There are two competing trends in the global fight against HIV/AIDS. On the one hand, there has been tremendous progress toward reducing the number of infections and deaths from HIV/AIDS over the last twenty years. Scientific advances in treatment and prevention, new policy tools, and political and funding commitments have driven down HIV/AIDS to the point where it is possible to foresee an AIDS-free world in the not-so-distant future.
On the other hand, over the last few years, that progress has suddenly come under threat. COVID upended HIV/AIDS programs in much of the world, and more recently, sudden and swift funding cuts, including from the United States, are shaking the foundation upon which previous decades of progress were built.
On June 22 and 23, these two competing forces will come to a head at the United Nations, where diplomats are gathering for a major meeting on HIV/AIDS. According to my guest today, Mitchell Warren, the High-Level Meeting on HIV/AIDS at the UN presents a unique opportunity for multilateral coordination toward the goal of ending HIV/AIDS as a public health threat, but that goal may be stymied. Key countries that previously led the global fight against HIV/AIDS, including the United States, are stepping back from their leadership roles, potentially upending decades of progress.
Mitchell Warren is the executive director of AVAC, an advocacy group. We kick off by discussing some of the exciting new scientific innovations that may accelerate progress toward ending HIV/AIDS as a public health threat, then have a discussion of how cuts in funding and eroding political commitments are hitting just as these promising new scientific innovations are coming online. We then have a long conversation about how this dynamic may play out at the UN — and what to expect from the High-Level Meeting on HIV/AIDS.
This episode freely available across all podcast listening platforms, including Spotify and Apple Podcasts.
Transcript edited for clarity
Mark Leon Goldberg: Welcome to Global Dispatches, a podcast about foreign policy, international affairs, and often, as in today, global health. My name is Mark Leon Goldberg. I’m the host of this podcast. Mitchell, why don’t you introduce yourself?
Mitchell Warren: Great to see you, Mark.
I’m Mitchell Warren. I’m the Executive Director of AVAC, an organization that focuses on HIV prevention and the broader HIV-AIDS response.
Mark Leon Goldberg: So, Mitchell, we are speaking ahead of a major international meeting at the United Nations on June 22nd and 23rd — a high-level meeting as it’s known in UN parlance, which is intended to be a major inflection point on the future of the global fight against HIV and AIDS. And I want to focus our conversation on that meeting.
But before we get there, I’d love to have you set the stage for us a little bit. Where do we stand today in the global fight against HIV and AIDS?
Mitchell Warren: We stand at kind of a remarkable point in the AIDS response and in a way that I couldn’t have predicted. And I have a hell of an imagination, but certainly, the last 16 months have defied even my imagination. And we’re at a place where we should be talking in 2026 about progress towards a UN target to end HIV as a public health threat, was the term of art at the UN a couple of years ago, to end it as a public health threat by 2030.
And we, by 2024, early 2025, we were already off track for a number of reasons, which we can talk about. Some of it was still coming out of the emergency period of COVID, which derailed a lot of progress in HIV. But getting back on track, looking ahead to 2030, and then, of course, the disruption beginning on January 20th, 2025. And it’s coming at one of the, I would argue, one of the cruelest ironies of the moment is that we have some of the most exciting science and HIV in 45 years of the epidemic, coming at the most politically and economically challenging times that may cause us to miss the moment of opportunity.
Mark Leon Goldberg: So, let’s break down those kind of competing trends, as it were. On the one hand, exciting scientific developments. On the other hand, a kind of retraction of financial and political support towards those scientific developments. So, what are some of those exciting scientific developments of the last several years that you would cite as particularly impactful?
Mitchell Warren: So, it starts with the power of antiretroviral treatment. And we’ve known about antiretroviral treatment now for 30 years. But what we began to see in, even in the midst of COVID, is progress towards a global target created by the UN, endorsed by member states to get what were called the 95-95-95 targets. So, to make sure that 95% of people living with HIV knew their status, that 95% of those that knew their status got on antiretroviral treatment, and that 95% of those on treatment were virally suppressed, because we know that if you’re virally suppressed, you won’t transmit the virus.
And so, there were a number of countries in 2024 that actually began to achieve that 95-95-95 treatment target. But we still see the rate of new infections. And that’s where the exciting science came in, because in 2024, just about two years ago, we saw the results presented of the latest form of pre-exposure prophylaxis, or PrEP, in the form of an injectable that you get every six months called Lenacapavir, providing nearly perfect protection in the clinical trials.
