If you are like me, you may be starting the trek from your home to Rio de Janeiro, Brazil for AIDS 2026, the global conference on HIV organized by the International AIDS Society. If that journey is long, as it is for me, you may be looking for content to watch or listen to (hello!), and maybe flip through the conference program for sessions you are interested in. I invite you to see how many presentations and posters are devoted to the relationship between the climate crisis and the global HIV epidemic. And I guarantee that we will see more and more presentations and full sessions devoted to these two issues in future global AIDS conferences.

I know I bore people with my line that HIV is like Ebola in slow motion, and Ebola is like HIV on acid. But it works as a meme, people get what I am trying say. Unlike Ebola, HIV infects, but it can take years, not days, to manifest, and there is no cure. While it is a line I keep coming back to, my thinking behind it is changing, and it isn’t the viruses. It’s the growing list of things converging on them — population displacement, drought, flood, fire, failing states — every one of them an accelerant for an epidemic that has always thrived on disruption.

So I was more than glad to get Arthur Snell back on the podcast. Arthur is a former British diplomat who served through Iraq, Afghanistan, Yemen and a posting as High Commissioner in the Caribbean, and who now writes and consults on geopolitics. We recorded the conversation the same week he was launching the US edition of his book, Elemental: The New Geography of Climate Change and How We Survive It — appropriately enough, during a European heatwave pushing temperatures into the mid-forties Celsius while we spoke.

Arthur has is not an HIV expert. That’s exactly why I wanted him on the show. AIDS2060 exists to look at the long-term trends that will shape the global HIV response for the rest of this century, and the people best placed to help us see those trends clearly are often the people who’ve spent their careers studying something else entirely.

HIV Flourishes in Disruption, Whichever Direction It Comes From

Arthur’s framing of the climate crisis in Elemental isn’t the standard ecological one. It’s geopolitical: how a warming planet reshapes power, migration, conflict and economic advantage between and within states. The word he kept returning to was catalyst.

“The climate crisis acts as a catalyst,” Arthur told me. “So it makes existing problems more severe, more intense, just as a catalyst in a chemical scenario does, as we all know from our high school science.”

That should sound familiar to anyone who has worked in HIV for the last four decades. We have never been fighting a virus in isolation. We have been fighting poverty, migration, stigma and the failure of institutions to reach the people who need them most, with a virus riding along on top of all of it. The climate crisis does not open a new front. It strengthens the forces arrayed against us on every front we are already fighting on.

This Has Already Happened, Not Just in a Model

Plainly this is not speculative. There is now a documented evidence base showing that climate shocks have already driven up HIV risk and disrupted HIV care in real populations, not hypothetical ones.

A Columbia University ICAP study conducted with the Lesotho Ministry of Health and the US CDC (oh how I miss the CDC!) found that adolescent girls and young women exposed to severe drought were significantly more likely to have recently acquired HIV, with drought years associated with a rise in transactional and commercial sex as households lost income and food security^[1]. A companion analysis published in PLOS Medicine, drawing on Population-Based HIV Impact Assessment survey data across Eswatini, Lesotho, Tanzania, Uganda and Zambia, found the same pattern of drought-linked risk behaviour among women in rural areas^[2]. A separate study from Malawi found that drought years were directly associated with an increase in transactional sex and sexually transmitted infections, including HIV, as girls and young women turned to sex for survival income when crops failed^[3]. Researchers at Bristol, reviewing this body of work in 2024, concluded plainly that droughts can trigger HIV transmission increases among women in rural sub-Saharan Africa^[4].

It’s not only slow-onset drought. Sudden disasters interrupt treatment, and treatment interruption for HIV isn’t a paperwork problem — it hits the health of the person directly, and at a macro level it drives viral rebound, resistance and onward transmission. When Cyclone Idai tore through Mozambique in March 2019, Sofala province saw a 25 percent drop in people collecting their regular antiretroviral supplies and a 60 percent drop in three-month drug distribution in the month after the storm, as clinics were damaged, roads washed away and health workers displaced alongside their patients^[5]. Médecins Sans Frontières spent months afterward simply trying to reconnect people living with HIV to their medication^[6]. Three years later, the April 2022 floods in KwaZulu-Natal — the province carrying South Africa’s largest provincial HIV burden, roughly two million people living with the virus — left patients without access to treatment for up to two weeks and damaged dozens of health facilities. UNAIDS ran a rapid emergency assessment of flood-affected people living with HIV, borrowing directly from lessons learned during COVID^[7][8]. One nurse running an HIV and methadone clinic in Durban’s Umbilo district told journalists that when her centre reopened after two weeks, a quarter of the forty people who relied on it for antiretrovirals simply never came back.

So to answer the question directly: yes. The climate crisis is already increasing HIV infections and already interrupting HIV treatment, in documented, published, peer-reviewed terms. This is not a 2060 problem. It is a right-now problem that will compound for the rest of the century.

What Compounds Next

What Arthur does spectacularly well is make the future crises feel like they’re already upon us, in concrete detail. The Sahel, he argues, isn’t simply experiencing a migration crisis — it’s watching entire countries cease to function as nation-states, with people pushed north across the Mediterranean and south into wealthier southern African countries.

“What the climate crisis does is turn this into a global phenomenon,” Arthur said. “So clearly the United States faces the challenges of people being pushed off the land in places like Guatemala. In Europe, we’re looking at the complete breakdown of entire countries in the Sahel region… but actually, in Asia as well… many Chinese living in the North China Plain are considering moving into the Far East of Russia.”

That is population movement on a scale the HIV field has, so far, mostly discussed in terms of individual country case studies rather than a genuinely global phenomenon touching the Sahel, Central America, South Asia and the North China Plain simultaneously.

Layer onto that the energy transition itself. Arthur is genuinely optimistic that Africa’s mineral wealth and renewable energy potential — solar and wind from Morocco powering homes in Britain is technologically feasible today — could finally let African countries own the value chain rather than simply exporting raw resources. But that transition will draw large numbers of men into remote extraction and construction sites away from their families, in exactly the pattern that fuelled HIV’s spread through Southern Africa’s mining industry a generation ago in Botswana, Zambia and South Africa. New infrastructure jobs are not automatically a new HIV risk. But we know from forty years of experience that remote, majority-male workplace environments, absent deliberate testing, prevention and treatment programming, reliably become one.

Then there’s the slower damage: malnutrition from a destabilised global food system weakening immune function, including in infants who might otherwise have been protected from mother-to-child transmission; wildfire smoke driving non-communicable disease burdens like asthma that compound already stretched health systems; and, as retreating Arctic ice exposes pathogens unseen for millennia, a genuine and rising pandemic risk that the global health community, by Arthur’s account, has still not folded into its planning with the seriousness it deserves.

And then there’s populism, which Arthur described as being in a kind of codependent relationship with climate denial. Populists don’t need the crisis to be false. They need only an answer, however dishonest.

“What populism is mostly about is not facts, it’s about fear,” Arthur said. “And so, ultimately… there’s this weird irony that the populists denying that the crisis is occurring are, of course, making sure that the crisis will occur even quicker than previously.”

If that sounds familiar, it should: it’s the exact playbook of Thabo Mbeki’s AIDS denialism in South Africa, dressed in new clothes and now deployed against climate science and against vaccines. Arthur and I wondered whether we’ll see it turned on the HIV response itself again, most visibly in the current US administration’s dismantling of PEPFAR-funded programming for the communities most affected. Managed by multi-tasking Secretary of State and USAID Coordinator Marco Rubio, he is likely missing a great deal across his sprawling portfolio, not least because Health and Human Services Secretary RFK Jr. has already spread HIV disinformation in publications and interviews of his own.

Two Movements, One Catalyst

Arthur points to something far more useful than a diagnosis of how we got here. It’s the reminder that the HIV and climate movements aren’t just facing a shared threat — they’re increasingly building similar infrastructure to respond to it. We have to make sure we don’t duplicate effort, and seize the opportunity to do more together.

PEPFAR itself has published on this. Probably best not to remind Secretaries Rubio and Kennedy, in case their boss responds unexpectedly in a late-night social media post. Nonetheless, climate shocks are now explicitly treated as a threat multiplier to two decades of HIV progress, and PEPFAR’s own mitigation strategy — including a push toward African-manufactured antiretrovirals and diagnostics — treats climate resilience and HIV programming as the same investment, not competing ones^[9]. In the broader global HIV movement, a clearer illustration comes almost by accident: Unitaid found that the global switch from efavirenz to dolutegravir-based regimens, made purely for clinical reasons, has cut cumulative carbon emissions by roughly 26 million tonnes of CO2-equivalent, simply because the newer drug needs a fraction of the active ingredient to work^[10]. Good HIV science and climate mitigation turned out to be the same decision. The Global Fund is in on the act too, committing that 71 percent of its 2023–2025 investment, and more than 80 percent of its malaria funding, goes to the fifty most climate-vulnerable countries, and launching a $50 million Climate and Health Catalytic Fund with the Gates Foundation and Sanofi to build low-carbon, climate-resilient health systems in the countries carrying the heaviest HIV, TB and malaria burden^[11][12]. The World Bank and the Global Fund have formalised a partnership aimed squarely at the health-climate nexus^[13].

There’s also an underused model sitting in plain sight in the emergency response itself. UNAIDS’ rapid assessment after the KwaZulu-Natal floods worked precisely because it drew on relationships and community health infrastructure that decades of the Joint UN Programme’s HIV work had already helped the South African government build. The same community health workers, the same ARV adherence clubs, the same trusted local networks that keep people on treatment in ordinary times became the fastest way to find and reconnect people after the water receded^[14]. That’s exactly the kind of infrastructure the climate response needs and doesn’t reliably have: trusted, hyperlocal, already-funded, already-trained. HIV programming has spent two decades building the exact relational capacity that climate disaster response is now trying to invent from scratch.

Arthur made one more point worth holding onto.

“Certainly we see it in Europe — wildfires have a positive effect of drawing countries together,” he said, pointing to the Los Angeles fires, when “countries from all over the world sent firefighters, sent special equipment, sent aid. Even Ukraine… you would think they’ve got enough fires of their own to put out, but they did that.”

Of course, the US Federal Government cannot be relied upon to be of much help. But nonetheless, and I want to sing this from the rafters, multilateralism is dead: Long live Multilateralism! It survives where the threat is elemental enough that no one can credibly deny it’s happening to them too. HIV should borrow that instinct rather than resent it: find the places where climate and health genuinely are inseparable — food security, migration, workforce health, disaster response infrastructure — and build the coalition there, rather than waiting for a seat at a table built for someone else’s crisis.

There is one curious observation that stands out. The US Federal Government has threatened to prevent support to wildfires in Democrat-governed states, like California. It is removing itself from the conversation. Its disruption of the global HIV response is becoming something similar. It restricts its support for HIV treatment to only pregnant and breast-feeding women. This, amongst other inexplicable actions, has disrupted the global response to HIV – it still isn’t really clear what the self-styled “America Global Health Strategy” is doing and what it has in mind for the long-term response to HIV. What if those of us interested in global solidarity, in a multilateral, multisectoral and rights-based response to HIV, just ignore the US for the time being, and just get on with it ourselves. We will not have the same level of financial resources that we used to have, but one of the intriguing lessons emerging from the last year and a half and that we will learn more about at AIDS 2026, is that countries are learning to make-do, rebuild with the resources they do have, and find new ways to achieve results. If multilateralism proves to be more effective in implementing responses to long-term emergencies like the climate crisis and the global HIV response, perhaps we can be less bothered with what the US is up to. I am only asking – but may well come back to this in a subsequent episode of AIDS2060.

What I’d Put on the USB Stick

Toward the end of our conversation, I asked Arthur what he’d want a future HIV policymaker to know, if we buried this conversation in a time capsule until 2060. His answer wasn’t really about climate science. It was about food, mobility, and trust: project the impact of a changing food system on malnutrition and immune resilience, stop treating population movement as a series of isolated regional crises, and find better ways of communicating with people who no longer trust institutions — because common sense and logic didn’t win Brexit, and they won’t win this either.

The UN General Assembly decided back in 2016 that AIDS would end as a public health crisis by 2030. It is, as I said on the show, wonderful to see how confident UN diplomats were that that viruses would respect international declarations. Well of course they don’t, and the climate crisis is making damn sure we know it. The two movements best positioned to do something about that are not natural rivals for the same shrinking pool of donor funding. They need to be the same movement, building trust with the same communities, for reasons the data now makes very hard to ignore.

Thanks for reading. You can find Elemental wherever you buy books — preferably from a small bookseller. A huge thanks to Arthur Snell for joining me, and to Eric Espera, our director and producer at A Shot in the Arm Media. As ever, I’d love to hear your thoughts on how we build this coalition — reply to this post or find me on Substack Notes.

