars of funding that it's made available quickly has also just recently made a decision to allow countries that its funding to use its uh online procurement platform to get ppps and other supplies and if you go look at that and you know they say we can turn around and approval for let's say ppes in a very short period there's still a one to two month wait to get those ppes delivered by air and something like a three to five month wait by sea freight to get ppe's for combat that is um dramatic that's that's a strategic just uh a disruption that uh likes of which we've not seen two other things that um the other another impact i want to highlight because i also i sit on the office of aids research advisory committee i'm the chair of that committee and one of the topics that we've been discussing on nih is research recovery because while the most important immediate things are the threats to people's lives who are living with hiv or at risk from hiv as we heard there's also this research pipeline issue and to the extent that clinical trials for hiv and other research have been disrupted and and halted as labs have had to uh you know close and and pause that is going to set back our our research trajectory for vaccines and for the other things so there's that aspect too um even the other issue that i think is really critical is funding because even before covid um just like with unaids annual update we released our annual update in conjunction with unaids and overall funding fell this is pre-coveted funding from all sources fell uh in 2019 compared to the prior year so instead of filling the gap getting the smaller what's needed the gap is growing donor funding fell as well and this is pre-covered and we know already that donors are are expressing are looking inward and wanting to respond to massive economic upheaval within their own countries and that's going to make funding low and middle-income countries um risky for them and then also there's been so much emphasis in the last decade on domestic resource mobilization and all the projections from imf and world bank show that um low and middle income countries are being hit so hard already that their their economic prospects are are severely curtailed so the ability for them to increase their own budget spending on hiv is very that much at risk so i mean this is those factors are have made a permanent i think impact on our future from the hiv perspective and are also causing a rethink about all these approaches so i agree that there's not necessarily consensus for how to move forward but there is definitely consensus that this is a fundamental impact thanks jen uh two quick points and then i want to ask greg to weigh and i mean first point is to follow on what jen just said the debates over debt relief and debt forgiveness are at a still at a very early point and when you look at the projections in terms of the debt overhang and the lack of fiscal space in these countries to have capital available to respond is is is is woeful and and and much more needs to be done on that front if we're looking at protecting hiv aids and other health health info health investments the the other point i want to make is in terms of an ability to get us resources into the pipeline the moment is upon us right now which is the fourth covid supplemental which is under debate today uh action may not be concluded until august there is a proposal on the table of somewhere in the order of 20 billion dollars toward of international assistance going to a variety of purposes there's a separate uh proposal on hiv which i believe is a 700 million dollar over two-year proposal um but these these are getting worked out right now and it's it's it's it's a delicate and difficult thing i mean even in a one or two or three three trillion dollar package where you see this type of 20 billion as a as a miniscule component it's politically very difficult to move but we have seen some bipartisan movement within the senate and within the house around this and we should be hopeful but this is the our best shot at getting a major investment into the emergency humanitarian into the hiv and into the uh coveted response and the vaccine preference those four streams all are embodied in that in that proposal in some form the hiv has not figured as prominently in those debates and could figure more prominently greg your thoughts on is this a strategic threat and if so what should we do about it thanks steve you you actually mentioned what i was going to mention in terms of what's taking place right now on capitol hill uh and and the degree to which the coveted response as well as our response for global health is really just is dovetailing um but i think one thing that i would mention that has not been mentioned is um you know vaccines you know right now we're in the process of going into phase 3 trials for some of the candidate vaccines and we know how important it is going to be to have some of these vaccines distributed domestically as well as globally many of the reasons that monica and others had said beforehand the disruptions that we're seeing both domestically as well as globally in terms of healthcare services disruptions in terms of people's livelihoods etc um and i think one of the looming questions next year if we have one or two viable vaccines is you know what is the distribution going to look like for some of these vaccines and what are the implications going to be uh for the economies of many of these different countries that may not have the same access uh to vaccines as other um uh on nations do um and i think that that's gonna be a question that we'll all be talking about next year during the international aids conference to try and figure out whether or not um the vaccines are gonna be able to help try and level some of the playing field and stabilize some of the economies um that that are being disrupted uh by covet 19 um as well as the um monies that are being misplaced uh from hiv towards dealing with covet 19 in various um uh uh countries thank you and we've got about 12 minutes left and um we wanted to touch on the question of what do people think about a virtual conference what what did we learn from this and what worked what didn't work and what's the future likely to look like we also