What's the state of PEPFAR now?

An interview with PEPFAR's former chief science officer.

It’s been a year since the Trump administration dismantled USAID and severely disrupted the operations of PEPFAR, the global health program that prevented millions from dying of HIV and AIDS.

Dr. mike Reid served as PEPFAR’s Chief Science Officer from 2023 until this April. He’s seen all these changes and more play out from the inside. Clara and mike discuss:

• The current state of PEPFAR

• Why the biggest impacts of last year’s cuts are probably yet to come

• How (and how not) to transfer responsibility to partner governments

• What to expect from new AIDS drugs (and AI)

• The problems with the USAID, and what we should build instead

This interview has been edited for length and clarity.

Clara Collier: I’m very excited to be talking to mike Reid. mike, you were the chief science officer of PEPFAR — the President’s Emergency Plan for AIDS Relief — until you left in April. So to start out, I want to establish: What does the chief science officer do? What was your job?

mike: My charge was to be the champion advancing scientific innovation within PEPFAR’s programs. So as new tools — whether those are therapeutic or diagnostic tools — came down the pipe, I would be the one responsible for consideration as to where they might fit in our portfolio.

In addition, historically, PEPFAR has funded a lot of research and science. As we’ve scaled programs, it’s been clear that there has been a lot of evidence gaps. So along the way, part of that role has involved commissioning and then translating science into programs. And then the third piece has always historically sought to be accountable to the broader scientific community. So I facilitated our engagement with our advisory board and the wider research community that is interested in or invests in HIV research in global settings.

Clara: This must have been such a strange year for you. On the one hand — and we’re going to talk about all of this in more detail — everything is getting ripped apart. And on the other hand, there’s are so many exciting medical advances, like lenacapavir — a new, highly effective antiretroviral therapy that lasts for six months. What was that like?

mike: I don’t want to overstate my own contribution here. Like many big organizations, there’s a whole team. We have experts in the particular technical domain, we have experts in engaging the pharmaceutical companies, and we have folks who are thinking about this from a country point of view.

That said, it’s hugely exciting. We’ve been tracking lenacapavir over the last three years through Phase III trials, and when those first results came out in November of 2024, particularly the PURPOSE 1 trial that showed 100% efficacy in adolescent girls and young women in sub-Saharan Africa, people were just so excited for the potential of this drug.

A lot of the work also involved engaging pharma and other stakeholders to think about how could we make it more affordable. What kind of volumes should the U.S. government be procuring that would shape the market so that generics would be able to enter at a competitive price? Those are all the things that people were thinking about, regardless of the change of administration. Obviously, that had a massive impact on how we were thinking about lenacapavir. And at the time of transition, it really wasn’t clear that the incoming administration had any appetite for lenacapavir. In fact, as you may know, they actually said “we want to put a pause on all prevention programming.” It took a fair amount of politicking and advocacy to persuade them that actually we needed to invest in prevention.

Clara: I know historically, PEPFAR has done a lot of market shaping for antiretroviral therapy and for other drugs. How has that been affected by what’s happened over the past year? What is PEPFAR doing for lenacapavir and some of these other new therapies now?

mike: There’s two questions there. In the very near term, I don’t think PEPFAR investment in market-shaping activities has changed from one administration to the next. With lenacapavir, there was a strategic pause, but then I think the incoming administration recognized that it also wanted to invest in len and saw the value of that. I think they were looking for a better deal for len than the Biden administration got from Gilead.

But from a 30,000-foot perspective, I don’t know that there has been a substantial shift in terms of the overall vision for using U.S. investments to drive down prices so that they’re affordable. One thing that the U.S. is moving towards is procuring all of its commodities through the Global Fund platform, through Wambo, rather than separately through Chemonics. That will allow procurement at even greater scale, and arguably help drive down prices even more. It may also increase inefficiencies, though, because Wambo is not nearly as efficient as Chemonics was. So that’s just one element of how these things are going to play out.

Clara: If the system is less efficient than Chemonics, why is there the expectation that switching would be an improvement? I’m trying to understand this.

mike: Chemonics is a private company. They take a big indirect. From a financial point of view, they offer a more expensive model of commodity procurement and distribution. But they also address many of the elements of the supply chain infrastructure that Wambo doesn’t. They facilitate addressing regulatory hurdles in country, they help support countries to actually forecast and then distribute drugs. Wambo is just a mechanism that procures drugs at scale. And so if the U.S. government decides that Wambo is its destination for commodity procurement, then they will also have to figure out: How do those drugs get distributed? How do you address the regulatory hurdles of introducing new tools?