^[1] Drought in Lesotho Heightened HIV Risk in Girls, Columbia University Mailman School of Public Health

^[2] Association between severe drought and HIV prevention and care behaviors in Lesotho: A population-based survey 2016–2017, PLOS Medicine

^[3] From a drought to HIV: An analysis of the effect of droughts on transactional sex and sexually transmitted infections in Malawi, PMC

^[4] Droughts may trigger HIV transmission increase among women in rural sub-Saharan Africa, University of Bristol

^[5] HIV Care Following Two Devastating Cyclones in Mozambique, PubMed

^[6] Mozambique: Treating HIV in the wake of Cyclone Idai, Doctors Without Borders

^[7] ‘I missed a dose for the first time’: How the KZN floods derailed HIV treatment, Bhekisisa

^[8] Supporting HIV services for flood survivors in KwaZulu-Natal, UNAIDS

^[9] Sustaining two decades of PEPFAR’s response to global HIV/AIDS: mitigating the impact of climate threats, PMC

^[10] New Unitaid report: World’s leading HIV drug proven to have reduced global CO2 emissions by 26 million tons, Unitaid

^[11] Global Fund Unveils Pioneering Climate and Health Fund to Accelerate Global Action

^[12] Climate Change and Health, The Global Fund to Fight AIDS, Tuberculosis and Malaria

^[13] World Bank and Global Fund: Stronger Collaboration to Tackle the Impact of Climate Change on Health

^[14] Supporting HIV services for flood survivors in KwaZulu-Natal, UNAIDS

For over a year now, the future of UNAIDS, the Joint UN Programme on AIDS, has been hanging in the balance. A quiet reference in paragraph 39 of the UN Secretary-General’s UN80 Initiative, launched in March 2025, made the recommendation to “sunset UNAIDS by the end of 2026,” with its functions “mainstreamed” elsewhere in 2027. Last month, a report commissioned by the UNAIDS Programme Coordinating board (PCB) was turned over to the PCB for review. While there’s uncertainty about what comes next, the report supports a continuation and transformation of the Joint UN Program (if not explicitly including the UNAIDS Secretariat), rather than its proposed “sunsetting.” If the past year has taught us anything, it’s not to take anything for granted. With this possible reprieve, it is crucial to be clear about why the Joint Programme on AIDS – Co-Sponsors and Secretariat - matter and which of the core functions must be preserved.

HIV is Not Like Other Epidemics

Tuberculosis and malaria are indiscriminate. You can get tuberculosis by breathing the same air as an infected stranger on a bus. You can get malaria from a mosquito that doesn’t care who you are, who you love, or what your government thinks of you. HIV is different in a way that changes everything about how you respond to it: it travels through the most private, most policed, most stigmatized of human behaviors — sex, birth and some forms of drug use (sharing needles).

You cannot build an effective response to a virus that spreads through intimacy and childbirth using only the tools of clinical medicine. You need something that can go where WHO’s biomedical mandate cannot: into the lives of sex workers, gay men, people who inject drugs, transgender men and women, adolescent girls negotiating their first sexual relationships in households where they have no power to negotiate anything. That is not incidental to the HIV response. It is the HIV response.

Ending AIDS as a Public Health Threat by 2030 Is Unachievable

This is also why the near-universal rhetoric around the original 2016 UN High Level Meeting’s commitment to “end AIDS by 2030” is so problematic. The 2026 UN Political Declaration on HIV/AIDS, adopted at the General Assembly’s High-Level Meeting this June with 149 votes in favor (and, tellingly, the United States and Russia voting against), reaffirmed that 2016 target and also set ambitious new numbers: 40 million people on treatment, 20 million on PrEP, 90% of those in need reached with prevention services, $21.9 billion a year in financing by 2030. These are admirable aspirations and, like many an HIV target before them, they will be likely missed.

But the difference between these targets and the WHO “three by five” target to treat three million people with antiretrovirals by 2005, is that this time political and financial forces are aligned against aspiration.

The forces that helped bring the world to the brink of the end of HIV as a public health threat are now headwinds, if not hurricanes, in the case of the retooled US HIV response, that are hellbent on rolling progress back. An aspirational target for an aligned field can play a useful forcing function. An unachievable target at a moment of fragmentation, dysfunction and transformation can cause confusion and the loss of confidence, as evidenced by the proposals to sunset UNAIDS. You cannot declare success against an epidemic whose true scale and trajectory you can’t see.

The Key Elements of a Future Joint UN Programme on HIV - with Secretariat

On a positive note, the HLM declaration also showed there is still life in the old Joint Programme model yet. Despite a striking lack of genuinely high-level political presence in the room, the General Assembly produced concrete, specific recommendations on services and, crucially, explicit recognition of key populations: the people at the actual center of transmission dynamics, and the people every “mainstreaming” proposal is most likely to drop quietly. Among the recommendations are three specific areas, which we consider fundamental to the long term HIV response and which we amplify below:

That mission matters most acutely for girls and women in Africa, who remain disproportionately at risk not because of a treatment gap but because of a power gap. A leadership rooted in the realities of HIV at this present moment will, by definition, make authentic connections between HIV and global threats, whether it is the climate crisis causing droughts and food insecurity that, in turn, elevate risk of HIV infection, or the rise of populism and the xenophobic, homophobic and transphobic laws that keep people out of clinics, hiding in their homes.

The UNAIDS Secretariat, in particular, has a long heritage of partnership with communities affected by HIV, which has been fundamental to its impact nationally and globally. The Joint Programme is still the only UN mechanism with representatives of the community on its governing board (the Global Fund doesn’t count as it is not a UN agency!). It is precisely because HIV is an intersectional epidemic with a vibrant, global network of organizations and activists living syndemic realities every day that it cannot be folded into another entity. WHO is a normative biomedical agency; UNDP is a development agency with no comparable leadership and governance function inclusive of impacted communities, and people living with the health condition(s) in question. There are examples where both Co-Sponsors (and indeed the majority of Co-Sponsors) have shown exemplary leadership on specific issues, but we must be direct, it will not and cannot be an institutional priority for either agency.

These country staff work closely with communities of transgender people and men who have sex with men when they are brutalized and arrested; they work side by side with government counterparts to develop sustainability plans that work for the countries’ own interests, and not for ‘America first’ (or any other nation, for that matter). They are allies for adolescent girls and young women, and women of diverse identities whose demands for choice-based HIV prevention, integrated sexual and reproductive health and rights still go unmet. This is slow, relational, often unglamorous work — the opposite of what an efficiency review is built to value — and it is precisely the infrastructure that keeps national HIV responses honest and locally led.

For years, the UNAIDS Secretariat has been part of a “three-legged stool” supporting the collection and analysis of data and facilitating strategic decision-making based on reliable global data. Here, the stool’s three legs are UNAIDS (the partnership between WHO and UNAIDS Secretariat, countries and PEPFAR. In the last eighteen months one leg of the “stool” has been broken, as the US turned the lights off on its PEPFAR data. Dismantling the Joint Programme at this moment, instead of using it as a critical support for a new fit for purpose data function, is shortsighted and downright dangerous. The partnership then between the UNAIDS Secretariat and WHO becomes even more essential. WHO’s data lens is biomedical and clinical. The Secretariat, and where needed with other Co-Sponsors, is the rest of it. Its country presence makes all the difference here: It mobilizes supportive environments that promote the participation of those populations that would never otherwise show up in a clinic’s numbers because they never felt safe walking through the door. Lose that half of the partnership and you don’t get better data. You get blinder data.

Why UNDP and UNOPS are the wrong answers

The recommendations circling the UN80’s proposal are bad. Housing UNAIDS’ functions inside UNDP is a structural conflict of interest: UNDP is already one of UNAIDS’s eleven Co-Sponsors, obligated to work as an equal partner alongside the Secretariat and the other ten. Making it the parent of the thing it’s supposed to be co-governing doesn’t strengthen coordination, it collapses it.

Turning UNAIDS – either the entire Joint Programme or just the Secretariat - into a program of UNOPS is worse. UNOPS has a questionable track record that commands little respect either inside the UN system or outside it. Further, its leadership has forced deep funding and staffing cuts that make it uncertain whether it can deliver on its existing commitments, let alone take on a new major global priority. Proposing it as the future home for the world’s HIV advocacy and coordination function isn’t reform. It’s a failure of imagination dressed up as one.

What Happens Next

The world still needs a strong, independent Joint Programme – Co-Sponsors and Secretariat: lean, yes — UNAIDS has already absorbed a 55% cut to its Secretariat staff, from 661 positions to 294, largely forced by the loss of US funding, which made up 41% of its 2023 budget — but independent, focused on the three things it alone does well: country-level relationships, joint surveillance with WHO, and informed, fearless advocacy at the highest levels.

The financial pressure on UNAIDS is real. The case for reform is real. But the answer to a funding crisis is not to dismantle the Joint Programme model – and the Secretariat in particular - built to reach the people the rest of the system can’t, and hand its remains to agencies that either have a conflict of interest in running it or a track record that disqualifies them from trying.

UNAIDS’ board - the Programme Coordinating Board - still has a decision to make, and it must prevent bureaucracy and backsliding that will lead to closing the Joint Programme’s doors for good. We are ever so slightly more optimistic that it will decide wisely, and it is thus vital that the global health field speak up loudly in support.

Let us sing it loud from the rafters! What is needed is forthright advocacy over the coming months to ensure the following message is understood and acted upon: We will need the Joint UN Programme on HIV/AIDS for as long as HIV poses a major threat to global health and security.

A few months ago, the distinguished ministers of health from around the world who make up the World Health Assembly had a video played to them at the start of one of their sessions. A young HIV prevention advocate named Siviwe Gaika, speaking confidently into the video function of her smart phone, told them something that most adults everywhere need to hear: that HIV prevention only works when it fits into real life, and that a system which turns a daily pill into “pressure” and “panic” — hiding the bottle, missing a dose, choosing between transport money and food — is not a personal failure. It’s a system failure.

Siviwe wasn’t asking for sympathy. She was demanding her right to make HIV choices be upheld. She was asking for long-acting injectable PrEP — cabotegravir, lenacapavir — to be funded, delivered through youth-friendly, stigma-free services, and freed from the red tape that keeps it out of reach for anyone without money, or the right connections and location.

“Long-acting injectable PrEP isn’t a luxury, and it shouldn’t feel like one. It’s a lifeline.”
Siviwe Gaika

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We opened the latest episode of AIDS 2060 — my long-form project asking what it will actually take to end HIV, and whether we have the nerve to do it — with Siviwe’s recorded message, and then I sat down with the person who has spent two decades making sure voices like hers get heard: Yvette Raphael, executive director of APHA (Advocates for the Prevention of HIV in Africa) and co-host of A Shot in the Arm.

I ask everyone on this project the same opening question: are we on track to end AIDS as a public health threat by 2030? Yvette’s answer was, in her own description, “diplomatic” — and then, true to form, immediately wasn’t. “I don’t think we’re on track,” she told me. “I don’t think we even have the energy in the gut and all the fight that we need to get us to 2030.”

The double tragedy

What troubles her most isn’t the missed deadline. It’s what the missed deadline does to a generation.

Decades of investment in preventing mother-to-child transmission have produced children born HIV-negative to HIV-positive mothers — a genuine triumph. But those children grow up, and some of them, girls especially, acquire HIV anyway, later, as teenagers and young women.

“My worry about young people born to us women living with HIV, staying negative, is that it’s now transferring onto our kids, because they’re starting to see the fear now. It is a double tragedy: The prevention worked once, and the epidemic still found its way back in.”
Yvette Raphael

Part of the why is money. The abrupt, then partially and incomprehensibly reversed, gutting of PEPFAR and USAID this past year has already started reshaping who gets served and who doesn’t. Yvette was blunt about the pattern: “we see now pregnant women being prioritized over young women and girls and other people” — a kind of triage that quietly writes off the group least able to advocate for itself.

Her response to that triage isn’t resignation. It’s defiance. “Our countries have a responsibility to ensure that their citizens are HIV-negative and do have access to health. Our countries can afford these medicines,” she said. She pointed to Zambia’s public resistance to a reported PEPFAR arrangement tied to mineral exports, and it clarified something for her: trading sovereignty for medicine a government should be funding itself is not a deal worth taking. “If you need my minerals in exchange for ARVs, it doesn’t make sense,” she said. “I would rather die.” Health sovereignty, in her framing, isn’t an abstraction — it’s the only guarantee that a teenage girl in Lusaka or Limpopo isn’t rationed out of the response the next time Washington’s politics shift.

Prevention as feminist advocacy

None of this is theoretical for Yvette. She was diagnosed with HIV at 25, infected, she told me plainly, because her partner refused to use a condom. It’s a fact she doesn’t bury — she leads with it, because it’s the reason her advocacy centers prevention rather than only treatment, in a field where treatment advocates are the more common voice. “I do advocacy for HIV prevention for my daughters,” she said. “I don’t mean my personal daughter — I mean African young women and girls: the girls that I work with, the girls that I don’t work with, the girls that I want to see flourish.”

That’s not sentiment. It’s strategy, rooted in what she describes as a feminist leadership tradition running through APHA and the African Women’s Prevention Community Accountability Board, shared with counterparts across Uganda, Kenya, Zambia, and Zimbabwe.

“We know how we got infected. Condoms require negotiation a partner may simply refuse. Abstinence and fidelity, the other two legs of the old ABC prevention model, none of those three worked for me. So the demand isn’t for one more option bolted onto a broken menu. It’s for autonomy — the ability of a young woman to walk into a clinic, get an injection, and walk out without having to ask for permission … without putting a ring in their vaginas and keeping quiet and carrying on with their lives.”
Yvette Raphael

Choice was never actually a choice

Yvette and a coalition of African women built a vibrant initiative called the Choice Manifesto — organizations and funders publicly committing to make a full basket of HIV prevention options genuinely available. I asked her the obvious, uncomfortable question: why, years on, hasn’t it had more impact? Her answer cut straight to the structural problem. “The choice is never ours,” she said. “It’s never the choice of young people, of what becomes available. Somebody makes a decision on choice.” A regulator, a funder, a program director decides a product “won’t work in this setting” without ever asking the fifteen- or twenty-year-old who would use it.

