Heavy Lifting: Advancing the Global HIV Response in Uncertain Times
Dr. Oni Blackstock, Member, Fast-Track Health Board of Advisors
The global HIV response has made extraordinary progress over the past four decades. From reducing HIV-related deaths to expanding access to life-saving treatments, these milestones have been driven by the advocacy and leadership of communities in the Global South, as well as racially minoritized, LGBTQIA+, and other marginalized groups in the U.S. and around the world.
Governments, health ministries, and global programs like the President’s Emergency Plan for AIDS Relief (PEPFAR)) and the Global Fund to fight AIDS, Tuberculosis, and Malaria (Global Fund) have also played vital roles in saving millions of lives, particularly in sub-Saharan Africa, where the majority of people living with HIV reside.
However, this progress is under threat. Backlash against the advancement of marginalized communities, coupled with shifting political priorities in the United States, a major donor nation, endangers the sustainability of the global HIV response. Domestically, anti-trans legislation, attacks on diversity, equity, and inclusion (DEI), and rollbacks on reproductive justice disproportionately harm communities most affected by HIV.
Globally, reliance on external funding mechanisms leaves nations vulnerable to political leadership and ideology swings, jeopardizing the lives of millions who depend on international aid. While protecting programs like PEPFAR is essential, we must also rethink how countries most impacted by HIV can build self-sustaining systems independent of external political influence. To address this challenge, we must strengthen critical connections, balance technical and adaptive solutions, and reimagine the future through visionary frameworks.
Strengthening Critical Connections
Backlash thrives on fragmentation and division, making critical connections essential for advancing equity in the HIV response. These connections involve intentional collaborations that amplify collective power and unite a range of careholders, including grassroots leaders, policymakers, and healthcare providers.
Advocacy groups in the United States and the Global South must collaborate to align strategies, share resources, and amplify their collective voice. Grassroots leaders from the communities most affected – such as Black, Latinx, and LGBTQIA+ groups – possess the lived expertise necessary to shape solutions that reflect local realities. Organizations led by people living with HIV are uniquely positioned to address barriers to care, build trust within communities, and ensure programs meet their intended goals. Strong coalitions allow for unified responses to challenges like funding cuts, stigma, and inequities in healthcare access.
Spaces for collaboration, whether virtual or in person, create opportunities to share lessons, celebrate progress, and collectively envision an equitable HIV response. These networks build the infrastructure to withstand political and social challenges while charting a course forward.
Technical vs. Adaptive Challenges in the HIV Response
Navigating the threats to the HIV response requires understanding the difference between technical and adaptive challenges. Technical challenges involve clear solutions, often implemented through existing expertise and systems. Expanding access to antiretroviral therapy (ART) or distributing pre-exposure prophylaxis (PrEP) are technical solutions that address immediate needs and save lives.
Adaptive challenges, by contrast, require deeper, systemic change. These challenges involve shifting cultural norms, addressing systemic racism, and redistributing power. While PEPFAR funding provides essential resources, an adaptive approach would focus on how nations most impacted by HIV can develop sustainable funding models—such as regional collaborations or public-private partnerships—that reduce dependency on donor nations. Adaptive work often meets resistance because it demands uncomfortable conversations, long-term commitment, and transformation at the root level.
Balancing technical and adaptive strategies is key. Technical solutions address urgent, short-term needs, while adaptive approaches ensure systems are equitable and self-sustaining over time.
Reimagining the Future through Afrofuturism and Speculative Design
Afrofuturism and speculative design offer bold frameworks for rethinking the future of the global HIV response. Afrofuturism, rooted in liberation and creativity, envisions a world where marginalized communities lead the design of equitable systems. It invites us to imagine public health and healthcare free from stigma and inequity, where local leadership and cultural knowledge drive solutions.
Speculative design complements this vision by asking, “What if?” What if nations most impacted by HIV created regional funding collaborations to support their health systems, eliminating dependence on donor countries? What if healthcare systems prioritized cultural safety and integrated traditional healing practices with cutting-edge technologies? These frameworks enable us to prototype solutions addressing systemic inequities while building inclusive and sustainable pathways.
This future requires centering those most affected by HIV. People in the Global South, LGBTQIA+ communities, sex workers, and people who use drugs must be co-creators of these systems. Their lived experiences hold the answers to crafting responses that leave no one behind.
A Call for Bold Action
The HIV response is a fight for equity, dignity, and justice. It is not enough to focus solely on defending past progress. We must also build systems that endure beyond external political influences, ensuring that communities most impacted by HIV are empowered to lead the way.
By strengthening critical connections, balancing technical and adaptive approaches, and embracing visionary frameworks like Afrofuturism and speculative design, we can turn this moment of uncertainty into one of transformation. Together, we can create a future where the end of the global HIV epidemic is no longer an aspirational goal but a reality.
Oni Blackstock, MD, MHS, is the founder and Executive Director of Health Justice, a social consultancy focused on racial and health equity. She previously served as Assistant Commissioner of the New York City Department of Mental Health and Hygiene, where she managed the city’s response to the HIV epidemic.