That will probably require a thousand different solutions in a thousand different countries. And unless you’re going to use a single partner like Chemonics — which is not the desired trajectory — that’s how I think there may be inefficiencies, even though we’re moving away from a more expensive model.

Source

PEPFAR today

Clara: This relates to another big thing I wanted to talk about. When I was preparing for this interview, I asked people who work in global health nonprofit what they were most curious about. The number one thing everybody wants to understand is: What is the current state of PEPFAR? What systems still exist? What stopped? What data sets are we still collecting?

We had this whole system for providing treatment and providing care and distributing these medications. What does this look like on the ground now? And I know this is a huge question, but is there a 1,000-foot overview of what is currently going on?

mike: Yes. There are still functions. It is beholden to the same legislative mandate that it was two years ago. Nonetheless, this administration has sought to do a couple of things that have had profound programmatic implications.

The first is that it has made a really rapid transition towards country ownership. That’s a good thing. Everybody in the PEPFAR space — almost everybody — is excited about the possibility that in the long term, HIV programs are funded, run, overseen by partner governments rather than the U.S. And in service of that trajectory, the U.S. has signed memoranda of understanding with many — not all, but many — partner governments, with an expectation that over the next five years, those partner governments will invest more in their own healthcare systems. They will hire more of their own healthcare workers rather than rely on the U.S., and they’ll increasingly procure more, and eventually the entirety, of all the commodities needed to fund their HIV response.

At the same time, the current administration has made an explicit strategic priority to reduce inefficiencies and waste, and move away from some activities that they felt to be ideologically out of sync with the America First approach. So some of those policy decisions included dismantling USAID, which was perceived to be a fairly inefficient agency. The health programs that were relevant to PEPFAR that were run by USAID have been folded into PEPFAR.

But many of the peripheral activities that were not central to PEPFAR’s mandate, but were done by USAID, ceased to exist. A lot of the work around economic empowerment and providing an enabling environment for populations at greatest risk of HIV — those have all gone away. In addition, we’ve moved away from supporting specific programs that this administration has deemed to be out of sync with their ideological priorities. So that includes some of the equity-informed programming that ensured that prevention services were made available to transgender women, MSM, commercial sex workers. To your point about data: Out of a conviction that a lot of the data that PEPFAR was collecting was expensive and generated inefficiencies, this administration has decided to cull substantial amounts of our data reporting infrastructure.

Clara: I know this must be different in every country, but let’s say I’m an HIV positive person living in, say, Zambia. How is my access to care materially different because of these changes?

mike: It’s a good question. I think the answer is, it depends. If you’re a gay man, or you’re an adolescent girl who lives in rural Zambia, the differences may be profound. You may no longer be able to access services at a touchpoint where you feel safe, or where you don’t have to wait for hours and hours and hours.

If you’re somebody who is accessing care at a big central clinic in Lusaka, where there is substantial domestic government response, you may not notice the difference right now. I think the other area where we may not see the impact until it evolves over time relates to supply chains. If countries aren’t able to procure commodities at the same volumes that the U.S. government did, then over time there may be stockouts. People may go without treatment. And that’s where I think the rubber will hit the road, so to speak, for individuals.

Clara: If you had to put numbers on this — which, again, I realize it’s complicated — do you have a rough idea of what percentage of people who PEPFAR was previously serving are now going to be experiencing significantly increased barriers to accessing care?

mike: Again, it depends. If you’re thinking about people who have HIV who are receiving regular treatment, the impact of the recent changes may be fairly marginal. Available data that has been published by PEPFAR suggests that the number of people on treatment now, compared to the number on treatment before the Trump administration came into power, is about 3%.

But when you look at other elements of the programming activities, like prevention programming or testing programming, that percentage is substantially lower. I think there’s been a 17% decline on testing. And then when you stratify that testing capability by urban versus rural, then you start to see really big increases.

I think the key message here is that some of those differences may not become evident until time has gone on. What we’re seeing now may be a more favorable programmatic footprint than we see in a year or two’s time, based off of how partner governments invest. The amount of money on the table right now means that in five years’ time, there probably isn’t going to be sufficient money to cover their whole epidemic.