That fight is now aimed squarely at industry. Yvette’s coalition recently pressed ViiV Healthcare — a signatory to the Choice Manifesto — to explain why cabotegravir remains unavailable across most of Africa, and to consider private-sector as well as public-sector distribution. It’s a genuinely a completely new way of framing an HIV advocacy demand on the continent: not only “give us aid,” but “see us as a market.” It is a profoundly different philosophy from the advocacy for accessible, affordable treatment access pushed by Northern HIV treatment activists for three decades.

Framed that way, Yvette’s ask to pharmaceutical companies stops being about charity and shame in driving costs down, and starts being about long-term commercial relationships — and that includes normalizing the idea that a young woman with a job might choose to pay for her own prevention, the same way she’d pay for anything else she valued. But it has to be affordable and readily accessible. African markets are different in size and scope from American or European pharmaceutical markets. They are defined by the promise of high volume, based on a shared commitment to the lowest price to the consumer.

Where this choice agenda has already produced something concrete is in clinical research. Yvette was one of three recipients this year of a leadership award from the American Association for the Advancement of Science, for work with Gilead on the PURPOSE 1 trial that, for the first time, built a credible pathway for pregnant and breastfeeding women to take part in HIV prevention research rather than being excluded “for the safety of the baby” — a justification a young Ugandan advocate, Shakira, punctured with one line: “Don’t men die?” The mechanism the advisory board landed on was simple: women could enter the trial, become pregnant, test, and reconsent, rather than being dropped. Yvette calls this “much bigger than just women being in the trials” — it demonstrates, in the data itself, that women have agency over their own bodies without needing patriarchy, or a fetus’s hypothetical risk, to decide for them. She wants the same principle — informed reconsent, not exclusion — to become “standard of care” for every future HIV trial, with post-trial access to the drug guaranteed for the communities who made the trial possible in the first place.

What unity actually requires

So what does it take to genuinely fold teenage girls and young women into the next phase of the response, rather than talking about them from a podium? Yvette’s answer isn’t a slogan — it’s an operating model: intergenerational leadership, deliberately built rather than assumed. She recalled Lillian Mworeko’s story of young advocates once told, mid-protest inside the UN building, to “just let them be” — tolerated rather than taught. APHA’s alternative is mentorship as infrastructure: seats at the table, the tools to walk into rooms “we did not have,” knowledge of what didn’t work in the past so it isn’t repeated, and a willingness from those of us further along to be their servants, not their servant leaders.

It also requires refusing a very specific kind of division — the instinct, hers and mine both, to talk about “them” (African children, African girls) rather than acknowledging that the same vulnerable populations, the same unmet needs, exist everywhere, including in San Francisco and New Orleans. Yvette pushed back hard when I framed the agenda as one purely about African capacity: “Why does a programmer in the US think they are doing the program for African children? Make it make sense.” The uncomfortable truth underneath her irritation is real — well-meaning Northern advocates, myself included, have too often built systems that assumed Washington or Geneva was the default headquarters of expertise, rather than treating APHA’s Choice Manifesto, South Africa’s constitutional protections, or community outreach models pioneered across Uganda and Kenya, as templates the rest of the world must learn from – including community-based organizations in the USA.

And it requires documentation — a discipline Yvette raised almost as a warning.

“My biggest fear, Ben, is waking up and somebody says AIDS was never there, that the record of how the community response actually worked — through COVID, through PEPFAR’s collapse, through decades of adolescent girls quietly organizing each other over WhatsApp — gets erased along with the funding. If nobody writes down what worked, it can be argued away by whoever inherits the next crisis.”
Yvette Raphael

The right just to be young

I keep returning to one comment of Yvette’s near the end of our conversation. It compresses the whole argument into a sentence: “Young people have the right to just be young people. Not a statistic, a target population, a beneficiary, or a case study — a teenager whose biggest worry is the ordinary chaos of being a teenager, not whether this is the year she becomes one more new infection in a column that funders have quietly deprioritized.”

That’s what Siviwe was demanding of the World Health Assembly: fund the tools that let her live an ordinary life, deliver them somewhere she can actually reach, and stop treating her right to prevention as negotiable whenever the money gets tight. Yvette’s entire career is the long version of the same demand, made to funders, to governments, to originator and generic pharmaceutical manufacturers, and — pointedly — to people who look like me.

We are not going to end AIDS as a public health threat by 2030. Nobody serious argues otherwise anymore. What determines whether teenage girls and young women continue to pay the price for that missed deadline, or whether they finally get the choice, the agency, and the seat at the table they’ve been asking for since long before Siviwe was born, is not a negotiated date on UN resolution. It’s whether we do the unglamorous work Yvette described: fund the basket, hold governments, the private sector and international organizations accountable to what they committed to, document what works, and hand over the room to the new generations of populations at greatest risk of HIV – especially and pointedly, teenage girls and young women.

AIDS 2060 is a project of A Shot in the Arm Media. This episode featured Siviwe Gaika and Yvette Raphael of APHA — Advocates for the Prevention of HIV in Africa.

Just Cross Your Legs and Say No

My sister likes to observe that her entire HIV education as a 1980s teenager consisted of Sister Kieran of the Convent of the Nativity in Sittingbourne Kent, UK, advising her and the other girls in her charge “to cross their legs and say no when boys looked at them in a funny way”. If that is not enough to put yourself off sex, I don’t know what is.

Talk of crossing your legs and saying no, many male global health advocates I know from countries like the UK and Japan, have a similar sense of discomfort when the HIV prevention role of voluntary medical male circumcision (VMMC) is brought up. It makes us slightly queasy, bringing on an overriding desire to cross our legs to protect our own crown jewels – as it were.

So, you’d think I would be unbothered by remarks by US Secretary of State Marco Rubio in a recent Senate hearing that he was “proud” that US funding for Mozambique’s VMMC program has been terminated1. Yet his remarks were deeply disturbing for anyone supporting evidence-based and locally led HIV interventions.

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The procedure, which reduces female-to-male HIV transmission by around 60 percent[1], is a low-key triumph of the HIV response — a single, low-cost, once-in-a-lifetime intervention with no recurring cost and a body of evidence behind it. Evidence that came from three landmark randomized trials, conducted not in London or Bethesda but in Uganda, Kenya, and South Africa, by African research teams working with African study participants.

In other words, African science, generated by African researchers, on African evidence, for an African epidemic.

Which makes it all the more galling that, in February 2025, the Trump administration’s Department of Government Efficiency listed a $10 million voluntary medical male circumcision program in Mozambique among its proudly cancelled “waste”[2] — the same week Elon Musk was insisting, wrongly, that $50 million in USAID condoms had been destined for the Gaza Strip in the Middle East, before being forced to concede that the funds were in fact intended for Gaza Province, a rural region of southern Mozambique named centuries before anyone in Washington had heard of either place[3].

It would be funny, in a bleak sort of way, if it weren’t symptomatic of something much larger: a program co-invented by African scientists, built on African data, delivering African-led prevention, casually struck off a spreadsheet by people who could not locate the country, let alone the province, on a map.

This pattern of behavior – not the cut itself, but what it reveals – underpins the second episode[4] of AIDS2060, a multi-media project devoted to understanding what is needed to bring the HIV epidemic under control, how long that will take, and why the world has been unable to do so far. My guest was one of the Ugandan researchers contributing to the VCM data, Dr Andrew Kambugu, Executive Director of the Infectious Diseases Institute (IDI) at Makerere University[5] in Kampala, Uganda.

I have known Andrew for a couple of decades. We collaborated in the early 2010s with the World Health Organization, the Clinton HIV/AIDS Initiative (CHAI) and the Gates Foundation to identify biomedical interventions that could be “optimized” for use in resource-limited healthcare settings, particularly in Africa[6]. He is one of the smartest and experienced East African clinical researchers I have come to know, and I was keen to get his observations and views on the long-term future of Africa’s HIV response. I wanted to talk to him about where the science – from an African perspective - is heading. I came away with something closer to a meditation on power: who funds research, who owns it, and who gets to decide which evidence counts.

Interconnected, not Silo-ed Priorities

Andrew’s framing of where we are right now is admirably uncomplicated. He describes three overlapping priorities, themselves not surprising, but his insistence that none of them outranks the others, is intriguing and new – or at least new to me.

The first priority is prevention: We are all excited about the new generation of long-acting injectable PrEP — six-monthly shots, but it is one of a number of options, alongside the existing oral pill, set out in the Choice Agenda[7] of prevention tools for teenage girls and young women, like the davipirine ring, as well as VMMC give people, and especially the young women in Africa who remain three to six times more likely than men to acquire HIV, an actual choice of tool rather than a single, often unworkable, option.

The second priority is treatment: keeping the millions of people already living with HIV durably suppressed, using injectable antiretrovirals and simplified two-drug regimens that reduce the lifelong toxic load on ageing bodies, built on the now unimpeachable evidence that an undetectable viral load means zero transmission risk. In the future, fixed dose combinations of anti-HIV drugs with medications for other conditions like TB and malaria, that aren’t necessarily a priority in the industrialized world, will be important enabling patients and their physicians choose options that are appropriate both for their individual situations and for the broader community they live in. Robustness of these medications – their ability to be stored at room temperature and to survive long periods in hot temperatures is also an African priority – not necessarily one that matters in the global north. In addition, it may not be the case that injectables are always the priority. Where community health workers serve as patients’ front line healthcare workers, delivering long-acting oral medications – whether weekly or monthly – could be more important settings. Patients themselves in ARV clubs, that take turns in collecting their three-monthly supplies of medications, will continue to play a supportive role in promoting adherence, and may be better adapted to support long-acting oral medications than injectable formulations. Over the coming decades, new classes of medications are going to be needed that provide sustained viral suppression (reducing to almost undetectable levels of the virus in the blood stream), which in term will restrict the ability of HIV to develop resistance to these medications. These are priorities for both industrialized and developed world settings, but given data on emerging population-based resistance to some medications used widely across the continent, the priority becomes acute for Africa.

The third, equal priority is diagnostics: Often left out of the conversation entirely, is diagnostics — the unglamorous individual testing and surveillance infrastructure that HIV programs built over two decades, and that Andrew is now trying to repurpose for the next emergency. He pointed to the DRC’s Ebola outbreaks as the case in point: cheap, reliable diagnostic tools, developed and proven through the HIV response, sitting ready to be redirected the moment a new pathogen turns up at the border.

It’s the Tap - Not The Mop

Andrew used the metaphor of cleaning a floor to describe both the current state and future direction of African HIV research and development. You can (and must) prioritize the treatment and care of HIV positive individuals, but if you are not investing with equal seriousness in prevention and in the diagnostics that tell you where the virus is moving next, your solutions become limited. You have just got very good at mopping the floor.

Some mops. Photo courtesy of Pan Xiaozhen

Until you turn off the tap, the water keeps running, and so do the infections. Andrew’s argument, in essence, is that the entire global HIV architecture has spent the better part of two decades rightly investing in the mop (treatment), but also under-investing in the tap (prevention and diagnostics) — because treatment is countable, fundable, and politically satisfying in a way that prevention, which asks you to invest now to prevent an infection that might happen later, never quite is.

Treatment alone is just very good mopping. Until you invest with equal seriousness in prevention and diagnostics, you have not turned off the tap — you have just got better at cleaning the floor.

Whose Clinical Trial Is It Anyway

The contradiction shows up starkly, and absurdly, in the recent history of voluntary medical male circumcision.

Andrew’s response to the USA’s erratic behavior over the last two years is not despair, but a direct, blunt argument for African self-reliance. If a prevention tool is proven, cheap, and permanent, there is no reason why African public health authorities, private health insurers, the private sector more broadly, non-profit healthcare delivery services including from faith-based communities should keep waiting for a donor in Washington to decide whether it remains a funding priority this fiscal year. He told me Uganda is actively making the case that national health insurance schemes should simply cover VMMC as a standard, evidence-based prevention benefit — not because the United States has withdrawn, but because the evidence has always justified it, regardless of who is paying.

Writing the Agenda from Kampala, Not Geneva

This is where the conversation moved from a single intervention to something bigger: What does an African research agenda set by African researchers look like, rather than receiving one, fully formed, from elsewhere?

Andrew’s answer starts with epidemiology, not ideology. If you look at where new infections are concentrated in southern Africa — overwhelmingly among young women, and overwhelmingly shaped by structural drivers like economic dependency rather than individual behavior — then a genuinely African-led research agenda has to ask different questions than the ones a Northern funder typically prioritizes. He gave me a deceptively simple example: the data linking a girl’s continued enrolment in secondary school as a measurable reduction in her risk of acquiring HIV. The “intervention,” in that case, is not a pill or an injection. It is universal secondary education — a whole-of-government commitment, not a line item in a health budget. That is not the kind of finding that survives contact with a donor logframe built around biomedical deliverables, but it is exactly the kind of finding that an Africa-rooted research agenda, designed by people living inside the epidemic, can identify and act on.

