It’s tough at the top

2. OPINION
31 Aug 2022
Global AIDS Leadership - not an enviable position to be in

The global response to the HIV and AIDS pandemic may be facing a leadership crisis. There have been modifications that may reflect and lead to new directions. This article looks at leadership roles in three key organizations: the Global Fund to Fight AIDS, Tuberculosis and Malaria, the US President’s Emergency Fund for AIDS Relief (PEPFAR) and the Joint UN Programme on HIV/AIDS (UNAIDS). It should be noted that COVID-19 meant that the global AIDS conference in Montreal, AIDS 2022, held between 29 July and 2 August, was the first opportunity for many, including the author, to see these leaders in person.

Peter Sands, a former British banker, was appointed as Executive Director of the Global Fund in early 2018 but barely had time to make his mark before the pandemic led to lockdown and much less exposure than the Global Fund executive director would usually have. He was born in 1962 and had a varied career, most notably as the chief executive (CEO) of the Standard Chartered Bank from November 2006 to June 2015. He does not have a medical or health background.

Ugandan Winnie Byanyima, born in 1959, was appointed as the Executive Director of UNAIDS and an Under-Secretary-General of the United Nations in November 2019. This was following a leadership crisis in the organization that had arisen because of reported cases concerning cronyism and sexual harassment. She holds a B.Sc. and M.Sc. in engineering from British universities and held a range of government and international positions. In 2013 she was appointed as the Executive Director of Oxfam International. In 2019 she was selected for the top job in UNAIDS. She was the only women among the five candidates. The Lancet quoted an African medical doctor as saying, “certainly a strong candidate who is a woman from the Global South would be, for many member states, a priority, although in the end, they will look for political qualities as well”. She does not have a medical or health background.

Dr John Nkengasong was appointed to head PEPFAR and took up the post in June 2022 at the age of 58. Born in Cameroon, Dr. Nkengasong is the first person of African origin to hold this position. Prior to this he was the director of the African Centre for Disease Control based in Addis Ababa. Nkengasong is a virologist with a B.Sc. from the University of Yaoundé, an M.Sc. from the Institute of Tropical Medicine in Antwerp, and a Ph.D. from the Faculty of Medicine, University of Brussels. PEPFAR is the largest commitment by any nation to a single disease and this includes support to the Global Fund.

So, what are we to make of this leadership on show at a major international event for the first time in two years? The Montreal AIDS Conference gave the AIDS community an opportunity to observe all three in face-to-face action for the first time since the COVID-19 pandemic hit. None of the new incumbents have medical degrees: one is a banker, the second an activist and politician, and the third a scientist.

After four years or so, Sands is well-versed with regard to the mandate and possibilities for the Global Fund and is a realist. He was careful to connect with people at the conference and was particularly impressive in informal meetings where he fielded numerous questions. His next challenge is the Seventh Replenishment Conference scheduled to be held in New York in September 2022. Sands called for at least $18 billion to be pledged, “This is the minimum required to get the world back on track toward ending HIV, TB and malaria, to build resilient and sustainable systems for health and strengthen pandemic preparedness, making the world more equitable and safer from future threats.”

The Fund notes that $130.2 billion is needed from 2024 to 2026. Of this $25.2 billion will come from donors other than the Fund, and $58.6 from domestic resources. With the Fund’s contribution the gap is still $28.4 billion.

Byanyima comes across as an activist without much nuance. Of course, of the three she has the fewest resources at her command. It is believed she is getting the right advice and has appointed technically skilled people. At the moment the signs are not good, much of what she said is still boiler plate activism. However, it was disappointing not to see UNAIDS formally attending the the International AIDS Economic Network (IAEN) meeting, as had been promised, that took place before the actual conference itself. 

Nkengasong has impressive credentials, and his early months will be interesting and important. He has a supportive president in Joe Biden. Political will is crucial to PEPFAR's continued success. Given some of the current trends in politics in the US this is by no means certain and we await the next election with concern.

There is the need for realism. It does not matter how often we call for more resources and how much we make the case that this is the ‘right’ thing to do, the world has changed and become more introverted and selfish. Economic tools such as cost effectiveness and cost benefit analysis need to be deployed to ensure we get the best value for money. Of course, it must be acknowledged that global priorities are wrong. For example, the US presidential request for defense for the financial year 2023 was $773 billion, the largest percentage share of the federal budget. This is nearly six times the amount needed for HIV.  Byanyima is right when she said we do need drastic, indeed revolutionary, change.


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