Clara: Right. So if the ultimate goal of PEPFAR is containing the epidemic — or at least making sure that everybody who has HIV has access to treatment — the gaps now compound, because if there’s no data, you don’t know who you need to test. People who aren’t getting tested aren’t getting treatment. Populations that are disproportionately likely to have HIV don’t have access to treatment at all. And it compounds and compounds and compounds over time.

mike: That’s right. That’s exactly right. The current administration — they’ve pivoted away from saying that PEPFAR should be responsible for epidemic outcomes. Those are the responsibility of partner governments, and moving forward, our responsibility is to transition our programmatic infrastructure to partner governments. That tautologically shifts the responsibility and perhaps how they frame the issues at hand.

And again, some of that’s not a bad argument, right? I mean, I think countries should be responsible for their HIV epidemic rather than relying on PEPFAR. But I think there is concern that we’re so close to ending the epidemic in so many countries, and yet we’ve taken some steps that actually will make it harder for us to achieve that final goal than it needed to have been.

Shifting responsibility for the HIV epidemic

Clara: I have a bunch of questions about the MOUs — the agreements with partner governments. They all boil down to: How realistic is this? What support are we providing? What are we asking countries to do? And are the things that we’re asking things that these partner governments actually can deliver?

mike: I think it depends a little bit on the country, and on areas that are specific to those countries. But zooming out, I think a challenge is that many governments we supported are overwhelmed with substantial amounts of sovereign debt, right?

Zambia is a great example, where I think 85% of the HIV response is paid for with donor resources currently. And Zambia spends 50% of its own revenue, its own domestic revenue, paying off interest on other debt. So the expectation that they would be able to somehow mobilize additional resources is an optimistic one, particularly when mobilizing domestic resources takes a ton of political energy. Mobilizing domestic resources means taxing people, and that is something that you often have to do under an electoral mandate.

When you’re the finance minister or the chancellor of the Treasury, or whatever they call you, health is almost always at the bottom of your list of priorities. Business, industry, education all rank higher in your list of priorities than health does. As a consequence, it may be really challenging for many partner governments to be able to meet their obligations.

Nonetheless — and I think this trajectory is worth pursuing — if PEPFAR can encourage countries to invest more in their healthcare systems, if we can crowd in more resources from other places, if you can make the pie bigger, so to speak, then those are all good things. And it’s clearly not tenable, both for the U.S. citizenry but also for global health writ large, to continue to have a massive donor like PEPFAR who props up the HIV response in perpetuity. HIV is a chronic disease.

The challenge really needs to be: How do we support partner governments wherever they can to be able to fund their own health systems? And I think that’s a vision that people on both sides of the political aisle will align around.

More than a buzzword

Clara: What would doing this well look like? If we want Zambia to be able to fully fund and stand up their own HIV response, how could we actually make that happen?

mike: It’s such a great question. I think I have like two or three answers. One is, we still need to focus on equity. I think the ideological decision to move away from equity as a framing concept within public health, which this administration has decided to do, is just bonkers. It doesn’t make any sense. Handing programs over responsibly needs to mean empowering partner governments to embrace an equity-informed public health response.

Clara: Step back and explain why this is so important for the health response. Why is equity is not just a nice-to-have?

mike: Yeah. Well, certainly for HIV, but for many other diseases as well, it’s a disease that affects people at the margins, right? It affects gay men. It affects transgender women. It affects commercial sex workers. It affects poor young women who have to engage in transactional sex to put food on the table.

And those are all the constituencies that are not well served by a public health system that really primarily exists to serve the needs of people who are going to vote in elections, or who constitute the majority of the healthcare system. But from an epidemic point of view, if we agree that those groups are the ones where HIV is likely to be transmitted without optimal control, then that’s the place where we should be putting our resources.

Clara: Do you think there’s a tension here? As you say, the goal of transitioning to partner governments is a good one. And part of this is that it’s good for countries that are accountable to their own voters and their own domestic populations to own that response. But also, if, candidly, a lot of people in Zambia are not in favor of gay rights, how should a country like the U.S. balance wanting to give their government more control over how these programs are administered, and the fact that there are maybe quite deeply and sincerely held ideological beliefs that these governments might have that will just make it harder to do the job effectively?

mike: Yeah. I think this is a challenge at the core of a lot of global health programming. And in particular, I think there is a political answer and an epistemological answer. From a political point of view, one of the roles that donors can play is in supporting local advocacy groups that can change the law, who can be a noisy voice for change.