The institutional architecture for this is, slowly, being built. Andrew pointed to the African Union’s continental health arm, Africa CDC, and its newer sibling agency, the African Medicines Agency (AMA)[8] — an attempt to do for Africa’s fragmented, 54-jurisdiction regulatory landscape something like what the EMA does for the countries of the European Union. The ambition is for a small number of regional R&D and manufacturing hubs — Andrew named South Africa, Kenya, Uganda, Egypt and Nigeria — feeding into continental regulatory reliance, rather than every product having to clear fifty-four separate national bureaucracies before it reaches a patient.

The private sector piece of this is further along than might first be expected. Andrew pointed me to Quality Chemical Industries Limited, a Kampala-based pharmaceutical manufacturer that built its business twenty years ago on Indian generic licenses, became the only producer in Africa of triple-combination antiretroviral therapy, listed on the Uganda Securities Exchange, and is now exporting across the continent and expanding into oncology and biologics[9]. Heads of state visit its factory floor. It is no longer even foreign-branded — its former Indian majority shareholder sold out to an African investment firm in 2023, which on its own tells you something about the direction of travel. IDI now partners with the company on dosing and antimicrobial resistance research, training the master’s and doctoral students who will, eventually, be the ones designing the next generation of African clinical trials, rather than just enrolling patients into someone else’s.

This gives Africa, he considers, the chance to research new products and other innovations that meet Africa’s needs:
- highly effective new medicines of course, but able to be stored and distributed without being disturbed or destroyed by the constraints of Africa’s often high temperatures.
- new medications that are rigorous enough to continue working, even after a few missed doses.
- Medications that can be prescribed or distributed by primary health care workers, often rooted in the community, that wont rely on patients having to seek renewed prescriptions.
- Formulations that can be stored and managed by patients themselves - very often young women who may have physical safety concerns of being able to control how visible their status is to friends, partners and family.
- Prevention anti-retroviral medications that take account of the same issues - now, long acting formulations are an exciting global development - and future innovations, unlike the COVID Vaccines which had specific cooling needs.
- Little or no interaction with other drugs, notably in TB.
- The basic research into potential compounds for prevention and treatment may be the same the world over, but Africa has specific formulation needs that need to be prioritized in any research and development program being developed in the coming decades.

Andrew was refreshingly unsentimental, too, about the field’s own history. The “treatment optimization” era of the 2000s and 2010s — the very work he and I collaborated on - lower-dose antiretroviral regimens, simplified formulations, decisions made under real resource constraints — gets criticized with the benefit of hindsight for tolerating toxicity that today’s better-funded science would never accept. Andrew’s view is that history should judge that era fairly: those studies were driven by a coverage problem, an honest attempt to do the most good for the most people with the tools available at the time, not by negligence. The lesson he draws for today is not embarrassment but consistency — don’t repeat the mistake of confining African patients to second-best, more burdensome options purely because better generics haven’t yet been licensed locally, when the entire point of an African manufacturing and regulatory base is to close exactly that gap.

An African-led research agenda doesn’t start with a drug. It starts with knowing your epidemic — and asking what intervention follows from that, even when the answer is universal secondary education rather than a pill.

The Stupidity of Walking Away

South Africa. Oh South Africa! The Trump Administration’s erratic behavior towards the country, including offering immigration to white “persecuted” South Africans is… peculiar, at best. How it serves US interests is unclear, but the events of 2025 and 2026 in South Africa look decidedly less like fiscal discipline and more like ignorant self-sabotage. South Africa has the largest HIV epidemic on Earth, more than eight million people living with the virus, and arguably the deepest bench of HIV clinical and research expertise on the continent — the same South African research group, in fact, that helped prove circumcision works in the first place. Just recently, the Trump administration moved to end PEPFAR funding to South Africa entirely, citing the country’s unrelated political disputes with Washington over land policy and its diplomatic ties to Iran as justification[10]. Back in January 2025, the sudden interruption in funding to PEPFAR partner countries - like South Africa - saw NGOs that had run HIV services for two decades, including major providers like the Anova Health Institute and the Wits Reproductive Health and HIV Institute, lose their funding overnight and began shutting clinics within days[11]. Independent modelling for the South African government found that a permanent end to PEPFAR-supported services could mean well over a million additional HIV infections and more than half a million additional AIDS-related deaths over the next twenty years[12].

This is a special kind of stupidity. It is not simply that withdrawing funding abruptly, with no transition plan, is cruel to the people who depend on these clinics — though it plainly is. It is that the decision has been explicitly tied to demands that have nothing whatsoever to do with public health, while the program being punished has been, by every available metric, working. South Africa is not failing to control its epidemic; it is making real progress, in no small part because of the scientific leadership Andrew described — leadership that the United States itself helped build over twenty years, then discarded over a political grievance about an entirely separate matter. You cannot rebuild a clinic, a supply chain or two decades of community trust by reinstating a grant a year later. As Andrew put it to me about circumcision, but it applies equally here: African governments and African private capital now have both the responsibility and, increasingly, the means to stop waiting to find out whether Washington’s mood will improve.

Conclusion: It’s Africa’s Century, and It’s Not Waiting for Permission

What stayed with me longest from this conversation was Andrew’s evident, almost stubborn optimism — not naivety, but the resilience of someone who has watched his own country’s research and his own country’s pharmaceutical industry mature far faster than anyone outside Africa expected, while the political ground underneath the global HIV response keeps shifting. He is not waiting for permission. The science of prevention, treatment and diagnosis has never actually been owned by Washington or Geneva; it is increasingly discovered or invented across Africa, by people whose names rarely make it into the press release.

The question for the rest of this century, the one that AIDS2060 keeps circling back to, is whether the institutions that fund and regulate global health finally catch up with that fact — or whether African researchers, African manufacturers and African governments simply forge ahead themselves, and stop asking for permission.

[1] https://www.devex.com/news/death-reform-and-power-rubio-spars-with-senate-over-usaid-cuts-110121

[2]https://www.npr.org/sections/goats-and-soda/2025/03/06/g-s1-52361/trump-says-male-circumcision-in-mozambique-is-a-scam-whats-the-program-about

[2]https://clubofmozambique.com/news/mozambique-doge-cuts-e9-5m-male-circumcision-programme/

[3]https://www.newarab.com/news/condoms-trump-claimed-went-gaza-could-have-gone-mozambique

[4]AIDS2060 Episode 2 features Dr. Andrew Kambugu, Executive Director of the Infectious Diseases Institute at Makerere University. Listen on Spotify, Apple Podcasts, and YouTube. Follow A Shot in the Arm Media on Substack, LinkedIn, and Facebook. [link to episode]

[5] https://idi.mak.ac.ug/

[6] https://iris.who.int/items/6c5f7bee-fde5-48f8-be3f-96388a4942c4

[7] https://avac.org/project/choice-agenda/

[8] https://au-ama.africa/

[9]https://en.wikipedia.org/wiki/Quality_Chemical_Industries_Limited

[10]https://www.wusa9.com/article/news/nation-world/state-department-says-pepfar-funds-to-south-africa-will-end-aids-hiv-health/65-dfea1e0a-be2b-4760-b288-bbf51ba5e00f

[11]https://iol.co.za/news/2025-12-19-the-2025-pepfar-funding-crisis-a-pivotal-moment-in-south-africas-battle-against-hiv/

[12]https://pmc.ncbi.nlm.nih.gov/articles/PMC12262123/

I want to tell you about a bar of Suchard’s Milka Praline chocolate. Ninety grams of Alpine perfection — down from 100, which is the subject of an actual German court case, but that’s a story for someone with fewer tumours and more time. I have coveted this chocolate since I discovered it on a school ski trip to Austria at age seven, a trip where I also lost my teddy bear on the night train from Paris to Salzburg, and was told by a teacher to “sleep at the other end of the bed and stop bothering everyone” while I was being spectacularly sick.

Formative times.

Recently, that bar of Milka sat on my dining table. My seven-year-old self wanted to inhale it whole - forget going through my mouth. My body, currently hosting stage four colorectal cancer and a fortnightly 46-hour infusion of a chemotherapy drug - 5FU - which I’ve taken to calling Five F**king U, had other ideas.

My body, it turns out, felt like a pool of battery acid. It was not interested in chocolate. It was not interested in anything. And so began another round of what I’ve come to call the Food Fight.

Why Eating Has Become My Most Exhausting Daily Battle

At times I truly believe my cancer is trying to starve me out. Other times, that I’m eating for two (well more than two as - Colin as I call the stage 4 cecum cancer that started this whole mess - is joined by innumerable little Colins in my peritoneum). Colorectal cancer, particularly in its later stages, triggers something called cancer cachexia, a metabolic syndrome that turbocharges your body’s energy burn while simultaneously chemically suppressing your appetite. The bugger. Charming.

Then you add the 5-FU chemotherapy - my maintenance therapy - which targets rapidly dividing cells and cheerfully attacks the entire lining of your digestive tract from top to bottom. The result: nausea, metallic taste, jaw and tooth pain so severe that for two days post-infusion I am essentially vibrating with discomfort, and mouth sensitivity that makes spicy food feel like a personal assault.

Not to be dramatic, but a grind of black pepper now causes the same sharp, sore, lingering pain as a super hot chilli or a mouthful of raw ginger.

I, a man who spent thirty years bravely overcoming
English boarding school cuisine to develop a genuine
appreciation of spice, am now defeated by a Jaffa Cake.

A Field Guide to My Destroyed Taste Buds

I’ve spent some time thinking about the layers — and yes, there are layers — of what cancer and chemo have done to my sense of taste. Consider this a public service announcement for anyone who thinks “taste changes” sounds like a mild inconvenience.

The metallic baseline. A persistent low-level metallic taste that never fully leaves. It is the house band that plays every night whether you want them to or not.

The sulfur problem. Eggs — which I have always enjoyed and desperately need for protein — now taste and smell intensely of the devil’s concoction, sulfurous to the core the moment they come near me. Doesn’t matter how they’re cooked. The effect is immediate and horrifying. Squash does the same thing, although I’ll be honest, I was never squash’s biggest advocate to begin with. My friend Yvette Raphael, visiting from South Africa, made a magnificent five-colour dish recently. I ate four of the colours. The squash and I agreed to disagree.

The tasteless tier. Strawberries are in season here in Sacramento. They are beautiful. I sense nothing. Zero. They may as well be warm water in fruit shape.

The texture problem. Meat — any animal protein — has developed a deeply unsettling quality in the absence of taste. It sits in your mouth longer than expected. It is simultaneously slimy and woody. It is, to use a precise clinical term, really bloody peculiar, and I say this as someone philosophically adjacent to the “meat is murder” school of thought who nonetheless cannot shake a longing for bacon. Specifically, bacon cooked to the point of the thermonuclear. The cure and the crunch still breach the nausea barrier. I am not proud. I will stop one day.

The survivors. Orange juice. And. Flavoured sparkling waters — which is bewildering because they market themselves as barely flavoured and yet somehow scale the wall of my nausea with ease. And, then of course, the Milka chocolate. The nausea fought hard. The chocolate won on points.

So What I’m Actually Eating (Erik will tell you it’s not enough.)

Eric, bless him, is engaged in a continuous low-grade campaign to get more calories and protein into me. This involves protein shakes, high-protein chips made from milk whey, and a running tally of what I have consumed that day, a task I find both irritating and deeply touching. He is right to worry. Am I not eating enough?

Breakfast: two slices of heavy multigrain toast. One with crunchy peanut butter. One with marmalade. Occasionally, if I’m feeling reckless, choco hazelnut spread instead of the marmalade. Two coffees. Non-negotiable.

Lunch: soup. Whole Foods pasta and kale, or a loaded baked potato soup that I have become slightly obsessed with. “Loaded” in America means bacon crumbles and cooked onion, which sounds modest but functions as a meal. Eric remains unconvinced.

Dinner: this is where it gets complicated. Pizza works — specifically a surprisingly good artisan frozen thin-crust with pepperoni or mushroom. Eric does a masterful pork loin with either ramen or mashed potato and Swiss chard from our garden, and that can work. What no longer works is pasta, which has adopted the same grimy texture as overcooked egg and is now dead to me. Bolognese, vegan or otherwise, is off the table — literally.

Dessert: fruit-flavoured Greek yogurt, or a Häagen-Dazs chocolate and almond vanilla ice cream lolly, consumed before 7:30 PM sharp, because I have discovered — the hard way — that eating later causes painful overnight reflux. I have added an antacid to the already considerable evening pill situation. We do not speak of it.

The Pot Chapter

I want to be straightforward about this because I still have some reluctancy about cannabinoids and I think my reluctance is still reasonable.

Kaiser referred me to an infectious disease specialist in their global health department who advises on cannabinoids. I was skeptical — the lack of clinical trial data makes dosing largely a personal experiment, which sits uncomfortably with my strong belief that patients should lead their own care while also having actual information to base with. I am not a card carrying member of the knit your own yogurt school of self health. But here is where I find myself.

Eric helps me with dosing. During the day: a CBD-only tincture for pain and fatigue. At night: a thicker blend of CBD with hints of CBN, CBV, and THC, taken about an hour before bed.

The daytime tincture, on at least one occasion, produced something genuinely remarkable — a veil of calm descending on what I can only describe as zombies of pain wandering aimlessly around my body. The night tincture hasn’t knocked me out directly, but it does something useful to my feverish, overactive mind and eases it toward rest.