And that product was then approved by a number of regulatory agencies in record time, particularly in low- and middle-income countries. The product was meant to be delivered at the end of last year and early this year. And it is now reaching the first dozen countries in Africa right now. And that’s where we get into the challenging moment. But the science of Lenacapavir, you know, partnering with the power of antiretroviral treatment, really gave us a view that you might be able to think about ending this epidemic by 2030.
Mark Leon Goldberg: Yeah, I mean, the power of that injectable seems to be premised on the idea that, you know, behavior change is a much more difficult public health endeavor than just taking a medicine that will prevent you from spreading HIV.
Mitchell Warren: Yeah, that is true. And there is a behavioral component of every intervention. I think one of the things we’ve certainly learned in the last decade is for all the talk of biomedical advances — We had oral PrEP approved first in 2012. Then we had different forms of PrEP leading up to Lenacapivir. And there are remarkable technologies, each of them in their own right, very safe, very effective products.
And we think of them as biomedical interventions. But we also know that getting into the clinic to take an HIV test, to get a prescription and then take a pill every day also has a behavioral component. The advantage to this every six-month injection is that you kind of delink it from the daily reminder that you might be at risk of HIV, of condom use, or of oral prep. And so, for many people, that idea of the injectable was, is tantalizing and powerful.
The one other thing that’s really interesting, and we’re beginning to see it in some of the early programs delivering Lenacapovir, is that it’s bringing new people in to find out their status, to find out if they’re living with HIV or not, because they think if they’re not and they’re at risk, they might get Lenacapivir. And at least in the early programs, we’re seeing people newly diagnosed, which is important because the sooner someone’s diagnosed, the quicker they get on treatment, the better for their health. And so, Lenacapivir really is this opportunity for both diagnosing, treating, and preventing.
Mark Leon Goldberg: You mentioned earlier that there were a few African countries in particular that were on track for that 95-95-95 target. Which countries were they, and what were they doing right?
Mitchell Warren: So, there are a number of countries that are near or achieving that 95-95-95 target — Botswana, Eswatini, a number of other countries in the region, and also countries in Asia and Latin America. The success of treatment really comes down in many countries to the power of investing in health systems and in HIV programs. A lot of the countries that achieved the 95-95 targets were PEPFAR recipient countries.
PEPFAR, along with the Global Fund to Fight AIDS, TB, and Malaria, over the last 20 years have driven incredible progress. And so, where you see those investments, you see impact. And I think one of the things that was really important about the PEPFAR approach was not just procuring drugs and delivering into clinics, but the data systems of PEPFAR were really a crown jewel, which is now being destroyed, but a crown jewel of being able to see when you were reaching your targets, but also in a district or a clinic where you weren’t and what you needed to course correct on.
And so, data for decision making, not just to track progress, but to actually find, in a continuous improvement approach, has really been a secret to success, not so secret, but a key component of success.
Mark Leon Goldberg: So, it seems, and you’ve just intimated this, that sort of running head long against this scientific progress and policy innovations is this new kind of funding environment in which PEPFAR, the George W. Bush era president’s emergency plan for AIDS relief, which is a huge injection of funds into the global fight against HIV and AIDS, is being dismantled in certain ways. Can you just describe the headwinds against the progress that you’ve seen over the last several decades?
You described this amazing scientific progress, but now we’re in this odd moment in which you have these amazing scientific innovations and policy innovations, all of a sudden, in a much different political and funding environment.
Mitchell Warren: So, we should be building on strength and success. And instead, we are really clinging on to the vestiges of the PEPFAR program that are really imperiling that progress. And I think there was a moment last month that kind of describes the cruel irony incredibly well. So, in mid-April, PEPFAR, along with the Global Fund and Gilead Sciences, the company that made Lenacapivir, they announced an increase in commitment from 2 million people getting access to Lenacapivir over the next three years to 3 million.
So, a 50% increase with great fanfare. This is a huge priority for this administration. And that’s great news. And in fact, it’s maybe the only policy of the Biden administration, who originally created the partnership with Global Fund around Lenacapavir, maybe the only policy that this current administration kept from the Biden era. So that’s the good news. Five days later, though, PEPFAR released the first data in over a year.
And again, PEPFAR was very proud of their not just the data collection, but the transparency of that data. And it was available every quarter to all stakeholders. And they hadn’t done that for over a year in the new administration. And lo and behold, five days after the big Lenacapavir announcement, they shared the data. And they did it with great fanfare and said it was showing that they were back on track.
