Earlier this month, Winnie Byanyima, a high-profile diplomat and Ugandan politician who ran the nonprofit Oxfam for the past 7 years, took over a top job in the HIV/AIDS world—where she is far from a known figure.
Byanyima now heads the Joint United Nations Programme on HIV/AIDS (UNAIDS), a Geneva, Switzerland–based operation that sets the global agenda for ending the epidemic. It provides authoritative epidemiology and has offices in 70 outposts that help countries improve their treatment and prevention efforts.
Byanyima, who has a long history working for social justice and women’s rights, steps into a job at a tumultuous time. Not only is a UNAIDS-led push to end the AIDS epidemic falling short of its targets, but the organization itself was also subjected to harsh criticism last year.
The inhouse turmoil came to a head in December 2018, when an independent panel sharply criticized the organization, and its leader Michel Sidibé, for fostering a “boy’s club” culture that did not properly thwart sexual harassment and bullying of women. Sidibé, who challenged many of the panel’s assertions, stepped down in May to become minister of health and social affairs in Mali.
In its campaign to end the epidemic by 2030, UNAIDS had set a 2020 interim goal dubbed 90-90-90—90% of the HIV-infected people in the world know their status, 90% of that group start treatment, and 90% of people on medication fully suppress their virus—that will surely fall short. Reaching the goal would require 30 million of the estimated 38 million HIV-infected people in the world to be receiving treatment, but a UNAIDS report issued yesterday—World AIDS Day is on 1 December—says the total hit just 24.5 million as of the middle of this year. Only about half of the infected people in the world fully suppress their HIV.
Although HIV/AIDS has never been the central focus of Byanyima’s work, her unusual background could help her address the long list of formidable political and cultural challenges facing UNAIDS. She grew up in Uganda, a country hard hit by HIV/AIDS, in a household that took in a young man named Yoweri Kaguta Museveni, who became the country’s president in 1986. Byanyima, who has a bachelor’s degree in aeronautical engineering and a master’s in mechanical engineering, once worked as a flight engineer for Uganda Airlines. “I’m numerically literate,” she says.
Byanyima also fought in Uganda’s National Resistance Army with Museveni, who once asked her father whether he could marry her. (He said no.) After the resistance movement prevailed, she served as Uganda’s ambassador to France and then twice won a seat in Parliament. She is married to Kizza Besigye, a physician and politician who has run for president four times, strongly criticizing Museveni. (Besigye has repeatedly been arrested on various charges, none of which has stuck.) In 2013, after serving for 7 years at the United Nations Development Programme (UNDP) as head of gender and development, Byanyima took the helm at Oxfam.
Science spoke with Byanyima from her home in Nairobi, which she was about to leave to move to Geneva. This interview has been edited for brevity and clarity.
Q: What’s your vision for UNAIDS?
A: We have a goal, that by 2030, we should have ended the epidemic. I believe we can achieve that. HIV is for me not just a disease like any other, but it is very much an issue of human rights and social justice. Scientists tell me that with the combination of prevention, treatment, and care that exists today if they were available to all those who are at risk or living with HIV, we could end AIDS as a global health threat.
We have to deal with four things in a new way in the next 10 years. First, we can push governments to remove the barriers that are in the way of key groups who need HIV services: women and girls in Africa, men who have sex with men, sex workers, people who inject drugs, and prisoners. Second is women’s rights and gender equality. Third is addressing the issue of financing, which has been dropping because UNAIDS and others have become victims of their own successes. The fact that 24.5 million people on treatment today are living longer healthy lives and that AIDS-related deaths have reduced by about 50% has led to complacency in some governments and a feeling that this is not a problem. The last area where we need to step up is in the threats to civil society, which keep increasing.
Q: Everything you said has been on the UNAIDS agenda over the past 20 years or so. What can you really do that’s different to hit the 2030 goal?
A: It is a case of the glass half full or the glass half empty. It is true, we are not going to reach the 90-90-90, because we have only 79% of the people living with HIV who have tested. But of those, we have 78% on treatment and of those 86% are virally suppressed. That’s not where we wanted to be, but if you look at the data differently, you have a positive story to tell and lessons learned for going forward. The center of the epidemic is sub-Saharan Africa, which is the region that has made the biggest progress. New infections have been reduced dramatically: 40% in 8 years in South Africa, and the entire region almost 30%. But then we see increases in other regions in Asia Pacific, the Middle East and North Africa, Eastern Europe, and Central Asia. Why the crises in these areas? It is the key populations. The challenge now is more on the side of prevention. We know the tools, they are there. We need to scale up.
Q: The HIV/AIDS world doesn’t know you all that well. You’re not an outsider entirely, but you haven’t been focused on HIV and AIDS. What are you bringing to this?
A: I may not be known as a leader in this area, but I’m known as an activist on social justice issues including addressing the social dimensions of HIV/AIDS. All my life I’ve been a social justice activist, whether this was the women’s rights movement, where I’ve been a leader from the grassroots up to the global level, or fighting against corruption and the rights of community in my country as a parliamentarian. I have also been involved in global climate change and using the leadership of women to assert that climate change has dimensions that are gendered. And I have fought on HIV/AIDS—many, many times in civil society, in my jobs at UNDP, in my work at Oxfam, and I was recently a member of U.N.’s high level panel of the secretary-general on access to medicine, where I took actually a dissenting position that the right to health has to come before the need for profit. I have led a global program to address unpaid care work that is done by women in context of HIV/AIDS, where you have a whole movement of women’s grassroots organizations bearing the burden that should be the state burden of taking care of the people who are dying and finally women caring for the orphans.