I have also come to appreciate the tinctures for something unexpected: they have taste. The night one especially — a thick, dark, earthy elixir that breaks through the nausea barrier and feels properly medicinal. Old pharmacy medicinal. All it needs is a cold poultice for my head and some leeches on my legs.

We shop at two dispensaries here in Sacramento. The first is enormous — supermarket scale, security checkpoint, endless rows of product that make little sense to me but which Erik navigates with impressive competence. The second is a converted craftsman house in central Sacramento with a grand staircase, individual apothecary rooms, and a refrigerator of cannabis-infused soft drinks. I adore it. It has the energy of somewhere that has figured out how to be both a pot dispensary and a candidate for Interior Design Magazine simultaneously.

Do they improve appetite? The jury is out. The night tincture occasionally sends me to the kitchen at 1 AM with a sudden and focused desire for high-protein nacho chips. This is, I’m told, the munchies. I have reserved a bag of Werther’s Original soft chews for day time emergencies. I have not yet needed them. I remain prepared.

Peculiar Things to Mention

Despite all this gnashing of teeth and wrenching of clothes - despite every bloody I have written about above - here is the thing: I have gained weight. Specifically, a new hard, protruding belly that does not behave like body fat — it is firm to the touch and shifts with gravity when I lie down. I don’t know what it is. It could be fluid in the peritoneum. I am doing my best to be resigned about this, which is easier said than done, and I am raising it at my next palliative care call. I mention it here because I believe in transparency and also because Dr. Google and I are spending some quality time together and I’d rather you hear it from me first.

The Actually Good Bit

The garden is extraordinary right now.

We have strawberries, peppers, squash, and tomatoes planted — and I can see actual tomatoes forming, actual strawberry buds emerging, squash and pepper plants rooted and thriving. The lemon tree’s lone citrus fruit has been joined by baby oranges on the orange tree my sister helped me replant. Two elderberry plants are producing elderflowers. And — genuinely, a small miracle — a solitary fruit has appeared on our long-suffering pomegranate bush, and both guava plants are beginning to fruit.

I might not be able to taste strawberries right now. But I can sure as hell grow them! And there is something in that — tending to things, watching them come to life, having them be completely indifferent to cancer and chemo and the whole exhausting business of it — that I find enormously settling.

The garden has been one of the most reliable tools of calm throughout this journey. That it is now bearing fruit in quite so many directions feels like a bit of a gift.

Well thank you Erik Espera for everything as well as directing and editing this podcast. You can find Colon, Meet Cancer episodes on A Shot In The Arm Media’s YouTube Channel and wherever you download your audio and video podcasts. Don’t forget to subscribe and if I may humbly ask for 5 stars in review…

And a big thanks to you for staying on this journey with me.

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HIV: The contradiction of the Long-Term Emergency

I recently recorded a podcast[i] with three experts from the San Francisco Community Health Center, the first episode in a new series, AIDS 2060. I asked them two questions which have been bothering me: What does ending HIV mean, and what have we to start doing now and over the coming decades to celebrate the very last person on Earth to contract HIV?

The three, Lance Toma, the center’s Chief Operating Officer, Dr. Dan O’Neill, Chief Medical Officer, and Dr. Tatyana Moaton, Chief Strategy and Workforce Officer, all pointed to a disturbing contradiction at the heart of the current global response to HIV. You cannot run an emergency response for the long term. The two things are, by definition, incompatible.

Emergencies mobilize. They attract funding, political will, and public attention. But they are temporary by nature. They have a beginning, a middle, and — in the imagination of the governments and donors who bankroll them — an end. The moment the language shifts from emergency to chronic condition, from crisis to managed challenge, the money starts to find other priorities. The politicians find other speeches. The communities left behind are told, gently, that progress is being made and that they should remain hopeful.

The HIV epidemic is an emergency that is also, somehow, always just around the corner from being resolved. We have to stop thinking this way. We need to express clearly that what lies ahead is not a sprint to a finishing line but a structural reckoning with everything that has kept this virus alive and thriving not least in the world’s most marginalized communities. And that reckoning does not have a target date. It has a set of choices. And we are, right now, in the middle of making the wrong ones.

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The Anger of a Quiet Man

I have spent most of my professional and voluntary life since the 1980s in the fight against HIV and AIDS. I have quietly been part of the establishment, and I have been part of the anti-establishment – and on occasions, I have been both at the same time. However, a year ago I was diagnosed with stage 4 colorectal cancer, and that gave recognition to an anger that has been festering inside me all these years. For whatever time the Universe has left me with there are things I want to say, more directly and passionately. The HIV movement has had its achievements – which relate primarily to HIV treatment access – but we have all too frequently been out-smarted by those in power, and too often we have exaggerated our impact and influence. If we are going to end HIV as a threat to human health in this century, we need to own our mistakes and focus on implementing those achievable goals for tackling HIV in the future – goals that only we can really identify. AIDS2060 is my contribution to that debate.

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What and Why is AIDS2060

AIDS2060 is a short series of podcasts and Substack articles devoted to understanding what is needed to bring the HIV epidemic under control, how long that will take, and why the world has been unable to do so far. The first podcast episode looks at the future of providing HIV services to those marginalized populations who fall through the safety net in US cities, like San Francisco. Further episodes will follow with political, clinical and community voices from around the world, culminating at the global HIV conference, AIDS 2026 in Rio this summer. The resulting content will be collated into an online open resource for anyone interested.

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An Epidemic of Unmet Targets

“Getting to Zero[ii].” “An AIDS-Free Generation[iii].” “Ending AIDS as a Public Health Threat by 2030[iv].” The history of the global HIV response has, in part, been shaped by a history of targets — aspirational, internationally applauded, somewhat opaque, and almost entirely unmet. Some would say that this is exactly the point: Aspirational targets give us something to aim for. Achieving the target itself is secondary. However, each one shares a quiet, structural feature: It is set far enough into the future so that the authorities who endorse it can justify reducing their current budgets, with promises to increase investments somewhere into the future. It is far enough away that, when the date passes and the infections continue, the blame can be laid at the door of whoever happens to be in charge at the time.

International targets, especially in this new era of geopolitical chaos, have ceased to hold value. Let us accept that ending AIDS by 2030 will not happen. Let us hope that the UN does not set a new one in its political declaration for the upcoming General Assembly High Level Session on AIDS in June. Let it not distract us from the job at hand. Let us no longer be unhealthily beholden to the wishes and needs of one particular stakeholder – the public sector funder. The collapse of US government funding — at home and abroad — has exposed what was always true: public-private partnerships, paradigm shifts, and innovative funding mechanisms were never much more than paper tigers.

* * *

The Language Problem — Are We Ending AIDS or HIV

Language shapes ambition, and ambition shapes investment. In terms of raw grammar, “Ending AIDS” does not mean “ending HIV”. And that distinction — quiet, technical, almost bureaucratic in its framing — is to my mind, one of the most consequential sleights of hand in the history of global health policy.

The target that has guided (or constricted) the international response for the past decade, was decided by the UN General Assembly in 2016: End AIDS as a public health threat by 2030. Not end HIV. Back in 2016, I took “Ending AIDS” to mean the management of existing epidemic of a chronic disease to the point where the international community could reclassify it as something other than a crisis and redirect its attention, and its funding, accordingly. And I haven’t changed my mind since.

If the stated goal is treating our way out of a crisis, then the harder, slower, more expensive work of preventing new infections in the communities bearing the greatest burden can be — and routinely has been — quietly deprioritized. The emergency, on paper, is being addressed. The pipeline for a vaccine (notwithstanding the scientific challenges), or the structural interventions that might make marginalized communities less marginalized — these remain perpetually in “the next phase.”[1]

“Ending AIDS” does not mean ending HIV. That distinction is one of the most consequential sleights of hand in the history of global health policy.

* * *

Why Start with San Francisco?

I wanted the first podcast and Substack of AIDS2060 to be rooted in San Francisco – not because it is unique – but precisely because the challenges it faces can be found, in different guises and situations – all over the world, as we shall we see shortly. Furthermore – and this is not San Francisco’s fault - one thing above all else has disturbed me over the last few decades. The United States, the largest contributor to global health, has been extremely effective (even and especially under previous administrations) in telling countries how to spend those development dollars. Yet we have lived with the contradiction that the country has failed to provide cost effective, accessible and effective healthcare to the people living inside its borders.

San Francisco’s relevance to the future of the global AIDS response is not just historical. While the first recognized cases of AIDS were reported in June 1981, when the CDC published reports of a rare Pneumocystis carinii pneumonia in five young gay men in Los Angeles, San Francisco was a fast follower. By 1984, San Francisco had the highest per capita rate of infection in the US, largely in its LGBTQ community. It was a catastrophe that the federal government refused, for years, to name. What emerged from that catastrophe was the San Francisco Model[v] - of community-led care, of radical inclusion, and of the insistence that the people most affected by an epidemic must be the ones designing the response to it.

Interestingly, this approach to HIV care also began appearing in other parts of the world – in Uganda, for example through TASO[vi] (The AIDS Service Organisation) founded in 1987, and community support networks in other countries in East and Central Africa, including through faith-based networks. The models were born out of necessity – the lack of funding and lack of healthcare professionals. It has been interesting to see how supposedly well-resourced cities like San Francisco have taken approaches that mirror those taken in Africa and other parts of the world over the last few decades. The San Francisco Community Health Center’s street outreach programming bears similarity to community outreach programs in poor urban areas adopted by LVCT Health[vii] in Kenya, Pangaea Zimbabwe AIDS Trust[viii] in Zimbabwe, and Shout It Now[ix] in South Africa, for example.

The San Francisco Community Health Center sits in the Tenderloin — the epicenter of the city’s fentanyl epidemic, home to over half of San Francisco’s unhoused population. They are the hardest-to-reach, most multiple-marginalized people in one of the wealthiest cities on earth.

The San Francisco’s Getting to Zero strategy was a somewhat of a success story until January 2025. New HIV infections in San Francisco were halved — from over 300 per year to around 140 — through a three-pronged strategy: Pre-exposure prophylaxis (PrEP) expansion, rapid treatment initiation, and active re-engagement of people who had fallen out of care. It worked. And then it hit the wall of political reality. There has been a recent uptick. The full consequences of the federal budget cuts will not be visible in the data for another two years, but Lance Toma’s assessment was unambiguous: we are set back years.

What the Center’s work shows us, concretely, is both the potential and the fragility of progress. Long-acting injectable antiretrovirals — administered by street medicine teams who know where their patients sleep, who go to them rather than waiting for them to come in — have been genuinely transformative for people whose belongings, including their medications, are routinely swept away in city clearances. In the Tenderloin over the past year, half of unhoused people had their belongings confiscated; of those, half lost their medical supplies. Only ten percent ever got them back. For that population, a once monthly or twice-yearly injection is not a convenience. It is the difference between being virally suppressed and not.

The center’s model, as Tatyana Moaton described it, is whole-person care — integrated, affirming, beginning from where the person is rather than where the system would prefer them to be. You cannot begin a conversation about HIV care and treatment with a trans woman if you have not first seen and affirmed her as a person. You cannot address viral load in isolation from housing, food security, addiction, immigration status, and safety. This is not a radical proposition. That it is still considered radical is preposterous.

* * *

Where We Actually Are — Not Where the Press Releases Say We Are

The numbers[x]: 40.8 million people living with HIV globally. Only 31.6 million of them on treatment. 1.3 million new infections per year. Read that again. This is not a crisis winding down — it is a crisis that has been managed into a state of tolerable, fundable permanence.

Then last year, in January 2025, came a seismic shock to the system. The United States — the single largest investor in the global HIV response — didn’t just reduce and deprioritize its investments. It did so suddenly, chaotically, and with the cruelty of people who have no idea and no concern for what they are cutting. PEPFAR gutted. The CDC and NIH decimated.

But here is the rub: You cannot flip this switch back on. The clinics, the staff, the supply chains, the surveillance infrastructure, the community trust built over decades — these are not line items. They are ecosystems. And ecosystems, once destroyed, take generations to grow back. As Dan O’Neill put it to me in San Francisco: when someone shows up at their clinic to collect their HIV medication and there is no clinic, no staffing — you cannot rebuild that for the next generation by passing a resolution at the next UN General Assembly.

The clinics, the staff, the supply chains, the community trust — these are not line items. They are ecosystems. And ecosystems, once destroyed, take generations to grow back.

There is also the surveillance catastrophe[xi], which is receiving far too little attention. The United States funded most of the world’s HIV monitoring infrastructure and then dismantled it. The consequences are not merely technical. Funding follows data. If you cannot see the epidemic — cannot track where new infections are occurring, in which communities, under what conditions — you cannot make the case for the resources needed to address it. Dan O’Neill noted, erase the data, and you erase the argument. This is not an oversight. It is, as he put it plainly, a deliberate strategy.

* * *

The Populations We Are Leaving Behind — By Design

One clear indicator that the people most in need of services are not being met can be seen in PrEP access numbers which are, frankly, scandalous. According to CDC data from 2022[xii], around 94% of white Americans who could benefit from PrEP have been prescribed it. For Black Americans, that figure is 13%. For Hispanic and Latino Americans, 24%. Young people aged 18 to 24 are barely registering in terms of consistent coverage.

94% of white Americans who could benefit from PrEP have been prescribed it. For Black Americans, that figure is 13%. This is not a market failure. It is a policy failure, and in the current US environment, something closer to a deliberate one.