But that’s what the press release said. But you don’t do data by press release. You do it by looking at the data. And what we found in the data is that the PrEP programs, that PEPFAR has been the lion’s share of investment in PrEP around low and middle-income countries, about 90% of PrEP programs have been funded by PEPFAR in low- and middle-income countries.
There was a 40% reduction in PrEP access under PEPFAR programs year on year between late 2024 and late 2025. So, just as we see this excitement around Lenacapavir, the foundation on which to deliver it is being decimated. And it’s pretty clear to me that in that five-day window, the folks who made the positive announcement about Len and then released the data didn’t see what the rest of us are seeing, this incredible disconnect.
How do you deliver this new technology when you’ve just gutted the programmatic infrastructure that’s meant to deliver it? And the one other piece that’s particularly challenging is that a lot of that PrEP programming was focused on what are called in HIV programs, the key populations, or key and vulnerable populations — gay men, transgender individuals, sex workers, people who use drugs. PEPFAR pretty much dismantled all of those key population programs in which it had previously invested and is no longer even keeping track of the data disaggregated by those populations.
So, we see this, you know, cut by 40% of the program and the erasure of the populations who can most benefit from PrEP. So, it’s, it is that cruel irony of, of, of the current state.
Mark Leon Goldberg: You know, beyond sort of American cuts in HIV/AIDS response, and again, as you said, PEPFAR was like the lion’s share of some of these key interventions, have you seen a retraction from other governments as well? Are they kind of following Americans lead at this point?
Mitchell Warren: Well, it’s an important question because this current environment is not just about the U.S. government. It is a global trend that we’re seeing. And I think one of the great illustrations of that is in what happened late last year around the Global Fund. And every three years, the Global Fund does what is called a replenishment. So, they basically get pledges for the next three year cycle.
And Congress, 20 years ago when Global Fund was created, created legislation to support the Global Fund in addition to PEPFAR. It’s a fabulous partnership between the two funding entities. And the U.S. government can give up to one third of the Global Fund budget. And that’s written into law by Congress. And the good news last December at the replenishment is that the U.S. government, surprising many of us, actually doubled down on their commitment to the Global Fund.
And they’ve really prioritized the global fund as a key partner, which is great. But the Global Fund, ahead of the replenishment, put out their kind of need forecast of the next three years. And they were hoping to raise $18 billion for the next three years, which would have been an increase from this last three-year cycle of about $14 billion. Sadly, the pledges, so far, are sitting somewhere around $11 billion for the next three-year cycle. So, far, far short of that commitment.
The U.S. is still committing significant resources, but we saw reduced pledges from pretty much every other country. And that signals that this is not just a U.S. government issue. A lot of the European donors are obviously very focused on their borders and on investments in supporting Ukraine, which is a good decision. But it’s meant that global health investments are shrinking.
Mark Leon Goldberg: So, I think this was like a really good setup for a conversation I want to have with you about this key meeting at the United Nations, the high-level meeting on HIV AIDS taking place June 22nd and 23rd. What is this meeting and what do you see as its potential significance?
Mitchell Warren: Well, it’s incredibly significant. And this high-level meeting follows a series pretty much every five years since 2001. And the 2001 was called UNGASS, the UN General Assembly Special Session on HIV and AIDS. It was the first time that a health issue commanded a special session of the General Assembly. And it changed the trajectory of the epidemic. It is because of that political declaration in 2001 that Global Fund and PEPFAR really were galvanized in their financial support.
And that all the member states supporting the high-level declaration in 2001 setting targets. And so, every five years, these high-level meetings have really been both a kind of a way station, a checkpoint on the progress of the past five years. But more importantly, a vision of what the next five years can look like. And so, this year’s high-level meeting is a critical moment. And it’s coming at a time where, frankly, when we saw the last high-level meeting in 2021, it was right in the middle of COVID. It was mostly virtual.
And it codified the targets for the AIDS response, these UN targets around treatment and prevention, looking for 2025 to have reached certain targets, and then this idea of 2030, ending HIV as a public health threat. And what we know we’re going to see presented in June is that we are off track.
We didn’t meet the 2025 targets, and we’re way off track for 2030. The member states, we expect, will endorse a new global AIDS strategy, which was led by UNAIDS, which is the joint United Nations program co-sponsored by a bunch of UN agencies. Global AIDS strategy is a powerful document. It sets up commitments around treatment and scaling up Lenacapavir and other prevention methods. It talks a lot about human rights.
