The Urgency of Now: Leading the Charge at UNAIDS

Winnie Byanyima is Executive Director of UNAIDS and Under-Secretary-General of the United Nations. A passionate champion for social justice and a global leader on inequality, she leads the UN’s efforts to end the AIDS pandemic by 2030.

Before joining UNAIDS, Ms. Byanyima served as Executive Director of Oxfam International. Previously, she was elected for three terms in the parliament of her country, Uganda, where she led the first parliamentary women’s caucus, championing groundbreaking gender equality provisions in the county’s 1995 post-conflict constitution. Ms. Byanyima led the establishment of the African Union Commission’s Directorate of Gender and Development, served as Director of Gender and Development at the United Nations Development Programme, and founded the Forum for Women in Democracy, a Ugandan nongovernmental organization. She is the recipient of numerous awards, including the 2023 Hall of Femme Award bestowed by IWFSA (International Women’s Forum South Africa) and four honorary doctorates.

You recently led a UNAIDS delegation at the UN General Assembly in New York to urge world leaders to make new HIV prevention technologies—like the twice-yearly injectable lenacapavir—available to people at risk of HIV infection. What can advocates do to encourage them—and pharmaceutical companies like Gilead—to heed the call?

Lenacapavir is a breakthrough HIV prevention medicine that could be a game-changer for the HIV response. This medication could stop the HIV epidemic in its tracks if everyone who needs it can receive it. That’s why everyone in the AIDS movement has to keep up the pressure on Gilead to get the price down.

Right now, lenacapavir is priced for people in rich countries and that inequity has never served us well in the HIV response. Research shows that generic manufacturers could make this drug not for over US$40,000 that it’s priced for in America as a treatment, nor even for hundreds of dollars, but for less than US$100 per year in developing countries, coming down to US$40 in time.

Recently, Gilead announced a licensing agreement for the generic production of lenacapavir, and I applaud the company for licensing the medicine without waiting for registration. This should be normal.  We are fighting a pandemic and the speed at which generic versions come to market will dictate whether this medicine can be truly transformative and help us end the AIDS pandemic.

However, the exclusion of many middle-income countries from this licensing agreement is alarming and undermines the potential of this scientific breakthrough. HIV prevention tools need to be deployed where new HIV infections are highest and today, 41% of new infections are in upper middle- income countries. So UNAIDS is urging Gilead to secure further licenses for access in all low- and middle-income countries now.

The women I met in the favelas of Brazil—a middle income country—can’t wait! It must get to the gay men I met in Mexico—a middle-income country. This is urgent.

UNAIDS’ report, The Urgency of Now: AIDS at a Crossroads, states that the global community is not on track to end AIDS as a public health threat by 2030. Funding gaps, apathy from governments, gaps in access to treatment and prevention, and human rights abuses are a few of the barriers cited. How optimistic are you that we can overcome these barriers in the next five to six years?

I remain optimistic because there is a clear path to end AIDS as a public health threat by 2030, but success or failure will be determined by the decisions that leaders make today. The next twelve months are crucial.

Just nine years ago, only 47% of people living with HIV were on antiretroviral treatment. Today that number is 77%. This shows what can be achieved. But there is a lot left to do and we are not on track. A person dies from AIDS-related causes every minute. In three regions of the world— Eastern Europe and Central Asia, the Middle East and North Africa, and Latin America—new HIV infections are rising.

Three things must happen to get us on track to end AIDS: end the financing crisis, including by dropping the debt and by fully resourcing the response; get long-acting treatment and prevention options to all who need them, including in low- and middle-income countries; and ensure rights for all, including by tackling the stigma and discrimination that drive marginalized people away from healthcare services.

The AIDS response is based on an understanding that HIV is not just a medical issue, but a social challenge driven by inequalities—gender inequalities, income inequality, unequal access to healthcare and health technologies, and unequal protection of human rights.

Last year, global funding for HIV was US$9.5 billion short of the amount needed by 2025 (US$29.3 billion). To what extent is ending AIDS fundamentally a question of having adequate financial resources?

It is absolutely fundamental.

While US$20.8 billion was available for the HIV response in 2022 in low- and middle-income countries through both domestic and international sources, this funding was not enough to sufficiently finance the HIV response. Western and Central Africa, for example, had a funding shortfall of 32% in 2022.

In 2024 alone, Eastern and Southern Africa will need to mobilize almost US$12 billion to fully fund the HIV response. This amount will climb to around US$17 billion by 2030 unless new HIV infections are reduced.

“The only thing more expensive than ending the AIDS pandemic is not ending it!”