These are not the numbers of a response that is working for the populations most at risk. They are the numbers of a response that has, structurally and repeatedly, directed its most effective tools toward the communities that were already best placed to access them. This is not a market failure. It is a policy failure, a structural failure, and — in the current US environment — something closer to a deliberate policy decision.

The trans population is, in Tatyana Moaton’s phrase, the canary in the coal mine. According to the CDC’s own data[xiii], two in four Black and brown transgender women are either living with HIV or at acute risk of contracting it. This is not a margin. It is a public health emergency hiding in plain sight — and the current administration is engaged in a systematic effort to erase the data that proves it exists. As Moaton put it with quiet ferocity: the population does not disappear because an institutional body decides to stop counting it. The infections do not go away. They are forced to the margins, away from testing, away from care, away from the surveillance systems that might otherwise flag the scale of what is happening.

Tatyana also raised the increased risks for people who are not medication-adherent. The compounding effect of interrupted treatment, eroded trust, and the withdrawal of care is not just an epidemiological catastrophe. It is a deliberate one. A rising community viral load means rising transmission. The people who will pay for the current administration’s choices in new infections and preventable deaths have, in many cases, not yet been born.

To understand the extent of the current US administration’s hostility to trans populations, just read the counter-terrorism report just released by the US Whitehouse[xiv]. In addition to cartels and Islamist terror groups, the US counter-terrorism activities will also “prioritize the rapid identification and neutralization of violent secular political groups whose ideology is anti-American, radically pro-transgender, and anarchist.”

* * *

The Biomedical Pipeline — Cautious Optimism, Heavily Caveated

One of the scenarios that troubles me most for the long-term outlook is the possibility that the drug pipeline peaks in the mid-2030s, the market stabilizes around good-enough regimens moving toward off-patent availability, and the pharmaceutical industry moves its attention and its capital elsewhere. Plausible. Depressing. Yet, according to Dan O’Neill, wrong.

We are, he argued, at a genuinely seismic moment in the development of long-acting HIV therapies and prevention tools. New drug classes — capsid inhibitors, translocation inhibitors — have joined the existing arsenal. Lenacapavir, a once-yearly intramuscular injection represents a dramatic change to both treatment and prevention. Weekly oral options are in development. And unlike many areas of infectious disease, HIV retains commercial investment incentive precisely because it remains a lifelong chronic condition — there is a payer for the lifetime of the patient, which is not true of a course of antibiotics.

The caveat that matters more than the innovation is this: What is the point of a once-yearly injection if 87% of Black Americans who could benefit from the pill that preceded it cannot access that either? Dan is convinced that the next generation of tools will be remarkable. Whether they reach people in need at the same time both in rich cities in the northern hemisphere as well as large populations in less economically developed countries in the southern hemisphere depends purely on public and political will.

Dan floated an image that I found both appealing and politically treacherous in the current moment: the possibility of administering a once-yearly HIV prevention injection alongside the seasonal flu vaccine. Walking into your GP or pharmacy, getting your immunizations, and leaving protected. It is the kind of normalization that would genuinely change the calculus of access. It is also, in an environment of aggressive anti-vaccine sentiment and a federal government that has actively dismantled public health infrastructure, precisely the kind of proposition that requires enormous political and community will to implement. Framing lenacapavir as a something close to a vaccine, as he noted with dry precision, might not be the best strategy right now. The disease of mis and disinformation about health, and vaccines in particular, born in the USA, is being exported through social media throughout the world, potentially limiting their impact in other countries. Another form of health imperialism.

* * *

The AIDS Movement Itself — Still Fit for Purpose?

There is another question that the HIV community around the world does not ask itself: Are we fit for purpose?

I think we still are, in large part. I’ve just volunteered to be part of the Fight Colorectal Cancer’s Community of Champions network.[xv] The philosophy, strategies and tactics appear at first glance to be rooted in the lessons of the HIV response. Not so much the direct action of ACT UP, but the more “in your face” advocacy with decision makers that groups like South Africa’s APHA (Advocates for the Prevention of HIV in Africa)[xvi] excel at. It will be interesting to see how this plays out as I finally enter the family of “people living with…” in this case colorectal cancer.

The HIV movement is not perfect of course. It has been accepted for a while now that the the leadership of American AIDS organisations can still be reflected the demographics of the communities that founded them: largely white, largely gay men. That is changing. The San Francisco Community Health Center is, in some respects, a model of what a different kind of leadership looks like: led by and for the communities most affected, integrating trans leadership, communities of color, people with lived experience of the epidemic’s hardest edges. But the question of whether that change is happening fast enough, and in enough places, remains open.

What Lance Toma described happening locally at the San Francisco Community Health Center and nationally at NMAC[xvii] (where he is Board Chair)— building coalitions not just within the HIV world, but across movements — is essential. We cannot fight US federal far-right populism on our own. Further, the attacks on abortion rights and the attacks on gender-affirming care are not separate phenomena. They are the same phenomenon, directed at overlapping communities, using the same logic of erasure. The HIV movement learned to build coalitions in the 1980s because it had no alternative. It is being asked to learn that lesson again, at a moment when the communities it serves are under assault from multiple directions simultaneously.

The risk for the US HIV movement is that, understandably, it is coalescing around the crises of the moment — the war of aggression being waged by the Trump Administration. How do we prepare for what comes next? While I dare not predict the results of upcoming elections, it is fair to say that the electorate of the US is split, and while it appears that over half the population believes in rights and evidence-based policies, the other half places greater emphasis on ideological role-play, oblivious to the consequences. We may be shell-shocked, exhausted and under-resourced, but we cannot retreat into our corners and wait for a friendlier administration. Even if such an administration is elected in 2028, the list of priorities that need repairing are so great, we need to agree now how we advocate for the appropriate prioritization of our own communities, with other communities we haven’t traditionally worked with – for example cancer. We must be prepared for negotiation and compromise for the broader repair of the United States. The same can be said for the global HIV movement, and indeed the broader global health movement, in which we must firmly root ourselves.

The global HIV movement learned to build coalitions in the 1980s and 1990s because it had no alternative. It is being asked to learn that lesson again.

There is a counter narrative — and Dan O’Neill made it – and I cannot dismiss it — that moments of intense scarcity and political attack have historically produced the most creative and durable responses. That what looks like destruction might, in time, look like a hard reboot. My issue is that all too often organizations retrench and focus on – and fight for - their core services, rather than exploring outwardly how to build new partnerships and shared ownership. Perhaps both narratives have elements that we can work with. But neither argument excuses us from the fundamental challenge. We need to identify and agree the priorities that matter, and fight for them.

* * *

What Might the Future Look Like

I asked the three people I spoke to in San Francisco to imagine the closing plenary of the International AIDS Conference in 2060. Let us imagine that the conference has returned to San Francisco. What is the one announcement, the one moment, that would make it worthwhile?

None of them said: we will have ended HIV. None of them said: a cure was announced and being rolled out to every human being on earth. What they described, each in their own way, was something more structural and, in some respects, more ambitious.

Tatyana Moaton described infrastructure — not built and then abandoned, as so much of the global response has been, but built to sustain itself. Globally connected, community-owned, self-sufficient. Trans women in San Francisco exchanging best practices with trans women in Thailand. Referral networks operating outside the reach of executive orders. A system that is not dependent on any one government, any one party, any one donor — because this moment has taught us, with painful clarity, what that dependency costs.

Dan O’Neill’s vision was less about HIV specifically than about what HIV forced us to learn. He invoked the story of penicillin — not Fleming’s discovery, which is the part everyone remembers, but Florey’s distribution of it, the part that changed medicine. The long strategy to tackle HIV, in his imagining, would be the story of how the HIV response taught us to address poverty, gender inequality, addiction, housing insecurity, and racism — not as the social context of a disease, but as the disease itself. And how we applied those lessons to climate, to food scarcity, to the next emergency that will, inevitably, arrive.

For Lance Toma, black and brown trans people, drug users, immigrants, the unhoused — the communities that bore the epidemic’s worst weight, for the longest time, with the least support — were now running the show. Not being advocated for. Not being included at the table as a gesture of good practice. Running it. Claiming their victories. Because those victories, if they come, will belong to them.

The most important lesson from this episode was for me that targets in themselves have not been without some value. Building consensus around an aspiration is not unhelpful. But we must move on and break away from the contradiction that underpins our global HIV strategies: trying to end a long-term crisis with short- term tactics. Human society needs to digest and act on the reality that HIV is a challenge we will be tackling in one form or another for nearly all this century.

The small, stubborn, possibly delusional difference I am trying to hold onto — what does ending HIV take? And are we as a global society in solidarity willing to do it? In other words, will there ever be the last person to be infected with HIV? And are we prepared to meet them

[i] AIDS2060 Episode 1 features Lance Toma, Dr. Dan O’Neill, and Dr. Tatyana Moaton of the San Francisco Community Health Center. Listen on Spotify, Apple Podcasts, and YouTube. Follow A Shot in the Arm Media on Substack, LinkedIn, and Facebook.

[ii] https://gettingtozerosf.org/

[iii] https://www.unicefusa.org/what-unicef-does/childrens-health/immunization/hiv/aids-free-generation

[iv] https://www.un.org/en/academic-impact/countries-commit-action-end-aids-2030

[v] https://en.wikipedia.org/wiki/The_San_Francisco_model_of_AIDS_care

[vi] https://tasouganda.org/

[vii] https://lvcthealth.org/building-an-inclusive-future-lvct-health-at-the-african-regional-convening-towards-women-deliver-2026/

[viii] https://pangaeazw.org/

[ix] https://shoutitnow.org/

[x] https://www.unaids.org/en/resources/fact-sheet

[xi] By the way, the best, most timely and accurate description of what is happening as countries try to make sense of the US funding cuts can be found at friend of the Pod, Emily Bass and her own Substack https://emilysbass.substack.com/

[xii] Expanding PrEP Coverage in the United States to Achieve EHE Goals, October 2023

[xiii] https://www.cdc.gov/hiv/data-research/facts-stats/transgender-people.html

[xiv] https://www.whitehouse.gov/wp-content/uploads/2026/05/2026-USCT-Strategy-1.pdf

[xv] https://fightcolorectalcancer.org/

[xvi] https://www.apha.org.za/

[xvii] https://www.nmac.org

Let me start with what some might find a controversial statement: Chemo is your friend.

Not your enemy. Not an angel, not the devil. Maybe more like a close relative—you love them, but my god do they have issues. You need to know when to walk away, when to give them time out, but you still love them.

Chemo’s Unlikely Origins

Chemotherapy has its roots, like so much innovation in the 20th century, in its two world wars. On the battlefields of France, doctors discovered that soldiers poisoned with mustard gas showed lymphatic tissue and bone marrow destruction. This led medical researchers to wonder: could mustard gas treat cancer in lymph nodes?

Fast forward to World War II, and scientists discovered that people exposed to nitrogen mustard developed significantly reduced white blood cell counts. Two prominent Yale pharmacologists, Alfred Gilman and Louis Goodman, examined the therapeutic effects of mustard agents in treating lymphoma. A revolution in cancer treatment was born from violence.

Chemo gets a bad rap. It’s called poison (well, isn’t everything in the right dose?), accused of causing more pain than the cancer it treats, dismissed as unnatural. But here’s what I find fascinating: some chemotherapies have their roots in nature.

Paclitaxel, used extensively in breast and ovarian cancer treatment, comes from the bark of the pacific yew tree. Irinotecan—one I’m taking—is made from camptothecin, found in the Chinese ornamental tree Camptotheca Acuminata. Nature, it seems, has been working on cancer solutions longer than we have.

My First Tango with Chemo

My first cycle started just under two weeks ago. In four days, I’ll start round two. I want to share what this experience is really like—not the sanitized version, but the raw, complicated truth.

The treatment I’m on is part of the TRIBE-2 trial, which showed strong evidence for aggressive multi-chemotherapy for right-side advanced colorectal cancer. It’s spread over 46 hours: 6-8 of those at the Kaiser infusion clinic, the remainder with a pump attached to me.

Walking into that clinic with Erik, I met a terrific nurse. I’d placed a lidocaine patch over my port, so when the needle went in, I didn’t feel a thing. She admired the surgeon’s work—a small moment of professional pride in the midst of medical necessity.

The Cocktail

What follows is an unholy brew of different agents, each with its own personality:

Bevacizumab goes in first—the drug that slows the growth of new blood vessels, helping to stop cancer from spreading.

Then irinotecan, which blocks DNA replication in cancer cells. I love its mode of action: it blocks the enzyme topoisomerase I, crucial for DNA unwinding and replication. By blocking this enzyme, irinotecan causes double-strand DNA breaks. It literally rips apart both strands of DNA. Nothing can survive that, and the cancer cell dies.

Then comes the killer: oxaliplatin. Yes, I’m getting the platinum service, and yes, it’s derived from platinum. It has the most brutal and immediate side effects.

I’d nodded off, but I wake up with a swollen tongue. I’m cold, my jaw hurts. I sound like a bizarre mashup of British politicians—imagine Nigel Farage with a cigarette between his lips, a pint in his hand, and a Molotov cocktail in his mouth.

The nurse brings warm water. I drink it, and the swelling subsides.