And so, there’s a lot of anticipation because we know in the current environment, there are a lot of countries, including the United States, that are no longer interested in supporting rights-based AIDS responses. And so, the declaration that will come out in June, will include the protection and support of people living with HIV, of gay and transgender individuals, of sex workers, of people who use drugs. Because those populations are often marginalized and sometimes even criminalized in some countries. And now the United States, the largest supporter, is giving pretty good support for that kind of rights-denying approach.
And so, they’re all not just watching the high-level meeting, but engaging in the high-level meeting to push for a declaration that has teeth, that does get member states to recommit to a strategy about ending the epidemic. It’s very easy to do a declaration of niceties, of saying nice things. Is it going to reflect what happened in 2001 about actual political commitments, financial commitments, rights-based commitments in the AIDS response? And so, there’s a lot riding on this one.
Mark Leon Goldberg: So that’s interesting. I’ve covered many a UN conference over my 20 years of covering the United Nations. And I presume this conference, like those similar to it, kind of operate on this consensus idea that in order for a political declaration to be adopted, all countries need to get on board. And any one country or group of countries can derail the outcome document, as it’s known from these conferences, can prevent it from being adopted by consensus.
And it seems, as you’re describing it, that there’s a conflict that’s being set up heading into this conference insofar as you have some countries, you name the united states as maybe not backing in the same way it used to, what you mentioned as a rights-based approach is that approach that you this idea that you ought to target particularly vulnerable populations — men who have sex with men or injecting drug users, or whatever it is —in order to um spur progress on the global fight.
And then you also have this funding idea that’s hanging over the whole project of global fight against HIV and AIDS. How do you see those kind of political dynamics playing out over the course of this two-day conference?
Mitchell Warren: I do fear that they’ll play out badly, and I would like to be optimistic that we will get a strong declaration that does have consensus and commitments. Just a few weeks ago, there was a multi-stakeholder hearing in the lead-up to the high-level meeting. It took place in the UN.
Mark Leon Goldberg: And actually, that’s UN speak for civil society participation in these kinds of conferences. I can translate UN speak all day, Mitchell.
Mitchell Warren: They called it multi-stakeholder. It was 90% civil society, a little bit of private sector. And it is under the auspices. So, the conveners from the UN, the two countries that are leading are Botswana and Georgia. And their political leaders were there overseeing this hearing and being part of it. But it was very much about civil society. But historically, you would have seen the U.S. government represented there. PEPFAR would have been there. They were not in the room.
And so, we don’t know where the U.S. will actually push and pull. We obviously have seen over the last 16 months, this administration express a great deal of animosity toward the multilateral system and to the UN. And historically, for the past high-level meetings, beginning in 2001, the U.S. was a major driver, helping to develop the zero draft and really contributing to it. And I do expect it will be contentious and potentially obstructionist in the conversations over the next three and a half weeks.
The zero draft, the UN speak for that first version that is out for member states to review is available. And it will be interesting to see the track changes, what gets cut, what gets edited, what gets added. And will we get to a consensus document that matters, that actually commits member states to an AIDS response that is robust and that meets this moment scientifically and politically and financially?
Mark Leon Goldberg: That’s interesting because it leads me to, maybe like a broader question about the value and significance of multilateral platforms on global health in general and HIV AIDS in particular. Why is it, in your view, that a meeting like this matters big picture? I mean, does it really compel states to take certain actions? What does it actually do? What does it achieve?
Mitchell Warren: It’s a great question. And I would say, historically, certainly from the HIV AIDS response over the last two decades, we have seen multilateralism and these high-level meetings and the UN family and the co-sponsors of UNAIDS and the member states collectively prioritizing, committing, and delivering great progress. If you had said to anybody in 2001 that we might actually even be able to utter the words ending an epidemic in the 25-year period, you would have said that’s pretty ambitious and maybe even delusional.
So, the progress achieved over the last 25 years is nothing short of historic. The fact that 30 million people access antiretroviral treatment, the fact that PrEP exists in multiple forms and has been delivered, the fact that many countries have created rights-based key population programs, it’s because of the multilateral system. Obviously, it’s also because of PEPFAR and the Global Fund and private philanthropy, the Gates Foundation, and others supporting the investments.
But it all stems from shared strategy that these high-level meetings and that the multilateral system have codified. And so, I believe that this high-level meeting is not just a check-in on progress and a forward-looking strategic declaration. It’s a test of the concept. It is a test of the will of political leaders and of civil society. Are we still in a global discourse about ending an epidemic? Or are we closing borders and shutting down and leaving every country and every community to do it themselves? Because if we are, the end of this epidemic is going to be pushed out many, many years. And that’s the test of concept ahead of us.