Q: When you came into Oxfam there was a sexual misconduct problem. What did you learn from that experience that might apply at UNAIDS?
A: A scandal broke last year about how Oxfam had handled cases of sexual misconduct in Haiti 8 years ago. I was at the helm of Oxfam but I was not there when that happened. We have now to face our past and look at our present, and my experience there says the most important thing is to face the truth and look at yourself in the mirror and accept that you don’t look good and clean up. Transparently. We did that at Oxfam. I commissioned an expert commission of global experts to do an independent inquiry and give us recommendations, and we published them. Everybody saw what was wrong with us. We committed to implementing all the recommendations and I have left a much stronger organization for that. So I bring, quite humbly but confidently, some experience about how to recover from such a low depth.
Q: One of the big challenges that every UNAIDS director has faced is convincing the world to put more money into the pot. What can be done to meet the ambitious financial targets?
A: It’s true that the funding of the response has been declining, but it isn’t true that there are no resources to fund the response. There are many areas we can look at that will increase resources. Just recently the replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria raised a target of $14 billion. If every dollar of that $14 billion is stretched to achieve its highest impact, it will take us very far. Many countries are addressing an epidemic that is not their real epidemic. With better targeting, we can stretch that money. Many developing countries also are depending heavily on the donors currently. Governments have to be challenged to own their epidemics and to put themselves on a sustainable path of self-financing. You cannot convince me that a middle-income country cannot rollout secondary education for all of their kids. So I’m so optimistic on the question of finances.
Q: Let’s discuss a few specific problem areas. One is Russia, which accounts for more new infections than all of Europe. It’s not poor. But there are proven interventions that Russia rejects. How do you have impact in a country like Russia?
A: We have to engage them. And let me tell you, with all due modesty, I feel I’m in the right place at the right time. One thing that I have learned in my career is how to be a true advocate to influence government and even the corporate sector. Russia, like every country, has leaders who want to succeed. UNAIDS has a good relationship with them. One of the first ministers to approach me and express solidarity working me is Russia’s minister of health, an amazing woman. We are going to work with their civil society, particularly communities of gay men, and keep pushing. Russia is influenceable, just like any other country.
Q: In Uganda, your home country, how do you shift things politically there? For example, men who have sex with men are not the major driver of the epidemic there—HIV largely is spread through heterosexual sex—but it is a key population that continues to suffer in terms of human rights and justice.
A: There is a problem. But you have to start with things that are going right and recognize them. In the heterosexual population, Uganda is doing its part: Treatment is almost reaching the 90% goal, and it’s using more methods of prevention and rolling them out like voluntary medical male circumcision. Where things are not working is with the gay population. Indeed I’m speaking with people in authority, as is the country team, about the rights of the LGBT [lesbian, gay, bisexual, transgender] community, so they can access services. But let us look at the whole picture, and help a government to address its real epidemic. Uganda still has a lot to do for women and girls and we would like to hear you say that too, by the way.
Q: They’re not criminalized for being women and girls. It’s illegal to be a gay man in Uganda.
A: Yes, but women and girls are at huge risks of violence, of getting HIV, having no incomes, and being harassed everywhere. Uganda is not failing across the board. It has a challenge on the issue of the rights of sexual minorities. You confront them continuously while acknowledging that they also have challenges in other areas like the rights of women and girls and tackling gender-based violence.
Q: Are you on speaking terms with President Museveni? Your husband has been treated very severely.
A: I’ve always been able to speak not only with him, but with all the leaders in the country. If he bullies the opposition, that is something he shouldn’t be doing.
Q: To take another staggering challenge, Nigeria has more cases of mother-to-child transmission of HIV than any country. Can you do anything to help Nigeria improve and reduce mother-to-child transmission?
A: It’s is a question here also of political will. Nigeria is indeed now a middle-income country. But let me tell you a country like Bangladesh, which is poorer, has got better health outcomes for its people than Nigeria. It has got better outcomes for education, Nigeria has 10 million children not in school. This should not happen in a country like that. So we can advise, and we can support civil society to demand, but ultimately leaders must be able to decide to deliver for the people. That’s what they’re elected for.
Q: In many sub-Saharan African countries, girls and women are particularly at high risk of HIV infection. What specifically can UNAIDS do to help countries slow spread in this population?
A: Offer sexual and reproductive health services for all girls and young women, and combine them with HIV status testing. And if we can get governments to roll out secondary school education, keeping girls in school reduces their risk by 50%. These for me are achievable.
Q: What’s one thing you’d like people to know about you that doesn’t get enough attention?
A: People seem to think that change happens maybe by accident or because some leader is enlightened. No. Throughout history, change has come because people demanded it. This is something strong that I bring that is often overlooked, even by the United Nations to its own detriment. Power has always come from people making demands. We colonized people demanded and got the support of the United Nations to end colonialism in the world. Women organized to use the United Nations platform to win rights, from voting rights, to rights to have a voice in parliament, to right for girls to education. What I bring to an organization like UNAIDS is the need is to tap into the power of movements and use the movements to roll back the barriers to people who are affected and infected by HIV.