Oxaliplatin’s mechanism against cancer isn’t fully understood, but it seems to force its way into any DNA of cells thinking of replicating, preventing duplication and causing death. It’s the one we watch most carefully because it causes peripheral neuropathy—damage to nerves, particularly in hands and feet. This manifests as numbness, tingling, or sensitivity to cold.

It’s why I can’t eat anything cold, including the lovely mango Greek yogurt in my fridge. It’s also why my oncologist monitors this drug so closely—the neuropathy builds up over cycles, and treatment must stop before it becomes permanent.

Finally, there’s fluorouracil (5-FU), infused over 46 hours through a pump I carry home. Maximum time to kill as many cancer cells as possible.

Life with Myfanwy

That pump gets a name: Myfanwy. She’s housed in what I generously call a fanny pack—though I need to find something classier than the Kaiser Permanente freebie. Can’t let the dogs near me because they might get entangled in her tubes.

On Friday afternoon, we return so Erik can learn to disconnect both the pump and the port connection. Then the real fun begins.

I lose track of time. Don’t want to eat, don’t want to sleep—just a deep, agitated malaise and fatigue that washes over everything. This clears by Monday. Mostly.

The hiccups are relentless. Nausea, surprisingly, not so much. The fatigue is appalling and offers no respite, even with sleep.

I don’t go near cold water. I don’t drink coffee—can you imagine? I don’t think I’ve missed at least one cup of coffee a day since I was fifteen.

The Reality of Side Effects

The diarrhea and constipation caused by damage to my digestive system lining has been severe—so much so that there were moments I would have begged for hair loss instead. I’m constipated, but when I can go, it’s diarrhea. And it hurts.

This creates a confusing situation because I’m technically in remission from Crohn’s disease. There’s an art to tackling symptoms while understanding their cause and choosing the right treatment.

Following instructions, I took moderate doses of Imodium—two to three per day. But Imodium is too good at shutting everything down. Everything stops, and when nature inevitably calls with increasing urgency, disaster strikes.

That first Sunday evening, Erik left to collect our friend Emily just as I was tucked up in bed. Shortly after, I felt nature’s urgent call and made it to our bedroom toilet with my usual speed. But when I sat down, something strange happened.

I was straining—borrowing from the Rolling Stones, I couldn’t get no satisfaction. Then I saw stars, felt my body leer left, and was out cold. I woke up trapped between the toilet and the wall, having quite literally scored what my grandmother would call “a conflation of wind and water.”

As I struggled to stand, I saw stars again, felt myself tilting forward into an open IKEA towel stand, and woke with my head nestled comfortably on a towel. I briefly wondered if I could stay like this forever.

Learning New Vocabulary

The oncology nurse taught me a new word: “vagaled.” Some primordial response from evolution’s earliest days—my straining alerted the vagus nerve, which signals the heart to slow and blood vessels to widen. Blood pressure drops, blood flow to the brain reduces, and fainting results.

The vagus nerve first appeared in primitive vertebrates and connects all major organs, primarily involved in basic survival functions. Psychologist Stephen Porges hypothesized it evolved from a “vegetative vagus” in primitive vertebrates to a more complex system in mammals, supporting social engagement and emotional regulation.

Not a view widely accepted by the current social neuroscience field. I don’t even know what social neuroscience is. I think I’m disappearing down too deep of black hole. You’ve all got Google. Check them and Stephen out. Think Stephen would be a good guest for A Shot in the Arm Podcast.

I Meet My Cancer Head On

On the first Monday evening after chemo, I experienced the most excruciating pain of my life in my right colon. It radiated down into my buttock and up the ascending colon—as if a wine bottle opener were being corkscrewed into my flesh. Tears, clenching, spasms. Two oxycodone tablets, and within half an hour, the pain subsided, leaving me weak and nauseous.

My oncologist thinks it was likely the largest tumor on my cecum making itself known. So not only does my colon have cancer—I meet it very directly. It hurts, and I want it gone.

Right now, as far as I’m concerned, chemo is on my side.

What Chemo Actually Does

It’s not complicated—pretty direct, useful, and sometimes brutal. Chemotherapy uses powerful chemicals to kill fast-growing cells in our bodies. It destroys cancer cells by damaging them so they can’t divide and grow.

Different drugs work in different ways: damaging the cell’s control center, interrupting chemical processes in cell division, damaging cells while they copy genes, or damaging them at the point of division.

Cancer cells divide much more often than normal cells, so chemo is more likely to kill them. But here’s the rub: chemo doesn’t distinguish between cancerous and healthy cells. It destroys any cell that grows and divides quickly—hair, bone marrow, skin, and the digestive system lining.

I’m lucky. My regimen has mild to moderate risk of hair loss, comforting to my ego. But the digestive damage has been severe enough that there were moments I’d have preferred baldness.

The Art and Science of Treatment

My oncologist called the week after my first treatment—not to discuss efficacy, but deeply concerned about side effects. What was I feeling? How to address symptoms? What to expect?

I asked my oncologist what he might want from this podcast series. He said: “Break the silence, tackle the fear.” Exactly what I want to do.

The use of chemo in my treatment perfectly expresses the interplay between science and art in medicine. The doctor is called to do no harm as a minimum, but there’s an art to balancing benefit and burden, efficacy and quality of life.

Moving Forward

As I prepare for my second cycle, the digestive issues remain unresolved. I think this will be the key side effect I’ll navigate with my care team.

Friends have arranged to spend time with me during the four months I’ll be on chemo. Emily Bass arrived for a fabulous week—she, Erik, and me finding joy even in the midst of recovery. I watch them eat and drink wine while I sip and nibble, and somehow this becomes its own kind of beautiful.

A Sort of Relevant Side Bar, Possibly Not…

I have a phrase use in work in global health to describe a difficult, complicated, confusing, irrelevant or just downright baffling situation, behavior or person. It’s called “at the bottom of the garden with the fairies.” So that meeting or comment was truly at the bottom of the garden with the fairies. Or that person’s behavior, attitude - and sometimes just that person in Toto - is at the bottom of the garden with the fairies.

Sometimes, and this has happened more frequently since our global health movement has been under attack this year, the people the meeting the situation as well as the the fairies they have met at the bottom of the garden, have crossed over the fence and are now traipsing aimlessly in the orchard behind it and if they aren’t careful will be heading for the river bank. And then there will Be no guessing what will happen next.

Well, one afternoon, I’m taking a needed doze and I wake up, to see both dogs staring out of our bedroom’s sliding doors into our back yard. They are mesmerized.

Who or what has bedazzled them?

And there down at the bottom in front of my raised plant beds, sitting on a winding path and head poking above Sacramento native drought tolerant plants, as well as rosemary, olive and lavender, is Emily, speaking assertively into her cell phone. There is not, I’m delighted to say, a single fairie in sight.

The origins of this phrase at the bottom of the garden with the fairies are of no relevance, significance or even interest really, and so I’ll rush over them. According to Miriam Bibby BA MPhil FSA Scot, a historian, Egyptologist and archaeologist with a special interest in equine history in the historic dash uk dot com website:

“There are fairies at the bottom of our garden,” announces the opening line of a poem by Rose Fyleman first published in 1917. Coincidentally, that was also the year two intelligent and talented young conspirators managed to convince some very well-known people that there really were fairies living near Cottingley Beck, the stream that ran past the foot of their garden.”

So that’s us told then. Moving right along.

Wrap Up

Chemo is my friend. Complex, difficult, sometimes brutal, but fighting on my side. And right now, that’s exactly what I need.

This is part of an ongoing series about my cancer journey. Thank you for being on this path with me.

This post is about being diagnosed with colorectal cancer.

More than that, it is a promotion for a new series of podcasts about being diagnosed with colon cancer, “Colon, Meet Cancer,” launched today by A Shot In The Arm Media. I tell my story and I also ask, what purpose do digital stories told in real-time by people sharing their experiences of being newly diagnosed with life-altering conditions serve? Beyond the obvious self-centered, sometimes purient, intentions, do they make a positive difference? Or are they lost in the “me! me!-sphere” where everyone is a content creator?

See what you think.

It is the 22nd of May, 2025, and I check into Kaiser Permanente’s South Sacramento outpatient facility for my annual colonoscopy. I was diagnosed with Crohn’s Disease when I was in my late teens, and since I was in my forties, colonoscopies have become part of my regular care plan. A small camera winds its way up my rectum and into my colon see how much inflammation there is and what other bits and pieces might be there for the gastroenterologist to find interesting.

Crohn’s Disease is an inflammatory bowel disease found mostly in the gastrointestinal tract, but it can be found anywhere from your mouth to your anus. Symptoms for me are simple - diarrhea I can barely control, and chronic fatigue all over my body, found in my bones and joints. I was diagnosed when I was 18, although I likely had it for quite a few years before that, before or potentially even during puberty. Indeed, my father is convinced that it stunted my growth and is the cause of what he considers to be my little legs - thank you old chap!

So, I'm lying on an investigation table waiting for the GI doctor. I've spent the last 24 hours prepping with the foul soapy testing liquid that clears out the gut. The preparation has got better over the years. It's no longer the gag and spit across the kitchen followed by a dash to the toilet. It is, nonethless, horrendous.

I have not eaten for a day, and for the last few hours, absolutely nothing has passed my lips, leaving my teeth dry and oddly furry. I'm lying on my back, staring at a relaxing photo placed strategically on the ceiling in front of my eyes. It's blue sky, white sandy beach and a palm tree. Very relaxing. Except, I think this must have been what Bikini Atoll was like seconds before the detonation of Gilda, the first atomic bomb at the start of Operation Crossroads.

Then the medical team comes in - and knock US healthcare as much as you like (and indeed we must) - but you can't fault the efficiency of Kaiser Permanente's nursing staff: They get me to lie on my side, put a needle into my arm, and then the highlight of any colonoscopy, they give me the good stuff - the sedative.

It's not an anesthetic, and they say it won't knock you out, but it usually does. One colonoscopy a few years ago, it didn't completely send me to sleep, and I was in a sort of high-as-a-kite Disney ride, able to see inside my colon, multicolored and oddly fascinating. This time as I'm injected, I can feel the sedative weaving its magic, and I think I get as far as saying “Oh… Yeah…”

If that is indeed what I said, it is embarrassing.

I wake up and I'm in a recovery room with my spouse, and the GI doctor, and I'm not at all sure what is happening and what is being said to me. And the GI doctor, well, she has to keep prodding me to stop me from going back to sleep. She is trying to tell me something and I cannot tell you, for the life of me, what that is.

So thank God my spouse is there to take in all that is being said. I do notice that the doctor looks concerned. Actually, she looks a bit emotional, but of course, now that I'm waking up, I have got other priorities to focus on: The two McDonald's cheeseburgers that will be the first things I eat after the procedure.

All credit to my GI doctor. While I wish she would leave me alone and let me return to sedated sleep, she continues to poke me. As a result I realise;

a) a tumor has been found, an ulcerated mass in the ascending colon near the cecum, which connects to the ileum, which is where Crohn's is often found; and,

b) she has tattooed the area because she is referring me to a surgeon who will talk to me about removing the damn thing.

Of course, I focus on the tattoo bit because I've never had one before, and the I am struck at how absurd this is: that it should be on the inside where only the surgeon - and no one else - can see it. I'm also being referred to for a computed tomography (CT) scan, which may provide additional insights into whether cancer has spread elsewhere.

And then I remember that I need to make a pitch to the team to subscribe to my podcast “A Shot In The Arm Podcast”.

I mean, hey, it's a captive audience. Frontline healthcare workers - these are my peeps. I don't remember whether I do actually ask them to give me five stars wherever they download the audio podcast and to visit our YouTube channel, like it, and smash that notification button to get the heads up on when new episodes drop. But I know I try.

After two tasty cheeseburgers, I am being driven home and I am relieved that the procedure is over for another year. I am, therefore, upbeat and that is the way my spouse and I continue to feel for the next week. I get the CT scan, the results of which suggest there is no spread to other organs, although they come with such important health warnings from both GI doctor and scan technician, not to read too much into the results, one wonders whether they are of any value. But even so, I say to myself and to my spouse that we must, “slow down, people!”. We are not in a rush to get to a connecting flight at Oliver Tambo International Airport in Johannesburg.

And then the GI doctor rings. The biopsies have come back. It's cancer, it needs to be removed. Call the surgeon to get an appointment as soon as you can. In other words, “people, we must speed up”.

In fact, the surgeon's office calls me as soon as we hang up, which strikes me as a bit presumptuous for an isolated, ulcerated mass, which hasn't spread or which hasn't damaged my liver or kidneys.

The surgeon patiently explains to me that it is not possible, at this stage, to determine what stage the cancer is at. Although he says Hallelujah. It isn't the most serious stage four, where it's everything everywhere, all at once. We will not know if I will need chemotherapy, until an oncologist has taken a look at the tumor that the surgeon removes.

I ask, and it's just a day procedure, right? I seem to recall my GI doctor suggesting that miracles can be worked these days and I can be home at the end of the day. A sort of New Jersey “eat it and beat it” diner-approach to medical interventions. Well, no, he replies. It is an inpatient procedure, it is serious, and it will probably require me to spend three to four nights under observation. After all, the surgeon needs to be sure that the sewn up connection is secure and will not leak.