have a question a very important question around key population-led organizations and should we be as a matter of priority looking ahead investing paying much more attention uh in strengthening their capacity key population organizations in countries so they can they they can be better equipped to do the kind of rapid studies and report on service delivery and coping with these threats so i'm going to add that question in and i want to circle around and ask people to respond to both that key population question but also this question what did we learn from this conference was it successful was it something that still carried monica the spirit and the and the all of the work that was done in san francisco in oakland and did it did it still convey that spirit and and reality of how much mobilization there was what did you think monica uh i would have to say no unfortunately i'm not gonna like pretend that this wasn't profoundly disappointing this was um bringing um uh the international aids conference to a city uh is like the olympics like it's exciting to have it in the city there are massive opportunities for mobilization for fundraising for the city for bringing emphasis back for the city and to be honest uh it was so so disappointing and um there were there is nothing to replace in person interaction in my mind for advocates and patients and clinicians and researchers and policy makers and government officials and everything that the international aids conference is to come together so i i i'll now say something positive and and and optimistic but i'm not going to pretend that i wasn't profoundly fitted and so was someone else and no i didn't see my local san francisco thing and the fact that i introduced jane goodall and then it was such an incredible honor and my was wearing pajama bottoms like yeah this is no this is not like this is not the same thing but okay so let's go to the positive so uh the idea here would be um and i think it's true uh that uh there are people who actually cannot travel obviously and it is expensive and it is a big deal and whether you have 25 000 people coming together often for these international aids conferences many people get left out and it is um by making a platform that's accessible then you will increase accessibility and it wasn't free i mean meaning registrations were allowed uh even into the meeting which is different than an in-person meeting um but the aids 2020 meeting wasn't um though there were a lot of scholarships it wasn't free the coven meeting however was so the um ias decided and i think very fairly to make the covent meeting completely free for um to register because there were clinical implications for people to hear about and prevention and transmission around the country as there's around the world as there was a big pandemic happening and it was important to hear from um dr fauci and dr slim cream and dr burks and bill gates spoken that mary robinson and jane goodall and bill gates you know it was it was an exciting like lineup uh to hear from people who were who were thinking about it so much um and then the unh secretary general uh closed it out um but and dr chadros actually opened as well from the who but um so i do think that accessibility was helpful in terms of a platform to be honest we learned a lot um you know when people were on it all at once it wasn't as easy for everyone to be on it i think now people can go back in time and look at the talks but people will have to remember to sign their consent so no one can get dr peter piazza's talk yet because we need him to just really quickly sign his consent um so there's just like you know there are issues that happen when it's online so i ca i guess my overall message is it was no choice it went the best that it could go i think accessibility will be there for many for a long time but nothing for me replaces what we could have had which is in person and i think all of us wish coven 19 was not happening thank you monica that's very eloquent and powerful uh and i i can feel it um shannon yeah and i promise i did not plant the community k-pop lead question um but to take that on first uh absolutely are we you know seeing more than ever the need to consider community-led key population-led essentially organizations led by affected people for affected people um the need to invest in those kind of organizations for as part of the core infrastructure and resilience of our health and our beyond health responses period um you know i'm gonna i'm gonna take a little bit of a a nuanced exception to the idea of capacity building capacity and just say you know what we got to start funding there is plenty of capacity that is there and can be built but it's being starved to death by a lack of funding and a contracting civil society space um we we've done i think in recent years um some good funding of community-led organizations for direct service delivery and thank goodness because these are a lot of the organizations that are maintaining services and being creative under coven but there are two other really core functions of key pop and communal led organizations one is participation in governance and advocacy being at the policy and decision making tables and it's become over the years harder and harder to get the funding for organizations to do that work um and when we see our coveted national responses despite advocacy we are seeing that community-led organizations are in fact usually not at the national cove decision making tables and that's a problem on the other side we see the the real need for key pop and community organizations in the accountability and community-led monitoring side is what's happening on the ground actually meeting the standards of what was promised and the quality that needs to be delivered and is there a feedback loop for that um you know so we saw actually some really good data at the conference on how that can change services but yes absolutely we need to be investing and keep hoplet and community-led organizations as a core and role in several part of a resilient health infrastructure um second on the on the virtual meeting um uh i think looking forward there are just to build on what got monica said of course this didn't replace an in-person meeting um some things are really were