To enable increased domestic resource mobilization for countries to respond effectively to their pandemics, sub-Saharan African countries will need to strengthen their tax systems, including closing tax exemptions which currently cost countries an average of 2.6% of GDP in lost revenue across the region.

Donors will need to scale up financial assistance for health and the HIV response between now and 2030, while creditors should offer debt relief to heavily indebted countries to ease the chokehold and allow countries the fiscal space to spend on essential services. Debt servicing now exceeds 50% of government revenues in Angola, Kenya, Malawi, Rwanda, Uganda, and Zambia.

Leaders cannot let a resource crunch derail global progress to end AIDS as a public health threat by 2030. And let me add—the only thing more expensive than ending the AIDS pandemic is not ending it!

Preventing new infections among young women and girls is also critical both to protect the health and wellbeing of young women and girls and to reduce the risk of new infections among children. In 2023, there were 210,000 new infections globally among young women and girls aged 15–24, four times higher than the 2025 goal set at 50,000.

Gender inequalities and human rights violations are increasing women’s vulnerability to HIV and diminishing their ability to access essential services. Globally, nearly one in three women have encountered some form of violence during their lifetime, with adolescent girls and young women disproportionately affected by intimate partner violence. Ending gender-based violence is both a human rights obligation and a public health necessity.

A central focus of amfAR is to fund researchers working on a cure for HIV. If a cure were developed in the near future, what needs to be in place to make sure everyone, everywhere has access to it?

I am in awe of the research that amfAR supports in relation to finding a cure for HIV. Medical scientists and researchers are trailblazers in this field.

While waiting for a cure, we must make sure that all the current treatment and prevention options can benefit people in need of them. What’s required is a paradigm shift away from prioritizing the protection of monopoly corporate profits to protecting global health. Health technologies and the knowledge, expertise, and technology needed to produce them must be considered as global public goods.

In the same way, a cure for HIV would be a triumph for humanity and it needs to belong to all of us.

How can organizations like amfAR do a better job of engaging people—young people especially—in the global HIV response?

The activism of young people has driven so many of the gains realized by the AIDS movement. Young people know what works for them so it is vital that leaders listen to them and learn how challenges faced by young people can be resolved. Leaders can only successfully plan how to end AIDS and sustain the advances made by building effective partnerships with young people.

“A cure for HIV would be a triumph for humanity and it needs to belong to all of us.”

Young people living with HIV play a critical role in the fight against AIDS in their communities. They offer each other support and share important information about HIV that schools or parents might not want to talk about. They also challenge stigma and discrimination through social media, helping to save lives and encourage young people to adhere to treatment.

Young people drive innovation in the HIV response. For example, in Namibia a self-funded project by the Youth Empowerment Group uses e-bikes to deliver antiretroviral medicines, food and adherence support to young people who often cannot attend clinics because their schooling hours conflict with clinic opening times.

I recently invited two young African women HIV activists, Ibanomonde Ngema from South Africa and Jerop Limo from Kenya, to come with me to the United Nations Summit of the Future in New York to talk to leaders about their work. It was so inspiring to be with them! Young activists are not only the leaders of the future, they are the leaders of today. The human rights of young people, and the leadership of young people, must be respected if we are to overcome the AIDS pandemic. We elders need to squeeze in and make space for the young!

You have been Executive Director at UNAIDS since November 2019. How do you reflect on the past five years and the progress you’ve been able to make?

The progress we have made is our collective achievement—communities, governments, and the UN together. The end of AIDS is now within reach—if leaders are bold. The world today is rightly more than ever focused on tackling the inequalities that drive the AIDS pandemic. But we will need to act bravely and unitedly to succeed.

That means empowering young women and girls—keeping them in secondary school, making sure they are equipped to deal with adulthood by granting them access to comprehensive sexuality education, ending gender-based violence. Just one additional year of secondary education can reduce a girl’s risk of HIV infection by more than 50% in some countries. Girls’ completion of secondary education protects them not just from HIV but from child marriage, teenage pregnancy, violence, and discrimination, increases their access to labor markets, their earning potential and independence.

It also means challenging the criminalization and marginalization of gay men, people who use drugs, sex workers, and transgender people. Analysis of data from 10 countries in sub-Saharan Africa found that HIV prevalence among gay men and other men who have sex with men who live in countries that criminalize same-sex relations is five times higher than in non-criminalized settings. To protect everyone’s health, we need to protect everyone’s rights.

So UNAIDS today is pushing for a whole-society approach to reduce people’s vulnerability to HIV— it’s the only way to end the AIDS pandemic. We are hopeful that we will succeed—together.