Botswana is a great example here — the U.S. government funded local NGOs in Botswana for several years to address the fact that MSM were criminalized there. And eventually the law was changed, which meant that men who have sex with men were not criminalized, and then were able to access care in stigma-free environments without threat of penalty. And that substantially changed how we were able to control the epidemic in Botswana.

Now, I get it — there are different views of morality, right? And so my other framing here is an epistemological one, which is: I think there has to be room for more than one way of understanding the world. I do worry that a lot of liberal discourse right now is really illiberal. It’s not tolerant of differences of opinion. And here I would just say, I think it’s OK to have a public health response that champions the rights of conservative Christian constituents within a country at the same time as prioritizing care for the most vulnerable communities, including MSM, who may not be beholden to the same moral paradigms as that Christian majority. And I think understanding the epidemic and the public health rationale for that — if we don’t control HIV for everybody, it’s a threat for everybody — is the way to do that.

Clara: I could imagine — actually, I don’t have to imagine — a conservative Christian in the U.S. saying, “Why are we funding gay rights advocacy in Botswana? I don’t even support that here.” How do you manage those tensions on the domestic side? Because that’s also really important right now, if we want programs like PEPFAR to continue to exist.

mike: I think it comes back to articulating that good evidence-based practice is equity-informed. That if we want to control the epidemic — which is in the interests of your Bible study group in Michigan, right? — it’s in their interest to prevent the spread of drug-resistant HIV back to the U.S., to control it in partner governments before it comes back here.

But then when people understand what equity really looks like — caring, providing care for those on the margins, those that are underserved — that actually does align with the views of many Christians. There is a sort of dogmatism that gets in the way of understanding that. And that’s why people like me exist, to try and articulate that there is some nuance here, and that it’s in the interests of everybody. We live in an incredibly interconnected world. Whether we like it or not, we are responsible for each other. So that should be a motivation for folks back in the U.S. to understand why this makes sense.

Smoothing the transition

Clara: Let’s dial in on some of the more logistical elements. If we were to handle this transition perfectly, giving the countries the resources and the structure to do this well, what would be required?

Mike: It’s not just about equity. It’s about, first of all, helping them to mobilize domestic resources, right? And one thing that PEPFAR isn’t doing — because we’re moving at the speed of light —is really supporting countries to scale up their financial health systems.

USAID used to have a whole department that was focused on supporting public financial management systems in partner countries, helping partner governments to use their own domestic resources as efficiently as possible. Without USAID, we’re not doing that right now. So the financial piece is key.

And then from a programmatic point of view, to land the plane, so to speak — to support countries to assume responsibility for high-quality programs really does require support for effectively integrating those programs into their healthcare systems. PEPFAR was set up as an emergency initiative at a point 23 years ago where there were no healthcare systems, and the most expedient way to deliver HIV programs in sub-Saharan Africa was to establish vertical programs that solely existed to provide HIV services. So in many, many places across sub-Saharan Africa, you have HIV clinics that are completely separate physically, logistically, from a health information point of view, from the rest of the healthcare system. If we want to land the plane, then we also have to figure out how to support partner governments to integrate those systems effectively.

But you can’t integrate something into nothing. There are still some parts of some countries where there is no viable healthcare system to integrate into. In those cases, part of the transition needs to involve helping them stand up their own primary care infrastructure. I don’t know that this administration has the appetite for that kind of wholesale investment in broader health systems. Their response will be: “We’ve spent the last 20 years investing in health systems, and at some point we expect countries to assume that responsibility.”

Finally, as I alluded to before, we need to think about the supply chain and the commodity procurement piece of it. And here I think there is an opportunity for a much bigger vision for what this could look like. One of the things that PEPFAR and the Global Fund both do really well is procuring drugs at scale and at affordable prices. It’s conceivable that, if there was an appetite for it, you could actually procure far more drugs — GLP-1 agonists, chemotherapeutic agents, etc. We could help countries think through what procurement could look like — particularly what a broader procurement pooling system might look like, if you were able to procure drugs at scale in partnership with other countries in the region.

Clara: In your writing about your more recent experience with PEPFAR, and your ultimate decision to leave, you’ve talked about how transitioning to country ownership has been a major goal of PEPFAR for years, but it was hard to get real movement until this administration. I’m curious. Why was it so hard to move this ball before, if it’s broadly agreed that the transition needed to happen?

mike: I think at every step along the value chain of HIV-related activities, there were and there remain vested interests in the status quo. A lot of people have talked cynically about AIDS Inc., which is the industrial complex that built up around PEPFAR, whose needs were served by being in that ecosystem. And for all of those stakeholders, there was value in maintaining the status quo. USAID and CDC both had management and operations overheads that come from running programs.