for me really surprisingly good i found actually the quality of a lot of the content um maybe with so much that had to be filmed ahead um the presentations every single presentation i watched uh was gangbusters the content was out of this world so i don't know if it was the pressure of having to film you know as a compliment to some of the live sessions but i i just thought that the content was fantastic and i'm glad that is captured in an accessible way that we can keep replaying um you know we got greg here and i have been filmed ahead but you know clearly the pressure was on and he was fabulous um i think one thing though um that that i think we have to really be thoughtful about going forward is i think we all know just to talk about a sensitive issue a little bit you know directly that there was some fracturing in the planning of this conference between hiv 2020 and aids 2020 um that was really unfortunate um and and i was you know i sort of hoped that because everything sort of switched up and became virtual that that fracturing maybe would go away in the virtual setting but i didn't get the sense that we fully remedied that fracturing or built those bridges and so i just think we all as we look forward to the next year the next two years and what comes next we just have to be very purposeful about reuniting our entire audience and using these great new tools to do so and i'm very confident we'll be able to do that thanks so much shannon um we're gonna run a few minutes over if that's okay we're gonna hear from from jen and from greg on this question of what did we learn what do you think of this conference and then we're going to come back and ask each of them to speak for one minute on the question of what gives you the greatest hope in the midst of all of this uncertainty and drama and risk over to you jen uh what did you think of this what did you make of this i'll be quick um i'll be quick because i i really agree with with monica and shannon but also in the interest of full disclosure i'm a member of the iis governing council which is like the board of the iis i should have said that in the beginning and i um but in that capacity the governing council isn't the planner of the conference but we really you know had to we supported the iis staff in making some very difficult decisions and i really want to commend them for doing this under very very difficult um circumstances uh i you know as everyone has said i mean having a virtual conference in the midst of an emergency when that wasn't what you were planning to do is not a perfect science um and so it what you know sometimes the bandwidth wasn't good enough or whatever but on balance the fact that it happened the fact that so much good material got presented it was democratization by allowing more and more people to participate are really good signs and i think um going forward now when you can start planning a virtual conference from the outset that is your goal you can get a you can it can be much much better i mean this was really to quickly go from in person in a complicated way to online in a complicated way the last minute so some of the challenges were really that but i think by and large it's it is going to be the wave of the future i'm wondering what in person will look like for things and i i know there will still be in person but when and how will be a big question i think this proves that you can do a virtual meeting and share information and it has advantages so i'll just i'll leave it at that on the kp side completely agree i'm going to defer that to greg because he's actually in doing that work right now in terms of building capacity i think amfar is uh with with key populations in country so um thanks okay great greg sure i'll be really brief um in terms of um the conference going virtual i have nothing but kudos for the you know international aid society the whole team um it's it's i can't imagine moving from a 20 000 in-person conference to a virtual format within a matter of months and it's it's just incredibly difficult and i really think that the team did an incredible job of trying to pull this off as as well as possible and and did a good job in pulling quite a few things off um in terms of the um of what's taking place in the centrality of kp organizations i mean absolutely that's something that i um spent a lot of time on my plenary talking about um about the centrality of kp organizations one thing that we do see in the code response and and it's been wonderful to see is that um hiv scientists have taken a lead uh in the code response and i think that there is a plus there for us to remind policymakers as well as global citizens overall about how important hiv scientists have been in addressing infectious disease whether it be ebola coca-19 or other infectious diseases where i think there's a deficit though um is that we're not having as much attention being paid to kp led organizations um and and to community-based organizations we know that coca-19 is stigmatized hiv is stigmatized as well we know that community-led organizations and kp led organizations know how to reach communities um that have been stigmatized we know that we need uh to have contact tracing for covet-19 to try and get the epidemic under control um and yet we are not funding any of these organizations who've been doing this work quite frankly for decades who know how to do this work who have connections to these communities uh to do that work for the covet 19 response so i'm hoping that in in the years to come or over the next year that we could actually see some covet 19 funding going to kp led organizations to community based organizations to really help address that response and for those organizations to get the recognition that they deserve not only in addressing hiv but for covet 19 as well thank you greg okay we're getting towards the close here i want to say one thing first of all this conversation brings across again one of the remarkable features of this community uh that works in the world of hiv aids which is it's a community that has leadership with remarkable talent continuity and longevity all of you have dedicated your lives over many many years to this field and and it brings an incredible depth of perspective and what you've said this