Despite remarkable advances against HIV over the past two decades, “let us not confuse progress with success”, warned UNAIDS head Winnie Byanyima at the start of the United Nations High-Level Meeting (HLM) on HIV in New York on Monday.

Over 40 million people are living with HIV, yet “almost nine million people are still not on treatment, and last year 1.2 million people were newly infected,” said Byanyima, her address delivered to a sea of empty chairs – symptomatic of waning interest in responding to the virus.

“This is our last High-Level Meeting before the 2030 promise to end AIDS as a public health threat. We are just four years away, and the opportunity is extraordinary.”

Africa is unhappy with political declaration

However, African countries expressed unhappiness with the political declaration due to be adopted at the end of the HLM on Tuesday. 

“The text renders the objective to end HIV and AIDS as a public threat by 2030 unachievable,” said Malawi Minister of Health Madalitso Baloyi, speaking on behalf of the continent.

“We are very disappointed with several areas in the text,” added Baloyi, listing the failure of the international community to “strengthen efforts for transfer of technology, equitable access to medicines and vaccines to developing countries”

Baloyi also highlighted the removal from the text “of a commitment to the supply of medical products,  including to countries facing unilateral coercive measures”.

Baloyi added: “The language on financing has regressed compared to the 2021 political declaration, reducing financing responsibility to mainly domestic financing and rejecting principles of equity and burden sharing.” 

The European Union called for the political declaration to “serve as a pathway to accelerated and coordinated action, grounded in science, solidarity, accountability and human rights.”

The EU said that several requirements were needed to sustain the HIV response, including political will, strengthening synergies with co-infections such as tuberculosis and hepatitis; accelerated prevention, testing, and treatment, and country ownership with “stronger domestic financing”.

HIV is ‘the story of multilateralism’ 

President of the UN General Assembly, Annalena Baerbock told the HLM that “the story of HIV is a story of multilateralism itself”, and today, “reflecting the wider headwinds facing multilateralism, the HIV response stands at a crossroads again”.

“If we walk the last mile together, in the interest of all of us, we can end AIDS as a public threat. Or we can allow four decades of hard-won progress to be put at risk.”

UN Deputy General Secretary Amina Mohammed reminded the HLM of global achievements: “AIDS-related deaths have been reduced by 70% since their peak in 2004 and by 54% since 2010. HIV prevention and treatment services have reduced new infections by 40% in the same period, and today, more than 32 million people living with HIV are receiving lifesaving antiretroviral therapy.”

She appealed to member states to “summon the political will to accelerate and finish the global HIV fight”, based on the UNAIDS Global AIDS Strategy 2026–2031, which centres “country ownership, people-centred services, and community leadership”.

In 2021, the UN adopted the  95-95-95 targets, which involve ensuring that 95% of people with HIV know their status; 95% of people with HIV are on antiretroviral (ARV) treatment, and 95% of those on ARVs are virally suppressed.

Aside from the 95-95-95 targets, UNAIDS also wants 90% of people in need of prevention to use prevention options, including lenacapavir, a twice-yearly injectable that offers almost total protection against infection.

Financial crisis

The HIV sector faces a massive loss of development aid, driven primarily by the United States, once by far the biggest HIV donor. It is winding down its President’s Emergency Plan for AIDS Relief (PEPFAR), largely substituting it with bilateral memorandums of understanding (MOUs) in terms of its American First Global Health Strategy. 

The HIV component of the US strategy is focused narrowly on preventing mother-to-child HIV infection.

South Africa, the country with the largest HIV population in the world, has not been invited to discuss an MOU with the US – and the US finally confirmed on the eve of the HLM that it intends to halt HIV support to South Africa due to political differences.

Zimbabwe, Zambia, and Ghana have also been unable to reach MOUs with the US.

The silver lining of the MOUs is the commitment by countries to incrementally increase domestic investment in their HIV response.

The UN has proposed “sunsetting” UNAIDS as part of the “UN80” cost-cutting in the face of a massive loss in funds. UNAIDS is fighting to remain, but as part of its transformation, it has already slashed staff by over 55%, including an 80% reduction in staff at its Geneva headquarters.

Meanwhile, HIV activists are campaigning for much broader access to the injectable lenacapavir, pressuring Gilead to allow generics and to reduce the price of the medicine.