The huge fiscal footprint in Atlanta that exists only because of funding that goes to CDC programs through Atlanta. None of those entities really want to rock the boat. They were invested in the status quo. And so whilst what has happened over the last 18 months has been profoundly disruptive and has caused us a ton of institutional and personal trauma — which I do not want to diminish — it has caused sufficient rupture that many of those stakeholders or those institutions no longer have the standing, or can advocate for the status quo in the way that they did. Does that make sense?

Clara: Yeah, it does. I don’t think I’m saying anything new to you, but one point I do want to draw out is that I’ve seen a lot of responses, especially to coverage of unemployed former global health workers, that assumes that this is malicious, that these people were deliberately siphoning off money. And I’m sure you’d agree that these are all people who sincerely care about the goal of controlling the AIDS epidemic.

Mike: Yeah, I think that’s total bullshit. I think the amount of cynical, corrupt, selfish behavior is negligible within the PEPFAR space and in the global health ecosystem more generally. I don’t think that is an accurate reflection of what’s going on writ large.

The criticisms particularly placed at USAID — that individuals there were fraudulent or corrupt — I think is completely nonsense. But people are invested in what they do. They care about it, right? People at USAID, they loved what they did. And they did it because they thought it was really important. And it was. But nonetheless, it kind of held us in this state of inertia where it was harder to hand programs over to partner governments than it should have been. Does that make sense?

Clara: That all makes sense. So next question then: Ultimately, why did you leave when you left?

Mike: I left for a few reasons. My Substack post outlines some of them. Some of them I’ve indirectly addressed already.

I think it was increasingly challenging for me to live with the moral and scientific dissonance of the moment, right? I don’t think you can practice effective public health unless you put equity at the center of what you do. It’s not just a political woke term. It’s actually the most sound evidence base that we have. But then the other thing was, I was increasingly concerned that we were predicating our ongoing investment in life-saving activities on some specific financial or commercial interests. When you subordinate life-saving interventions and care for underserved populations to commercial interests, then that really changes the calculus. I just found it a bit unsavory and decided that I didn’t want to be part of it anymore.

How to rebuild

Clara: The state of global health right now is what it is, the state of U.S. involvement is what it is. But let’s say we get a more sympathetic Congress, a more sympathetic administration in 2028 — what would your first asks be for how we should rebuild?

Mike: These are questions I’m starting to think about. And to be clear, I don’t think we can go back. I don’t even think we should be thinking about restoring USAID back into existence.

I think three years from now, we may face some other challenges. For example: How do we responsibly enable countries to own these programs, and can we support them more responsibly to mobilize their own domestic resources? I think those are going to be clearer responsibilities that the U.S. government can play.

Zooming out, a lot of changes that we’re seeing in global health right now predate this Trump administration. There was waning political interest in PEPFAR before Trump came back into power. Biden only reauthorized it for a single year, really struggled to get Congress to add any funding to PEPFAR. So my point there is that this isn’t a Trump issue. This reflects broader fatigue within the donor community in high-income countries for global health programming.

When you look at all high-income countries, the vast majority of them have reduced their investment in donor programs. I think only Luxembourg and Norway have met this arbitrary target of 0.7% of their GDP going to overseas development assistance. The U.S., I think, comes in at 0.2% of GDP — a marginal amount. This is a phenomenon writ large. And it demands that we think more broadly about how we mobilize resources to support the poorest countries to improve their health. There needs to be a discussion around what’s the role of development investment, the development banks, sovereign wealth funds, crowding in private sector into LMIC healthcare systems.

The other thing I’m thinking about are programs that enable better agency for individuals and communities. I think AI, for example, potentially affords the opportunity for many in low- and middle-income countries to access high-quality consultative services much more affordably than ever before.

Finally, there’s the impact of climate on health. We have all of these unfinished disease problems: HIV, TB, malaria. But for me, the biggest threat on the horizon is just everything is going to get worse as climate worsens, as weather shocks increase, as parts of the world become increasingly inhospitable, and the healthcare or the public health sequelae of those are only going to worsen. A key imperative for the U.S. is to think about how we might put climate and health at the center of our global health agenda moving forward.