is this today in this short period is is both very sobering but also very inspiring and um and i want to thank you all for the for what you've done the the commitments and the leadership you've shown over over many many years it's quite inspiring we've asked the speakers to give us one minute each in closing on where do you find the greatest hope and strength as you as you look ahead in the midst of all of the challenges and uncertainties and risks that we've talked about today monica thank you for being with us it's great to see you and i'm going to ask you to kick this off yeah i am actually i'm feeling quite pro oh sorry can you hear me yes we can hear you okay sorry i am fine i am actually feeling profoundly hopeful um about uh and my heroes angela davis and cornell west i've been listening a lot to them during this time of um uh protest around the country um in in in reaction to several deaths um and police brutality but it was really in reaction to everything and people in the setting of covet 19 have both time and somehow turned their attention to uh how unfair and the disproportionate impact of covet on racial and ethnic minorities in this country and and so is hiv and i think this feels unprecedented i know right now there's oppression that's trying to go on in cities um from the other end but i i am feeling really like this is unprecedented and i feel hopeful and i feel like everyone's thinking about the disproportionate impact of infectious diseases on poor people with thinking about 30 years and if people are thinking about that more i feel like something could change so i'm i'm feeling hopeful thank you thank you very much shannon wow we might all converge on a lot of things um i i am hopeful in our chaos actually i am hopeful with this convergence of hiv of covid of racial inequalities um for what it seems to be meaning for people's real understanding across a lot of countries and a lot of settings of what um structural inequalities really look like that it's not just about one person here and one person there but what an uneven playing field on so many different elements means when a crisis happens um it's nothing new to us in hiv but i feel like that there is not just the activism but also more of an appreciation and understanding on that than there's ever been before and that's a huge moment in time and i think when that goes along at a very practical level of some of the things that craig greg already mentioned which is and you know what hiv leaders not just scientists but hiv leaders are stepping up around the world in the covet response the scientists yes but also the number of you know current and previous knack directors that have been called in to lead the national responses the community organizations who despite not being deemed essential service providers not despite not being funded are stepping up and creating solutions for their um communities i think this just re-emphasizes to me the privilege i feel being part of this community which is we don't wait to be asked we certainly don't let anyone put us in the corner and we say nothing is impossible we can meet this challenge overcome it but we can only do that together thanks so much shannon that's very very eloquent jennifer yeah i mean i can't top what shannon and monica just said i those actually i feel more hopeful having listened to them uh yeah the only the i'll have two things one is um and it relates to what they said with hiv um there are for many years and still often are where people working on hiv were yelling to be heard not everyone heard it was a phenomenon that we it is a phenomenon that we we know those of us working in affects everybody in some way but it's not a pub there's not a public consciousness of it this covid um is a global phenomenon in a way that um we've never experienced where virtually everybody is is aware of some something extremely profound that is affecting everyday life and while um and that's you know led to hardship and it's um disparities and all the things people said it that kind of um reach does have the potential i think to lead to to change so i do get hope in that and the second thing that i that is something i learned early on in hiv is what gives me hope is tony fauci if tony fauci is involved um i have hope so um that that's my i'll leave you with that thank you we'll have uh tony fauci here for an interview at 1 30 this afternoon eastern time so please tune in if you wish greg you get the last voice here this morning sure thank you um you know i i think what gives me hope is the fact that the conference gave us a glimpse of what can be um and and what i mean in terms of what can be um when we use science um in in hiv to make a difference um there are two studies that did not get a lot of attention that i thought were really important and both of them were prep studies and generalized epidemics there was one um with project echo that found that just 25 of women up to prep but there was a 50 fall in the rate of hiv infection um for people who are part of that study and then there was a second study um from the search study in kenya where they found that prep prevents an estimated three-quarters of hiv infections uh among people there so there's a big drop in incidents despite low use of prep that gives me a lot of hope that even with low use of prep within generalized epidemics that we can see these huge drops in new infections and just getting that glimpse of what can potentially occur if we still continue to invest in global hiv if we continue to invest in science if we continue to invest in communities gives me hope um and and i want to hang on to that hope uh to to make sure that we actually get to the goals that we've set forth by 2025 as well as 2030. so much greg and thanks to all of our speakers monica's had to exit uh vermont to take another call um we're at the at the close here again i want to repeat my thanks to all of our speakers for being with us today and for the audience that's joined over the course of this hour to maggie mccarten gibbs john montz clifton jones who put the program together so flawlessly and skillfully so we are adjourned we'll see you in two more years when we come back to do this again right jen [Music] definitely okay thank you thank you bye bye you