This is the third in a series of interviews with the Senior Disease Coordinators at the Global Fund to Fight AIDS, Tuberculosis and Malaria. In this Q&A, Friends spoke with Dr. Ade Fakoya, the Senior Disease Coordinator specializing in HIV/AIDS, about the opportunities to fight AIDS covered in our report, “At the Tipping Point: U.S. Leadership to End AIDS, Tuberculosis and Malaria”.

Thank you for being with us today Dr. Fakoya. Can you reflect on the areas where you think the Global Fund has been doing particularly well, and what specific factors you find that either contribute to these successes or could be improved to strengthen the Global Fund’s programs overall?

In general, we have done really well with treatment and prevention of mother to child transmission. However, we have more work to do when it comes to prevention among highly vulnerable populations and young people, particularly adolescent girls and young women in countries of east and southern Africa. Here new infections can be as much as 10 times higher among young women than among their male peers. We and others have already done a lot to address this but there is still much more to be done. It is crucial that we tailor responses to take into account factors such as age, gender and geographic locations, program to program, if we are going to successfully meet these needs.

We also need to work on improving program quality and implementation, most notably by rapidly implementing innovative models of service delivery and improving program management cost. This requires a better understanding of what it costs to deliver programs, as opposed to how much we pay for them currently. I mention that because we are currently involved in work with PEPFAR, the Gates Foundation, UNAIDS and others to align our investment categories to look at the best ways we can truly maximize our contributions.

Countries that we see doing the best in these areas tend to have strong civil societies, an engaged political commitment, strong health systems and domestic financing. Countries that may be falling behind are weak in these areas and tend to struggle with the organization and clarity of their data. All of this can make it challenging to maintain political commitment and ensure national quality programs.

How severe a threat do you consider the changing demographics in Sub-Saharan Africa where there has been a dramatic growth in the proportion of young people and what is the Global Fund’s response?

First, let us acknowledge that the growth in populations is due to a number of things and is overall a positive thing. Improvements in maternal and child mortality, and domestic and overseas contributions in development, all contribute. At the Global Fund we are focusing on the many aspects of the population growth (the so-called demographic bulge), particularly through our work on youth, human-centered program design and programmatic prioritization of young women and girls. They are a key component of the growing populations in southern Africa.

It is estimated that in 20 years, we will have three times the number of people under 35 years-old in Sub-Saharan Africa so we are going to have to work three times as hard to sustain the same progress. To address this challenge, we must differentiate our response. That is a fancy way of saying we do what is needed where it is needed, and don’t adopt a one-size-fits-all way to do things because it’s inefficient and you don’t achieve maximum impact.

Moving forward, we will need to rely more heavily on young people. This means continuing to involve them fully in all aspects of the response and giving them the power and responsibility for their own health outcomes.

The WHO and other partners have been pushing to expand stronger health systems as a means to better treat specific diseases. What do you think about the growing discussions comparing disease-focused programs and system-oriented interventions?

I think that the Global Fund is very much at the center of that push and recognizes the false dichotomy of systems versus direct disease approaches. You cannot have good disease specific health outcomes without strong health systems, period. My understanding is that the HIV community recognizes the need to address broader health systems and is generally embracing the push for more comprehensive health care approaches as an opportunity and not a threat. The recent Lancet Commission article on HIV and global health articulates this very well.

On the other hand, some HIV health professionals do worry that targeting an issue as broad and complex as bolstering health systems will take the focus away from the specific problem of AIDS, weakening our impact in this area. Health systems often struggle with the ability to care for vulnerable populations, so we need to retain a tailored response within the context of generalized health care to marry the benefits of both and make sure no one is left behind. We also must ensure that there is a focus on delivering measurable impact, such as lives saved, reduced incidence of new infections for all groups, and increased access.

While it is challenging to balance the targeted disease initiatives with the need to develop health systems more broadly, I think we are capable, and in fact as part of the Global Fund partnership, do both. As an example, 17.5 million HIV positive people received antiretroviral therapy in Global Fund supported countries in 2017, while nearly 700,000 mothers received treatment to prevent the transmission of HIV to their babies. We also note from analysis of our portfolios that 27 percent of funding currently goes to support systems for health. So it’s possible as a partnership to do this.

Partnership has always been important to the Global Fund’s work. Can you talk more about the roles of the Fund’s various partners today and the opportunities for new actors in the future?

One of the areas where I see the Global Fund doing particularly well is in our ability to engage in meaningful partnerships with bilateral and multilateral organizations like the WHO, UNAIDS, UNICEF and PEPFAR and private sector foundations such as the Bill and Melinda Gates Foundation. For PEPFAR specifically, we have been working intensely together to make sure we are maximizing the dollars from each of our contributions. For example, we are coordinating our funding applications so that our work prioritizes different areas.

As we move forward it will be critical to find new actors across many different areas. For example, bringing together local partners, private sector contributors and local academics will help build a stronger team capable of finding creative solutions to problems that we might not have thought of before.

For more on opportunities for the U.S. and partners to work toward ending the epidemics of AIDS, TB and malaria, see Friends’ Tipping Point report.