Clara: And what does this look like institutionally on the U.S. side? Like, if we’re not bringing back USAID, what kind of institution in government do we want to think about these issues?

Mike: A lot of technical expertise, particularly for outbreak management and supporting countries to stand up their own public health systems, still exists within CDC. I think it would be foolish to do away with CDC. But I think the development assistance arm of the U.S. government, at least in the near term, will probably sit within the State Department, within the Bureau of Global Health Security and Diplomacy, where it sits now, which is where PEPFAR is housed.

I think entities like the DFC will likely have a bigger role, if we all agree that development investment is going to be more crucial moving forward.

Clara: What is the state of DFC right now? Do you know?

Mike: I think they just recently got a commitment from more money from Congress. And I think there is willingness within this administration to lean into the possibility that they afford in terms of development financial investment writ large. I don’t know what that looks like from a specific point of view. But I could imagine in five, 10 years’ time, they have a much bigger role in advancing U.S. interests in global health.

Clara: So are you imagining someone in State who is coordinating across CDC, DFC, and these other entities, trying to figure out what the overall plan should be?

Mike: Kind of like what happens now. Yeah.

Clara: Okay. And are there any programs you think that, at least for the foreseeable future, either the U.S. government or an international body should own? Even as we move towards transitioning to partner governments, there’s anything that we should retain the capacity for?

Mike: One area that comes to mind is neglected tropical diseases. The five most common neglected tropical diseases are intestinal worms, schistosomiasis, lymphatic filariasis, trachoma, and river blindness. And the largest funder of all of those programs historically was USAID. And what USAID would do is invest about $100 million every year to crowd in pharma investment, and then pharma would commit about $1 billion of their own drugs, predicated on us investing 100 million. Probably the best value of any USAID program. And it’s gone away.

There’s many other areas, though, that are similar. All of the family planning and maternal and child health programs that USAID used to provide support that saved hundreds of thousands of lives a year by averting or preventing pregnancies in vulnerable women who died during childbirth — that’s all gone away. Those are things where I think we actually do want to think about restoring when there is a change of administration, because the both moral and public health value of those programs is huge. And they’ve been cut entirely by this administration.

What about philanthropy?

Clara: This relates to another question. People who are in the global health philanthropy space — what do you think the most valuable things they can be doing right now are?

Mike: Paying more taxes.

I’m totally serious. This is me on a bit of a political rant, but I think there is a lot of health-washing right now from particularly Bay Area philanthropy. If they just paid more taxes, and the money was used more responsibly, and it could be deployed through mechanisms that were accountable, then they could have a much bigger impact.

I’m fairly cynical about the role of philanthropy writ large. I will say that I think the Gates Foundation stands out as an institution that has done an amazing amount of good. And where they have particular value-add is taking those new tools and getting them from the clinical laboratory to the field, and really advancing how we think about the application of new tools. If Gates is an example to go by, then yeah, I think that’s a space where they can play a role.

Look, I think it depends on what philanthropy we’re talking about. There seems like there’s a lot more AI-related philanthropy coming down the pike. I think there’s a really important role that somebody needs to play in making the case that AI should be seen as public infrastructure, a global public good — not something that is given at the service of big tech, but is seen as something like general utilities that advance a country’s economic development. And I don’t know who’s going to champion that, unless it’s philanthropy right now. But I don’t think that AI philanthropy is interested in taking up that cause.

Clara: Part of me wants to say: Wait, if I’m a billionaire and the thing that I care about is global health, is paying more taxes right now really the best way to champion that? We’ve just talked about all the programs that have been cut by this administration, which no one is picking up.

Mike: I think if we got all of our billionaires to pay more taxes, then that would be tremendously good for the health of Americans. We could actually make America healthy again if we invested massively into American healthcare systems. But there’s so much money out there that billionaires are not paying.

Elon Musk, on his own, if he paid his taxes, could end world hunger. It wouldn’t take a huge amount of money. It’s a few billion dollars a year for the next 10 years. But he’s not going to do that unless somebody taxes him. If your argument is, could we get those people to invest their wealth into philanthropic initiatives — sure. But when we look at the vast majority of super-rich people, they’re not doing that unless it helps them to avoid paying taxes, right?

Clara: I’m trying to be very literal here. I have spoken to a lot of people who manage large philanthropies, who are trying to figure out what they should do for global health, given these massive program disruptions.