My gut is not a hose, I think, but then I correct myself. It is actually a hose, if you think about the need to move soft material and liquid from one place to another efficiently, and without anything leaking. Of course, preparation for the surgery is going to require another 48 hours of fasting and I will need add a course of antibiotics to the preparation. Worse still, I'm required to show up at 5:45 AM of the day of the procedure.

Now it may strike you and, perhaps it strikes me too that I'm being a bit blasé. But that may be because I can't face the alternative.

My approach is to let myself enjoy this moment, let me feel whatever I am actually feeling. I am somewhat removed, having an “out of Ben” experience. I know the diagnosis is likely serious, but I cannot appreciate the connection to me. This is interesting. I've always wondered how people respond to major life-threatening diagnoses. I mean, I've worked in HIV all my life and I've had a couple of narrow escapes myself (and you would know what Im talking about if you had subscribed to the Business Fights AIDS podcast, like it and give it five stars… ).

I have never taken myself, or my health, too seriously. There was a time in the summer of 2000 when I had a month in London before starting work at UNAIDS in Geneva, and I had nothing to do, so I went to the gym every day. I got myself a trainer and ate egg whites. At the end of that month, I was very disappointed that the outcome was really no different from when I started.

As I moved to Switzerland, I decided never to bother again. While I may not take my health or myself seriously, I do take my work and my vocation, as it were, very seriously. And so I'm wondering also whether this experience could help further my understanding of what the bloody hell I can do, if anything, to support the next phase of the global AIDS response, as the US Government forces it into free-fall (and more fool all of us for having relied so explicitly on the largesse of the US, soft power be damned).

Furthermore, now that we are half way through 2025, and everything is tits to ass up on its face, perhaps I am facing a set of serious issues - from my mortality, to pain management, and the effects the diagnosis may have on my marriage - that I simply cannot handle at the moment.

And how exactly would I handle them?

Negotiate with this ulcerated mass and say, look, I'll let you do this damage to me over that period of time, if you let me have this experience, read that new novel from Margaret Atwood and have these years my spouse, that final career opportunity….

If I am being honest, I have known something has not been right for a year. I thought I was experiencing a flaring of Crohn's symptoms. The need to use the lavatory, urgently without notice, the sharp pains to my insides after each bout of chronic diarrhea, and the raw fatigue underpinning my every move, these should have told me that something else was afoot. However, it was easy to misread them.

Which brings me to podcasting. I have decided to document the colon cancer journey I am embarking on - however short (because treatment is radically effective!) or long it may be. It is a 21st century version of diary-writing. And if people choose to watch or listen, they are most welcome. And if they dont like it, they can cancel me.

I have debated whether I should be doing this at all, whether my experience of colorectal cancer should rather remain deeply private like my family history in the 1570s (there is a podcast in that too, once we have got to the bottom of what actually happened). However, my colon cancer story may be useful to practitioners and policy makers, as well as resonating with people going through their own experiences, if I do share what it is like not from the perspective of a public health professional - But shock horror - as a real person.

There is a broader context too: All forms of evidence-informed content creation rooted in clinical science, are essential these days because, let's face it, in 2025, medical science in the United States of America is under unprecedented threat from wilful populist disinformation, not least from the foolishness of Trump’s Secretary of Health and Human Services and his coterie of internet skeptics. While we counter medical fascism for what hopefully will be no more than another four years, there is also the ongoing experience healthcare in the US that seems worth documenting. The US is the richest country in the world, and yet, unless you are extravagantly wealthy or never unwell, you are better off being treated in other countries with more equitable and affordable healthcare systems. I know that I would find it interesting to learn more about navigating healthcare in the Republic of California in the mid 2020s, warts and all.

However, it is busting the stigma and discrimination, whether from ourselves or from others, that strikes me as most problematic about colon cancer. I am an old dinosaur AIDS activist from London’s early 1990s. It is embedded in me that we not only smash down what we fear, but we build up community in the hope that we can be more comfortable talking about what ails us, and then demand research into and access to better treatment decisions.

So I end this preface with a conversation I had with my niece a few days ago, which it strikes me has a Proustian “ À la recherche du temps perdu” relevance for me in this moment.

She rang to express her condolences on the death of one of my favorite pop stars - Neil Tennant, one half of the Pet Shop Boys. Now hold your horses. Neil is as far as I'm aware, and at time of writing, still very much alive. No, my niece was confusing Neil with Brian Wilson of the Beach Boys, a mistake she considered easy for a Gen Z to make.

I offered to take her to a future Pet Shop Boys gig, assuming that their venues have abundant, accessible and clean toilets, which presumably are a must for most Pet Shop boys fans these days.

“They can still perform in public?” she asked in askance. “My God, they should call their next World Tour the Antiques Roadshow.”

Quite the wit, my niece.

And so, I hope that there are many more roadshows on this journey I'm embarking on. And that they will not just be about antiques from my life, but also new exciting experiences, people, books, and yes, podcasts encountered on the way (And see, dear niece, how I am able, albeit tenuously, to connect the Pet Shop Boys, the Beach Boys and Antiques Roadshow back to Crohns, the colon, and colon cancer).

For useful reference:

https://www.mycrohnsandcolitisteam.com/

https://www.cancer.gov/types/colorectal

https://www.cancer.org/cancer/types/colon-rectal-cancer.html

The global health community wrenches its clothes and gnashes its teeth in Switzerland at the 78th World Health Assembly - and it is going to be brutal. To ease the pain, Dr Mike Reid, Associate Director of the Center for Global Health Diplomacy, UCSF joins Ben for a wide ranging exploration of a positive, forward-looking agenda for global health. Topics include global health security, one health, mis- and disinformation in the doctor-patient relationship, health technology and specific future uses and pitfalls of AI to improve access to healthcare in developing countries. Mike offers a promise of a future episode on channelling philanthropic dollars into sovereign wealth funds for global health investment. And finally they reflect on their upbringing in the UK with its “free at the point of delivery” National Health Service, and argue over which of the modern Cambridge University Colleges they went to most resembles a multi-story car park.

And here’s Mike’s Substack for you to subscribe to!

mike’s Substack

“With and For” is a platform for reimagining global health through the lens of sustainability, science, and shared purpose—where solutions are co-created with communities and powered by innovation for lasting impact.

By With & For

💬 Join the Conversation How do you see the future of global health unfolding? Share your thoughts in the comments! 🔔Subscribe & Stay Updated Listen on Spotify, Apple Podcasts, or your favorite podcast platform Check out our Youtube channel for more in-depth global health discussions!

A poster of the Netflix Series “Adolescence being given to all UK schools (coutesy of Netflix)

Hello Adolescence

Netflix’s recent binge-watch smash the drama Adolescence has sparked global debate, exploring how the online “manosphere” might have influenced a British teenager to commit an unthinkable crime. As countries scramble to curb harmful online content—through censorship, banning cellphones in schools, or restricting access—one glaring question remains: What alternatives exist to counteract toxic influencers and populist rhetoric? Where are the role models who can guide boys toward healthy masculinity?

Leaving the Boys Behind

The gender equity movement has made remarkable strides, but its focus on empowering girls and women has unintentionally left boys and young men adrift. Without nurturing their emotional growth or addressing their evolving roles in society, many are left feeling marginalized. Many of us in the movement have been asking the tough question: Is it enough to prioritize the empowerment of girls and women alone, without building nurturing and health attitudes of boys and men? Should we be diverting resources and attention away from girls and women?

British journalist Emily Maitlis captured this tension bluntly on a recent episode of the podcast The News Agents:
"For F**’s sake, we’ve just started talking about the women. Do we now have to go back to feeling sorry for the boys, for the men?"*

The answer is yes—but not out of pity. Addressing boys’ needs is essential for long-term gender equity. Boys need guidance to navigate societal expectations that often feel contradictory: being told it’s okay to cry yet simultaneously expected to “man up.”

While we are on the topic of podcasts, let me propose for your delight and delectation, my own podcast, A Shot In The Arm Podcast. Two years ago, this confusion was poignantly expressed by Narayan Mbugua, a young Kenyan content creator, during an episode:

"It’s so confusing for the boy because girls have been empowered—and they should be treated equally—but then you’re told you’re the head. You’re told it’s okay to be vulnerable, but in another context, you’re told, 'Be a man!'"

This vacuum is fertile ground for toxic masculinity, which offers young men distorted ways to assert identity—often at the expense of women. To bridge this gap, gender equity initiatives must include boys and men—not as an afterthought but as active participants in creating a healthier society for all.

Challenges Facing 21st-Century Boys and Men

Neglecting boys’ needs can manifest in some pretty harmful ways:

• Mental Health Struggles: Anxiety, depression, and substance abuse are exacerbated by societal pressure to suppress emotions.

• Academic Underperformance: Boys face harsher discipline in schools and lower educational outcomes compared to girls.

• Rigid Gender Roles: Traditional norms restrict men’s emotional freedom while tying their self-worth to breadwinning.

• Perpetuation of Violence: Without intervention, patriarchal models continue to fuel bullying, harassment, and gender-based violence.

These challenges highlight the urgent need for positive male role models who can guide boys toward healthier coping strategies and inclusive values.

Toxic Masculinity vs. Positive Masculinity

The manosphere offers no meaningful solutions to these challenges; instead, it exploits confusion with harmful ideologies rooted in hyper-masculinity, misogyny, and pseudoscience. Concepts like the “alpha/beta hierarchy” (and we aren’t talking the Aldous Huxley’s Brave New World Caste System) or “red pill awakening” (yes, the Matrix film triology!) distort reality while attempting to reinforce dominance over women. These ideas are dangerous precisely because they thrive in bite-sized online content designed to grab attention within seconds.

But there’s hope. Figures like Andrew Tate—once emblematic of toxic masculinity—are increasingly discredited within these circles. However, others keep surfacing, not least from Silicon Valley’s dark web. The challenge for the rest of us is finding constructive alternatives that resonate with young men.

A Manifesto for Positive Masculinity

A revitalized vision of masculinity doesn’t have to reject tradition entirely—it can reclaim traits like strength, resilience, and courage while integrating emerging new traits such as empathy, collaboration, and emotional openness. This balanced approach benefits everyone:

• Emotional Expression: Men are encouraged to embrace vulnerability without fear of judgment.

• Inclusivity and Empathy: Healthy masculinity prioritizes compassion over competition.

• Community Engagement: Strong social bonds foster belonging and purpose beyond traditional roles.

Reclaiming Traditional Role Models

Community elders, religious leaders, fathers, teachers, and sports coaches have immense potential as champions of gender equity. By modeling fairness and compassion—whether through equitable partnerships at home or fostering emotional intelligence in schools—they can inspire younger generations to embrace inclusive values. For example:

• Religious leaders can use sacred texts to emphasize mutual respect between genders. I recommend two articles - firstly a piece in America The Jesuit Review by Brady Smith “Men and Boys Are Lost: The Catholic Church Can Give Them A Better Model of Manliness”. The Pakistani-American author Haroon Moghul wrote an extraordinary commentary for the American Institute For Boys and Men entitled “For A Model Of Muslim Masculinity, Maybe Don’t Look To The Manosphere.”

• Fathers who share caregiving responsibilities can challenge outdated norms at home.

• Teachers can celebrate vulnerability as strength while encouraging boys to support girls’ achievements.

These figures can bridge cultural heritage with progressive ideals—becoming powerful advocates for positive masculinity.

Global Champions of Positive Masculinity

Around the world, inspiring figures are already leading this charge:

• Tony Porter, CEO of A Call to Men, advocates for healthy masculinity and preventing gender-based violence.

• Jason Wilson, founder of a martial arts academy in Detroit, helps boys overcome emotional barriers through discipline and mentorship.

• Anto Neosoul, Kenyan musician and podcaster (Unlock Your Soul), celebrates community humanity through open discussions about male identity.

• Enioluwa Adeoluwa, Nigerian influencer with hundreds of thousands of followers on TikTok and Instagram, pushes boundaries on restrictive gender norms with humor and authenticity.

These leaders demonstrate that positive masculinity isn’t just theoretical—it’s actionable.

Where Do We Go From Here?

Redefining masculinity is more than improving men’s lives; it’s a societal shift that benefits everyone:

• Women see reduced caregiving burdens as men embrace shared responsibilities.

• Boys gain diverse role models who embody empathy alongside strength.

• Future generations inherit allies who advocate for policies promoting gender equity.

By embracing an inclusive vision of manhood—one that combines traditional strengths with modern values—we create a world where both genders thrive together.

This is the first of a series of articles exploring different models of masculinity that can support gender equity. I have no shame in stating that Perplexity AI helped me clarify concepts and edits.

Here are the topics we cover:

• Policy Analysis versus Political Action - how do we meet the challenge of institutional medical misinformation at the highest levels of our governments? Clue - it is about speaking truth to power, not accommodating denialists.

• Transgender health, equity and rights - and how they must be at the heart of global health action this year.

• Gamechanging biomedical innovations - in viral hepatitis, HIV, cancer and immunology.

• Pandemic Preparation Redux - its not just that COVID-19 isn’t over, its that avian flu H5N1 mutations are bringing us closer to mass human-to-human transmission.

• Elderly Care - transforming a part of healthcare that affects us all no matter where we live, but which is still ruefully cruel and barbaric.

But if you want to know how I weave Aliens movies and Elon Musk into the picture - you’ll have to listen, watch, and if I could ask your forbearance, subscribe!

Find us on your podcast platform of choice and on our Youtube Channel.