Mark Leon Goldberg: So again, having covered many UN conferences like this, it tends to be the case that certain groups of countries band together to pursue common positions. Some groups of countries are potentially more ambitious in what a conference can achieve. Some are less ambitious. What are some of the key negotiating blocks that are coming together ahead of this conference?
Mitchell Warren: Well, I think you’re seeing two really important things that will emerge. One comes, most importantly, from many of the African member states. And you’re seeing a lot of the conversation, just last week was a different UN structure, the World Health Assembly, and a lot of the conversations about African sovereignty, about the Accra reset, looking at global health more broadly. I do think one of the important elements too, is that we talk about HIV and the HIV high level meeting, but it is increasingly needed to be embedded in a larger health systems approach.
Because this is not just about HIV. There’s TB, there’s malaria. There are pandemics. We’re sitting here with an Ebola outbreak of epic proportion right now. But we’re seeing African countries with the Africa CDC, with the African Union, playing hugely important roles, not just as recipient countries of donor largesse, but rather as sovereign nations determining the health systems they want in their countries. And I think we’re going to see, I hope we’re going to see very strong language and very strong commitments from a number of African countries individually and then collectively as a block.
I think, historically, we’ve seen the European countries be particularly strong when it comes to rights-based language, and particularly the embedding of sexual and reproductive health and rights issues within the HIV response. HIV, of course, is an infectious disease, but it is transmitted in large part through sexual contact. So, you can’t delink it from sexual reproductive health and rights, although many countries would like to, because there are a lot of countries that would love to deny bodily autonomy, including the United States.
So, I think you’ll see hopefully European countries, as they have historically, be the strong voices for comprehensive sexuality education. And there’s often been good language in declarations. And I would hope that that continues, because without that, we also are going to inhibit our ability to succeed.
Mark Leon Goldberg: So, what will you be doing during those two days?
Mitchell Warren: Well, not a member state, although civil society, both in the run-up to the high-level meeting and on the margins of it — monitoring, holding people to account, making sure that the member states and the UN agencies that say the right things actually deliver on the right things. And really, this issue of accountability, I think civil society plays a critical role. And very often, advocates, we all have demanded things.
But advocacy is not just about making demands. Advocacy is at its heart about accountability. And so, we need to hold all stakeholders to account for commitments past made and for commitments to come. And so, a lot of what happens around the high-level meeting is holding people to account for the past and holding their feet to the fire for the future.
Mark Leon Goldberg: Maybe, lastly, to what extent is the goal of ending HIV-AIDS as a public health threat by 2030 contingent upon a successful outcome of this meeting?
Mitchell Warren: If there were not a political declaration a month from now, I would not say, “Oh, we can’t possibly deliver on the goal.” But it will facilitate many things because, again, back to accountability, it will allow civil society and other countries to hold each other to account for commitments made. I would say it is not the end-all and be-all. A political declaration is not an epidemiologic rights-based, well-funded AIDS response, but it is a foundational element of it.
And I would say that we might still be able to deliver on our target with a bad declaration, but it would certainly put one more hand tied behind our back. And we’ve already had a couple of our hands tied behind our backs these last 16 months because of such political disruptions and destructions. So, not having a good declaration would certainly make it harder. It wouldn’t make it impossible. And I think that’s one of the things.
You don’t work in HIV for three decades, as I have done, without being an optimist on some level. We cannot miss this moment. I believe a declaration will make meeting the moment easier. And I hope we get a good declaration. But we need to meet this moment with or without a declaration.
Mark Leon Goldberg: Well, Mitchell, is there anything else you wanted to add or mention before I let you go?
Mitchell Warren: Well, I would just say that it is a historic opportunity. I mean, again, if you had said to me 25 years ago, do you think you’ll see the end of the epidemic in 2030? I would have said, “No way.” We certainly are not on track for it now. But the idea that we’re even having the conversation is progress. And I guess I’d say never confuse progress with success. We have not succeeded, but we’ve made such progress, and we cannot go back. We have to go forward.
Mark Leon Goldberg: Well, Mitchell, thank you so much for your time. This was really helpful and interesting, kind of setting the scene for this key meeting. So thank you.
Mitchell Warren: Well, thank you for having me. It’s great to talk to you.