Mike: Okay. Look, I can give you a list of things where that money would be well used, right? But inevitably, they’re country-specific. Oftentimes they’re not very sexy. They don’t lead to a legacy.

I’ll be honest with you: 12 months ago, we had a bunch of high-net-worth individuals come to PEPFAR and say, how can we support your efforts? But none of them committed their resources — at least not to my knowledge — in a way that was meaningful. Because the kinds of things that are really necessary aren’t sexy things.

It’s really the unglamorous stuff of testing people in rural Kenya for HIV, linking people who have HIV to services on the islands of Lake Victoria. I guess I’m being a bit cynical here. I think there are some new tools that potentially could be transformative. But my instinct is that, with the exception of the Gates Foundation, philanthropy has not delivered at the scale it should do, given the amount of money that’s out there.

Beyond lenacapavir

Clara: Let’s talk about new technologies, then. We’ve talked about lenacapavir, we’ve talked about AI for a bit. What are you most excited about right now?

mike: Within the HIV space, I think lenacapavir is pretty cool, right? An injection every six months. Amazing efficacy in phase three trials. But it does require an injection. You do have to go to the clinic. Ironically, our prevention programming had moved away from being clinic-focused and towards getting out into the communities. And now with len, we’re trying to pull people back into the clinic.

Well, there’s a new drug from Merck — MK-8527. It’s a novel drug class. It’s a tiny pill that is taken once a month, and it protects against HIV for 30 days. It works within 60 minutes. So conceivably, this could disrupt the prevention landscape again, but in a really exciting way. And a couple of things to say: Because it works in 60 minutes, you could conceivably use it on demand. If you’re a gay man, or you’re a commercial sex worker, you just take it 60 minutes before you have sex, and you’re protected. Because it’s a small pill, it’s really affordable. So the rumors are that it will cost pennies on the dollar to make at scale — far cheaper than lenacapavir. I’m super excited about that.

In terms of AI, look, I think there are innumerable applications of AI that will have tons of exciting impacts. The things that I’m looking at really closely are, as I mentioned before, self-care. How can we use AI and agentic tools to deliver care to individuals so they don’t need to come to clinic? Or maybe they only need to come to clinic once every 24 months. It offloads clinics, it protects staff, and it gives agency back to individuals.

Clara: I’ve read about this in parts of China, like in rural Yunnan, there’s been an effort to implement AI diagnostic tools, because you’re not going to get to a doctor. The doctor is four mountains away from here.

mike: Yeah, yeah. And even in parts of Africa now, these kinds of things are being piloted. I think the trouble is, there are many challenges. One is that none of these tools are being validated. They’re often in pilot stages of use. And the governance or regulatory oversight for them is highly variable. If we really think that these tools need to be taken to scale, then they need to be regulated appropriately. And then we need to think of software as a medical device, not as a kind of a nice-to-have with —

Clara: That regulation — who’s doing the regulation? Is it the countries where the companies are based? Is it the countries where they’re being used? What does that process look like?

mike: Well, it should be the countries where they’re being used. Sometimes — I mean, certainly with diagnostics and drugs, many countries in Africa rely on the FDA or the EUA for the regulatory oversight. That doesn’t exist for AI tools. A key imperative is to support governments in LMICs to stand up that regulatory infrastructure, to be able to use regulatory sandboxes to pilot and evaluate these tools in real time. None of which is happening right now.

Clara: And let’s say I’m a developer who just wants to make this product and make it usable. What are the steps I can take to get it closer to being in the clinic? Or out of the clinic, as the case may be.

Mike: Well, I think the first thing as a developer is to actually have a solution to a problem that needs solving. And here, I think often the issue is that people from the Bay Area have tons of really great problems that they want to solve, but they’re not the problems that people in LMICs need help solving.

Think about co-creating your innovative new tools in partnership with communities, and then working with local regulatory infrastructure to ensure that you’re beholden to their requirements, which can be challenging.

I think the other thing I’d say is — and I’ll back up here and first make the comment that the vast majority of new innovation never gets out of the pilot stage. Part of the reason it doesn’t get out of the pilot stage is because they’re not solving a meaningful public health problem. But part is because they don’t have a viable business model — whether that business model is predicated on domestic government investment or private sector investment, and so on. So I think developing a new tool, you have to think about how is it going to be sustainable. And those are questions, I think, that often aren’t being answered, or if they are being answered, they’re being answered through a high-income country lens, where maybe the incentives or the investment or the profit opportunities are very different from LMICs.

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